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1. Student Profile:

Student Description:

Antonjah is a 16.8 year-old student enrolled in a transition-age classroom in a self-contained educational setting at the Jewish Guild for the Blind School in Manhattan, with a teacher:student:assistant ratio of 12:1:4.  She has been attending this school setting since 1998, when she transfered from the Preschool program at the same location.

Etiology and Developmental History: Antonjah is diagnosed with global developmental delay, with visual impairments including microphthalmia and coloboma, and hearing impairment defined in an audiological report as profound bilateral sensorineural hearing loss.  A specific etiological diagnosis has not been provided, although an early psychological report rules out Rett Syndrome due to the absence of “the characteristic loss of purposeful hand skills and the subsequent development of stereotyped hand movements.”  Antonjah classifies for Special Education services in New York under the IEP heading of Multiple Disabilities.

Antonjah was born at full term with an average birthweight and without complications; prenatal history was also unremarkable.  At one week old, after observations by her mother of abnormal pupil movement, Antonjah’s pediatrician referred her to an optometrist.  Over a four month period of examinations, Antonjah was diagnosed with bilateral micropthalmia and coloboma (“The coloboma bilateral and involves the optic disc and the macula”).  A visual evoked potential (VEP) examination in April of 1994 showed a “severe pathway dysfunction.”

According to reports mentioned below, Antonjah presented with significant delay in achieving developmental milestones in the domain of gross motor skills: sitting at 9-12 months; crawling at 18 months; pulling to stand at 18-20 months; standing alone at 27 months; walking at around age 6 years. At age 4 months, Antonjah was referred for Early Intervention services and began to receive Occupational and Physical therapies 5 days per week.  At 12 months of age, she developed an aversion to textured foods, and began feeding therapy.  By age 12 months, according to her mother, she was beginning to “babble and approximate ‘mama’ and ‘dada’ vocalizations.”  Close to this time, she was referred for an Auditory Brainstem Response hearing test, the results of which were within the typical range of hearing.  By age 2, Antonjah’s speech had not progressed beyond babbling, and had even regressed.  A second ABR test was conducted, which revealed a moderate to severe bilateral hearing loss.  According to her mother and previous reports, the cause of loss is unclear, and during her first two years she did not have ear infections or other medical conditions which may serve as an explanation.  Shortly after this ABR, a geneticist ruled out any associated syndrome.

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Sensory Function:

Vision:

No existing functional vision assessments are available to shed light on Antonjah’s specific use of vision.  An effective communication plan will necessitate the information provided by such assessment tools.  Antonjah is a visual learner who navigates her ambulatory environment apparently through using her peripheral vision, suggested by her direct, face-forward stare while walking and ability to avoid and move around objects above waist height.   Antonjah is able to locate objects using her vision and coordinate hand motions to pick up desired objects placed in front of her, observed with consistency at eye level of vision or on a table in front of her.  She does not show consistency in avoiding obstacles placed lower than waist level; however, she has been observed to bend down and pick up her shoes from the ground (shoe and sock preferences described later).  Antonjah has not consistently demonstrated visual tracking skills with objects or people upon observation.  Several early reports describe a preference for computer screens (she “put her pace up to the screen”) and bright lights.    

According to the literature, “The visual problems in coloboma depend on which part of the eye is affected and how extensive the coloboma is…If the back of the eye is involved, sections of the retina, choroid, and optic nerve may be missing…These defects can reduce visual acuity” (Schwartz, 2010).  In following the initial (and only, apparently) assessment of vision given, in which the optometrist determined that Antonjah’s coloboma involved the optic disc and macula), it can be assumed that Antonjah has a central vision impairment (“usually worse than 20/60” for individuals with optic nerve coloboma, and “visual acuity drops to 20/200 if the macula is involved”). Vision is typically stable in individuals with coloboma and magnification and learning media assessment are useful for working with students (Shwartz, 2010).  The classroom is equipped with a CCTV unit, which may be a useful form of assistive technology for developing instruction that is engaging and practical in Antonjah's educational plan.

Schwartz, Antonjah. (2010) Causes of visual impairment: pathology and its implications. In Corn, A. & Erin, J. (Eds.)  Foundations of Low Vision: Clinical and Functional Perspectives, 2nd Ed (pp. 137-187). New York: AFB Press

Hearing: Antonjah’s most recent hearing assessment was conducted in March, 2009, and was a Pure Tone Audiogram revealing responses at the 75-80 dB HL level for the frequencies of 250Hz- 1000Hz in both ears, speech detection threshold at 85 dB HL in the right ear, and 90 dB HL in the left ear.  This exam did not include audiological testing with hearing aids, as the report stated that the hearing aids were left at home on the day of the exam.

Antonjah has been prescribed hearing aids and recommended use of an FM system while at school, which according to reports and hearsay have not been used consistently over the past several years due to her aversion to wearing them.  In the past three weeks at school, due to collaboration with a Hearing Ed. Therapist from the Department of Education who is mandated

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to see Antonjah 3 times per week for 30 minute sessions, the observer and noted specialist have succeeded in communicating with Antonjah’s mother to send the hearing aids in with her daily.  Working closely with Antonjah to put the hearing aids in only in calm and quiet environments, she has permitted wearing them without resistance for increasing periods of time in the past weeks.  After some time, Antonjah will generally remove the aids and discard them on the ground.  While in a quiet classroom in recent observation, she has tolerated wearing the aids and Fm for up to 2 hours before removing and discarding them.  Over a three day trial period, she has consistently discarded them within 10 minutes in gym class; this may be due to the noise level in the gym, or the overstimulation she receives in this environment full of preferred motion activities.  She demonstrates, upon observation, awareness of speech sounds while wearing the aids, suggested by moving her head, or laughing and waving her hands after the aids are fitted and the facilitator begins to speak.  A log is being kept of this daily progress and relevant environmental considerations, and pages will be included in this communication plan.  Hearing is a learned skill, and Antonjah will require extensive auditory training with the Hearing Ed. Instructor, the Speech and Language Pathologist, the teacher and any other relevant communication partners in order to maximize audition for learning and interaction. It is important to consider enhancing the auditory environments in which Antonjah uses her aids and FM system, and to develop appropriate curriculum adaptations. 

Tactile:

Antonjah engages in perseverating tactile behaviors, such as “pill rolling” (rolling the middle and pointer fingers on both hands together), teeth grinding, and has been observed to “flip her eyelids back.”  She has no observable tactile defensive behaviors, although Antonjah often pushes or turns away when touched, which is notably an expression of disinterest in engaging with people and activities.  She enjoys playing with and being submerged in water, which she reflects by laughing and waving her hands apparently in enjoyment.

Vestibular:

Antonjah demonstrates observable desire for sensory activities that stimulate her vestibular system and proprioceptive stimulation (deep-pressure).  As noted by her Adaptive Physical Education teacher, “These (activities) include using a balance board or seat, swing, bouncing on a peanut ball or using the air mattress.”  When engaging in self-injurious behaviors, as will be elaborated on in this plan, a noted and practiced method of calming Antonjah is to apply slight pressure on or to rub her upper back.

Olfactory/Gustatory:

Antonjah exhibits an aversion to eating textured/solid foods, and demonstrates daily a preference for liquid meals, particularly a Pediasure drink which she seeks out and obtains from the classroom cabinet, then presents to a preferred staff member when she is hungry.  As noted, this aversion began as early as around age 12 months.  Conversations with the school’s Speech and Language Pathologist reveal that at some point (several years ago) feeding therapy had been recommended and a program was implemented to improve upon her eating skills and

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preferences for health and developmental purposes.  For a year, Antonjah was eating pureed foods with a wider variety of choice (as opposed to drinking 3 to 4 cans of Pediasure at school daily); this program was abandoned “due to a change in classroom teacher,” and no change in her diet has been attempted since.   According to the Speech and Language Pathologist, there is no related oral motor dysfunction, and the aversion is behavioral; further evaluation and planning is necessary to address this important issue.

 Cognitive Development:

Antonjah has been diagnosed with global developmental delay.  At this point, there are no apparently functional assessments available indicating her present level of cognitive development.  The psychological evaluation of 2009 mentions the use of The Vineland-II Adaptive Behavior Scales and the Wechsler Intelligence Scale, 4th Edition (WISC-IV) to assess cognitive functioning and adaptive/maladaptive behaviors.  Both of these assessments indicated results of cognitive functioning at between 10 and 24 months of typical developmental age.  It should be noted that neither of these assessment scales were adapted for students with visual or dual sensory loss.

It is difficult to make an observational assessment as to Antonjah’s cognitive functioning level.  Antonjah’s current IEP goals in the academic/classroom domain are entirely based on Activities of Daily Living Skills.  She is currently dependent on caregivers in toileting, self-dressing (although she is able to remove her shoes, jacket, and other clothing, she has not demonstrated ability to put on clothing), and all areas of personal hygiene.  Antonjah is able to drink independently from a cup, and demonstrates a level of joint attention in connecting both the cup to the beverage (she is working on pouring skills), and in recognizing the need for a facilitator to open the beverage for her and help her to pour it into the cup.  She also demonstrates joint attention in communicating with facilitators in accessing preferred activities, especially during gym class.

Selection and administration of an appropriate assessment for cognitive development is necessary for future instructional planning, and for the purpose of this communication plan.

Physical Development and Gross/Fine Motor Skills: According to a medical report, Antonjah’s gait is characterized by “right foot-drop, a steppage pattern involving right lower extremity, absence of heel strike bilaterally, and foot-flat floor-landing on the left.  The floor-landing pattern on the right is initially towards the front of the foot.  There is a tendency towards the front of the foot. (Antonjah) is out-toed bilaterally.”

Antonjah’s IEP provides a mandate for use of bilateral AFOs to correct unsteady gait; these orthopedic aids have not been observed in use or possession in the school environment in the past year, and a previous report indicates that, like her hearing aids, she often does not tolerate them being put on (or staying on).According to the school's Adaptive Physical Education teacher, “Over the past two years she has successfully integrated many different gross motor activities into her repertoire.  She will request

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walking on the treadmill, riding an adapted or stationary bike, or jumping on the trampoline.  She is starting to pedal a bike independently.  She still needs frequent prompts and physical guidance from staff, but she enjoys movement activities.”  APE is an important area of focus for Antonjah, as she expresses determination and preference for activity choices within this space.

Antonjah demonstrates use of fine motor skills in grasping familiar and preferred objects and people.  She has demonstrated the ability to utilize pincer grasp for the purpose of picking up smaller desired objects.  She does not currently hold a pen or pencil with appropriate grasp.

Hand Skills:

Although Antonjah’s fine motor skills reflect her ability to use her hands functionally, Antonjah’s self-stimulatory “pill-rolling” finger movements and hand-flapping often prevent her from exploring objects and participating in activities.  She often pushes objects or people away, or simply removes herself (or turns away) in refusal of presented objects or activities.  Objects which Antonjah will use her hands to interact with at this point, observationally noted, are limited to a mere few: a green cup she uses to drink with, her Pediasure drink/food, forearms/wrists of preferred people, preferred padded chairs, and her locker door and her jacket/backpack inside (when ready to get on her bus at the end of the day).  She does not apparently use her hands to explore, but rather to grasp or push away.  She demonstrates isolation of fingers, but rarely uses this fine motor skill in functional routines (it is often seen in her self-stimulatory behaviors).  Antonjah's hands are characterized by callouses and a thick, caked skin across her entire palm and most of her fingers; this may affect her use of hands and fingers to access tactile materials and to tactually discriminate.  It will be important to consider interventions for effective use of hand skills, concentrating on the issues presented to participation and engagement in her self-stimulatory “pill-rolling” and hand-flapping behaviors, and in promoting her use of hands for exploration, and for developing gestural communication.

Other Important Information About Student (Behaviors and Preferences):

Antonjah engages in self-injurious behaviors when she is apparently frustrated or in pain, including biting or digging with her nails into her wrists and head-banging.  These behaviors are generally accompanied by crying and sharp, high frequency vocalizations.  She also has been observed to bite, scratch, or dig her nails into others, both while apparently in pain (accompanied by crying and vocalizations) and when apparently overexcited (while laughing, waving her hands, jumping and shaking during a preferred activity).

Antonjah’s other known vocalizations are perseverating, repeated low frequency sounds (“guh guh guh guh…”) which she makes while “pill rolling” with her fingers.

In the classroom, Antonjah prefers to sit in a favorite  blue padded arm chair, placed against the wall of the classroom opposite the entrance.  There are two such chairs in the class, and she always locates and sits in that particular chair upon entry into the classroom.  Antonjah prefers to sit cross-legged in the chair, in “yogic pose,” generally facing sideways.

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Antonjah often locates preferred people and activities by moving to them and taking their forearm in her hand, which is generally followed by her attempting to direct the person to a preferred activity or object.  Current preferred activities/locations and objects include her Pediasure drink and green cup (she attempts to direct the facilitator to both objects), and the gym class and various movement activities/objects located there.  At this time, Antonjah shows resistance to and ambivalence towards facilitated participation in small or large group activities with her peers.  She does not tolerate hand-under-hand guidance in partial participation, and tends to stand up and remove herself from the environment when a facilitator attempts to physically engage her.  She does not presently demonstrate physical response to verbal prompts in observed activities.

Living Situation and Family: Antonjah lives with her mother and five siblings in New Rochelle, NY, and commutes to school daily by bus.  Her older brother is hearing impaired and utilizes bilateral hearing aids and an FM unit at school; he was diagnosed with a hearing impairment at age 3 (specific diagnosis unavailable), and developed speech at age 5.  Antonjah’s older sister is diagnosed with a seizure disorder, which apparently does not impact her learning ability.  Communication with her family primarily consists of phone conversations and text messages with her mother.

Currently Available Reports and Additional Assessments: Reports currently available include one audiological exam (conducted in 3/2009); psychological evaluations (5/2000; 1/2009); Social History reports (5/1998; teacher reports from 2000-2009; and recent related service reports for Occupational Therapy, Physical Therapy (discontinued as of 2/2007), Speech and Language Pathology, Adaptive Physical Education, and Music Therapy.  In this communication plan, the results of given assessments and reports will be integrated with individualized formal and informal assessments as well as observations in order to present a more complete and appropriate description of Antonjah’s individual domain skills and overall developmental functioning.

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2.  Justification of Plan and Review of Pertinent Literature 

“The summary of recommendations for improving the functional communication of deaf-blind children presented here is based on an analysis of literature.  The recommendations are concerned with conducting assessments, engaging in team planning, providing inclusive programming, developing the children’s residual senses and receptive communication skills, increasing motivation, using consistent communicative cues, increasing engagement, and generalizing skills.” 

(Engleman, Griffin, & Wheeler, 1998, p. 787) 

Introduction, Philosophies, and Overview: 

It is necessary to briefly address the basic notions, goals and components which must be manifest in greater detail within this specific plan in order for it to be successful.  Firstly, we must outline the philosophical structure upon which to develop effective and appropriate assessments, goals and interventions.  

The plan must be individualized, focusing on the student’s particular needs and preferences and developing adaptations and accommodations appropriately to meet goals and objectives.  The plan must be functional, assessing strength-based skills across a variety of daily activity routines and with a variety of people.  A functional plan will address the specific management needs and considerations for implantation, providing support for the educational team and the family in approaching goals and objectives efficiently and effectively.  In reviewing the literature, these precepts will be considered with regard to specific communication goals developed for the student by the multidisciplinary team, including to the extent possible, the student and the student’s family.  

Janice Light has described communication as “the essence of life,” defining a general, universal goal of developing what she refers to as communicative competence.  In outlining a philosophical and practical model for addressing this basic human need, she has written, “Building communicative competence requires a vision of what could be, and the courage and commitment to dare to make that dream real” (Light, 1997, p. 69-70).  It is critical to recognize this concept as not entirely self-evident for the variety of people who may interact with students with severe and multiple disabilities including dual sensory impairment.  Educators, and often, families, face the essential task of asserting the extension of this commitment to all who interact with the child who has challenges in communication.  In synthesizing the approaches of former studies in the development of functional communication skills for individuals with dual sensory impairments, Engleman, Griffin, and Wheeler have written, “A greater ability to communicate has been shown to be the key factor in improving a wide array of skills of young people with deafblindness, from making choices, participating in school, forming friendships, engaging in transition planning and gaining acceptance from the family to understanding cultural identity, participating in postsecondary education, and living independently” (Engleman, Griffin, & Wheeler, 1998, p. 786).  This plan will attempt to provide a child-centered outline which may

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guide the acquisition and strengthening of future communication skills for Antonjah, and for all who interact with her.   

The Communication Bill of Rights developed by the National Joint Committee for the Communicative Needs of Persons with Severe Disabilities (1992) should be regarded as a general philosophy for structuring all practices in the education of students with severe and multiple disabilities, including those with dual sensory impairments.  The rights outlined in this document remind communication partners to exercise patience and above all diligent compassion in all interactions, recognizing the responsibility they have in working to provide choices and opportunities, and to support the independent voice of  individuals with challenges in communication.  It is the responsibility of the communication partner to create rich environments for conversation on various levels of interaction and symbolic language (Miles & Riggio, 1999). As Janice Light states, “School-aged children need the means and skills to meet all four communication goals: expressing needs and wants, developing social closeness, exchanging information, and fulfilling social etiquette routines” (Light, 1997, p. 62).              

By using the four aspects of communication (form, function, content, and context) as a framework for creating what Susan Bruce refers to as a “Holistic Communication Profile,” it will be possible to develop a plan which allows for assessment, evaluation, development of goals, and implementation of interventions, each according to the specific individualized characteristics of the student’s communication environments (Bruce, 2010, p. 106).  It will be useful to focus on the aspects of communication through the following sequence-based steps and goal areas of Antonjah’s communication plan: 

1.   Assessment Practices: a brief description of the foundational principles, practices, goals and specific tools of assessment necessary to creating a functional plan. 

2.   Communication Goals for the Student and Communication Partners: the practices, areas, and specific target skills selected for this individualized plan.  

3.   Assessment of Supports and Plan for Interventions: an evaluation of the environmental and team-based supports necessary to address these goals, and identification of practices for developing concrete interventions for implementing the communication plan and developing staff and team communicative competence.  

4. Transition Planning:  a brief review of the importance of transition planning and the connection between the communication plan and the creation of an effective transition plan.

1.    Assessment Practices:            

The communication plan must be based on individualized assessment of communication skills according to evidence-based practices, utilizing the Communication Matrix developed by Rowland in conjunction with observational, informal assessments and interviews to the extent possible with all communication partners.  Development of a functional plan will rely upon the use of multiple forms, or methods, of gathering information about the student’s communication

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skills across a variety of settings.  Informally collected information, including that obtained from interviews with family and related services, as well as observational information taken from any other relevant context, will be useful as complementary material for assessing the student’s communication skills (Miles & Riggio, 1999). 

 For students with residual vision, the use of a Functional Vision Assessment is an important component in developing an appropriate intervention plan.   By gathering more specific information on the use of visual skills including tracking, scanning, attending, and localizing, it will be possible for the educational team to develop individualized instructional materials, adaptations and goals for functional vision use across the daily routines.  Functional Vision Assessment for the student with severe and multiple disabilities involves the use of individualized tools and materials, and observation of visual skill usage throughout functional daily routines and in the contexts in which these routines typically appear (i.e. during lunch, gym, etc.) (Chen, 1999).

 2.    Communication Goals for the Student and her Communication Partners: 

a.   Responsiveness of Communication Partners and Basic Approach (Encouraging Self-Determination)       

In their essay on concept development for children who are deaf-blind, Miles and McLetchie assert the absolute necessity for the child to have “at least one trusting, significant, meaningful relationship to serve as a center from which to explore the world in gradually widening circles (Miles & McLetchie, 2004, p. 3).  The development of communication skills for students with dual sensory impairments is contingent upon the foundation provided by interactions based upon mutual respect and responsiveness.  It is essential that communication partners build rapport with students with severe and multiple disabilties including deafblindness in order to support her desire to communicate.  The responsive communication partner is one who recognizes attempts at communication, interprets the meaning or function of these attempts, and responds appropriately in a range of meaningful forms (Bruce, 2003).  In addition to identifying appropriate goals and forms of communication for the student, the success of any communication plan or system lies in the development of interactions.  As Janice Light writes of successful AAC plans, “...the technology is only a tool: it is the people and the interaction that must be the main focus” (Light, 1997, p. 65).   

In his essay titled "Your Right, My Obligation?" Denis Mithaug has articulately described the connection between the rights of all individuals to self-determination, and the obligation of all others to recognize and respect those rights, and how this applies equally to individuals with severe disabilities who are often faced with significant environmental and interactional barriers to asserting their self-determination.  These barriers as identified by Mithaug are: "(1) limited opportunities for choice and control, (2) conflicts surrounding choice-making, (3) lack of flexible support services, and (4) lack of stable relationships" (Mithaug, 1998, p. 42).  He goes on to elaborate upon the work of Brown et al. and Wehmeyer in assering the direct relationship between communicative competence and the capacity for self-determination, stating that the key to developing both communicative competence and thereby self-determination is the existence of

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myriad and rich opportunities for social and intrapersonal interaction.  These opportunities, as we know from the previous literature, must be characterized by the existence of at least one stable, responsive communication partner.  This communication partner must facilitate access to opportunities for exposure to communication, social content across contexts, and critical to assuring the development of self-determination, choice-making.  Mithaug writes, "Recognizing that self-determination is a social condition explains why we should always assess it and develop skills to promote it in these social environments that give the experience meaning" (Mithaug, 1998, p. 43).    

b.   Hand-Under-Hand and Encouraging Engagement        

The hand-under-hand technique is a critical strategy component for developing communicative relationships with and providing routine instruction for students with severe and multiple disabilities including dual sensory impairment. As opposed to the intrusive and forceful use of hand-over-hand instruction, if used consistently as a method of interacting and teaching, hand-under-hand strategies can help to reduce behaviors of avoidance and defensiveness, which most likely have developed as a result of many years of directive instruction and physical manipulation.  Hand-under-hand promotes the meaningful use of hand skills by facilitating observation of modeled actions, and encourages independent participation in the steps of routines while promoting positive relationships between the communication partner and the student (Larrington, G.G., 2009).  This is essential to developing self-determination and reducing learned helplessness and avoidance of interaction.  In encouraging engagement, hand-under-hand technique must be utlilized by all communication partners during functional skills instruction, in conjunction with modeling visually. 

In supporting the student's active use of communication skills, her level of independence in participating in daily routines, and her development of concepts, communication partners must not complete routines for her before she has the chance to initiate communication.  Many individuals with dual sensory impairment and significant cognitive disability not been given ample opportunity to engage in meaningful communication due to the overgeneralization of caregiver support received in various contexts and domains of life.  This is a key contribution to the development of learned helplessness, which can cause low self-efficacy, maladaptive behaviors, and further delay in communicative development (Marks, 1998).            

Engagement in activities is dependent on a variety of factors, including the classroom environment, classroom routines, and teacher behavior; engagement can be enhanced by considering areas of improvement with regard to the individual child’s needs (Engleman et al., 1998).  Suzanne Becker, a TVI and classroom teacher at the Texas School for the Blind, has provided a useful outline of what a plan might look like for developing a classroom for students who are not actively engaging with objects or people in their current environments.  Her basic idea revolves around building structured learning centers in the classroom which “derive from natural occurring themes in the student’s lives (Becker, 2009, p. 20).  Centers are created to organize preferences of students according to distinct activities, including, for example, a calendar center, hygiene center, cooking center, clothing center, sensory center(s), vocational center, gross motor center, and even a throwing center.  This is an example of a classroom

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organized into “Activity Centers,” a common practice in following the pedagogy of Active Learning (Gaetano, Williams, & Volk, 1998).  Becker discusses her strategy of allowing the students to independently engage and initiate interactions within these structured learning centers, while she makes observations which will be used as a basis for continuing to develop these classroom spaces to meet the preferences and developmental needs of each student.  Becker’s suggestions follow the practical approach of Lilli Nielsen in promoting active learning for students with severe disabilities including dual sensory impairment and utilizing functional assessment for developing environments (Becker, 2009).   

The student with dual sensory impairments requires structured opportunities for social interaction in addition to the foci mentioned above for encouraging engagement within activities.  In facilitating social engagement with peers, which is critical to the development of self-concept and concepts of others, as well as to widening the circle of support and network of interactive communication partners, classroom and school staff (and other members of the collaborative team) must work to provide these setting-based opportunities.  Goetz and O'Farrell have cited Breen and Lovinger in identifying the need for "...continuous facilitation of social interactions between and among classmates through a range of planned and spontaneous activities and strategies" (Goetz & O'Farrell, 1999, p. 706).

 c. Preferred Activities, Joint Attention, Co-active Movement; Facilitating and Supporting Concept Development and Achievement of Cognitive Milestones:            

The achievement of developmental milestones in communication leading toward the development of symbolic language must be supported through general practices of interaction, and specific strategies of intervention and instruction.  Concept development in children with severe disabilities including dual sensory impairment cannot be taught simply through “discrete lessons,” but must be developed during meaningful experiences.  By encouraging participation in the entire process of meaningful and preferred routines, communication partners can enhance the environment for concept development (Miles & McLetchie, 2004, pp. 4-6).  Preferences must be assessed and used for motivating the student to participate in activities which promote development.  Preferences can often be found within what are generally described as “self-stimulatory behaviors”.  It is the responsibility of communication partners to develop activities around these preferences which encourage communication and therefore support developmental milestones (Moss & Blaha, 1993).  It is of utmost importance to support the student’s development by focusing instruction in communication around preferred activities during which she has expressed the most motivation to express communicative intent. The communicative partner can encourage communication by pausing during routines that require assistance, and engaging responsively in a turn-taking routine that is preference-based (Miles & Riggio, 1999).  

In developing the skills toward achieving important developmental milestones of communication and symbolic language, students with dual sensory impairments must be encouraged to participate in shared forms of communication that encourage the establishment of joint attention and imitation.   By developing individualized strategies and materials encouraging students to engage in joint attention in preferred activities, communication partners can work with the student in expanding participation in shared forms of communication across daily routines and

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contexts, and extending joint attention to objects.  Students develop concepts and have opportunities to acquire and express functional language by using preferred objects within structured learning centers and repeated activities, with the close facilitation of a responsive communication partner.  By providing materials for organized matching and sorting tasks and facilitating engagement through shared experience with the student during these preference-based activities, she will develop important discrimination skills which are essential to categorization in early language acquisition.  These interactions must be combined with relevant language in appropriate forms.  The physical proximity of communication partners is, of course, key to the opportunity for developing joint attention skills, in correlation to the ability for partners to recognize attempts at communication and to respond (Bruce, 2005).              

Concept development is facilitated through repeated experience in predictable and consistent environments and routines (Miles & McLetchie, 2004).  These are the structured contexts in which strategies are developed and implemented to address communication goals.  Coactive movement is an important teaching strategy that promotes participation and development, and supports the development of imitation skills which are also critical to active learning.  In conjunction with establishing resonance through responsive interactions using resonance phenomenon strategies, the communication partner engages the student in shared experiences, which will then be extended to functional routines.  Generalization is the essential skill for which we must provide repeated, consistent and predictable exposure to activities (MacFarland, 1995).  By simply sitting with the student and participating in her own established, internalized routines, often apparently self-stimulatory, the communication partner will begin to “lay the foundation for turn-taking interactions involving communicative starting and stopping cues” (MacFarland, 1995, p. 223).  Allowing the student to initiate interaction by stopping and allowing appropriate response time will promote her establishment of joint attention.  Communication partners can engage student participation by imitating her behaviors and establishing resonance.  Changing the routine or presenting a form of “sabotage” inviting protest will allow for the student to practice problem-solving skills, essential to developing cognitive milestones including higher forms of cause-effect/means-end (Bruce, 2005). Dr. van Dijk’s strategies for coactive movement form a useful foundation for understanding the development of responsive and structured communicative interactions, with the goal of learning about the world and promoting independence through increasing meaningful participation in a variety of functional routines (MacFarland, 1995).  This begins with building resonance and coactive movement through individualized routines.           

d.      Choosing Forms of Communication:            

“Learning the meaning of symbols is not enough to ensure that the child will share quality interactions.  It is the child’s rich history of interactions at the pre-symbolic level that prepares the child to most fully use the symbols in interaction with others, to express thoughts, and to gain access to the thoughts of others” (Bruce, 2005, p. 234).  In addressing the forms of communication which will be useful for the student's development toward more meaningful interactions with others, and more efficient involvement in the expression and reception of the four communicative functions (refuse, obtain, social interaction, information-seeking), we must assert the method over the medium.  As Bruce has suggested above, the most important factor in

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facilitating communicative development is the provision of a rich environment of language and meaningful experience.  This environment should be structured as well as open to the spontaneity of daily routines, and forms of communication should be selected based on individual sensory modes and personal preferences.

Engleman, Griffin, and Wheeler have suggested that the use of multiple modes of communication will allow the child who is deaf-blind “to use their own modality strengths during specific interaction situations, as needed,” encouraging the child to select appropriate forms for herself and to generalize skills across environments (Engleman et. al, 1998, p. 790).  Recognizing and interpreting the child’s expressive communication in intentional behaviors will be important to developing communication goals.  In addition to informally implemented modes of communication which are not specifically part of this plan, the modes selected for direct instruction of language acquisition and facilitation of expressive communication will be: object cues (used in an anticipation calendar system), conventional gestures, sign language (ASL) accommodated to meet the student’s individual visual needs, and speech in connection with auditory training as deemed appropriate.  All forms of communication should be presented with the appropriate amount of “wait time” as determined by observation in a variety of contexts (MacFarland, 1995).              

The use of an anticipation calendar is appropriate for reinforcing language within important daily routines in the school environment.  As Antonjah does not at this point demonstrate clear recognition of gestural or other cues for anticipating activities, and does not have an organized form of expressive communication for requesting and rejecting, it is appropriate for her to use an anticipation calendar as opposed to a daily calendar.  She does show understanding of and engagement with the people or objects, and even the time of day associated with specific activities (at around 2 P.M. every day she gets up and goes to her locker, and sometimes picks up her shoes and attempts to give them to a communication partner).  The anticipation calendar will be a useful tool for enhancing her receptive and expressive communication and developing abstract language.  The anticipation calendar will consist of a time piece that represents the past, and a time piece that represents the future (Blaha & Moss, 1997; Macfarland, 1995).    

Object cues will at this point be most appropriate for using in conjunction with the anticipation calendar.  Object cues should be pieces or representational parts of real objects that are used to represent them as reminders for activities that have either been completed or will be presented in the near future (Engleman et. al, 1998.  An example object cue developed specifically for Antonjah is a small piece (about 2” x 2”) of her preferred Pediasure drink container, cut out and glued to a piece of cardboard and attached to a black velvet display board with Velcro for the purpose of introducing choices or initiating the activity of mealtime.  The object cues should be relatively concrete representations of the object, activity or person, with the goal of transitioning into more abstract forms of communication, including tangible cues or picture symbols.              

The use of conventional gestures is an important step in the development of symbolic language.  A student with dual sensory impairments who is currently communicating at an unconventional level can gain access to conventional communication through communication partners consistently and repeatedly modeling natural gestures and body signs, which can be

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visually accessed by repeated observation and experience, matching signals and gestures with activities and objects.  This is just one part of the extensive plan to label the environment with language in various meaningful forms (Engleman et. al, 1998).  Susan Bruce describes the importance of consistently and predictably labeling the child’s world in developing language skills from word acquisition to the construction of proto-categories and the movement toward generalization of concepts.  For example, by consistently signing the word for “food” whenever the child is engaging in mealtime activities, across food experiences, the child will begin to develop the category of “food,” while also beginning to learn the words for specific foods (Bruce, 2005).                       

It is appropriate for a student with low vision and additional multiple disabilities to observe communication partners use of Sign language (ASL) because she should have exposure to more complex forms of communication in order to develop awareness of their function.  Sign language should be used throughout the day to connect words to their referents and to allow the student the opportunity to observe the uses of functional communication.  Engleman, Griffin, and Wheeler remind us that repetition and wait time are important considerations, and that approximated signs should be encouraged in developing expressive communication (Engleman et. al, 1998).  While combining sign language (ASL) with other, more concrete forms of communication, it is important to use appropriate accommodations for low vision according to the specific findings of the student’s Functional Vision Assessment.  Considerations for development of accommodations for sign language partners include distance, background lighting/illumination, pace/speed of signing (which should be slower in supporting cognitive and developmental impairments associated with delays in communication), contrast of backdrop, and signing space (smaller area for communicating with individuals with reduced peripheral vision) (Morrow, 2009). 

e. Developing Functional Vision Use            

As mentioned earlier, it is imperative that communication partners adapt environments and their own modes of communication to encourage the student with dual sensory impairments to use her residual vision to participate in activities and to receive information related to developing communication skills and acquiring language.  Special accommodations and adaptations can be made to increase receptive communication within routines (Engleman et. al, 1998, p.789). 

As Downing and Bailey state in their essay on developing functional vision use for students with multiple disabilities, instruction must be developed to facilitate the student to learn how to use her vision functionally.  Functional vision use can be taught in functional routine activities, and is preferably taught by multiple communication partners.  First identifying important routines, then determining the vision required to participate in these skill-related activities, communication partners will apply knowledge gained from the functional vision assessment in order to adapt materials and instruction appropriately.  Task and discrepancy analysis can be useful tools for determining the need for intervention (Downing & Bailey, 1990).   

The primary visual skills necessary to consider in developing functional vision use are localizing, tracking, shifting gaze, scanning, and reaching.  Of course, soliciting engagement by providing

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motivation is an essential aspect of a functional vision use plan, and student preferences must be the basis for determining what is realistic in compliment to what is functional for development of instruction (Downing & Bailey, 1990).      

d.   Encouraging Meaningful Use of Hand Skills            

Antonjah freely moves about her environment and uses her vision to locate preferred objects, people, and activities.  This is an important strength which, if facilitated with structure and purpose, will assist in her cognitive development and her development of communication skills.  Movement is the key to exploration, which is critical to cognitive development and interactions that promote understanding of and participation with the world and others (Miles & Riggio, 1999).  However, Antonjah’s current use of her hands does not promote tactile exploration, and often prevents her from participating in meaningful interactions.  The importance of developing functional and meaningful use of the hands for individuals with dual sensory impairment cannot be overstated.  Barbara Miles writes, “...the hands of person who is deafblind can become, in addition to their usual role as tools, useful and intelligent sense organs, allowing people without sight and hearing to have access to objects, people, and language that would otherwise be inaccessible (Miles, 2003, p.1).  Although Antonjah has residual vision which assists her in exploring her environment, she must learn to use her hands in order to receive and express information.  Antonjah’s communicative development will rely on the “education of her hands,” which, as Miles points out, provides the means of exploring in order to acquire language, develop self-concepts and concepts of others, develop concepts of the world, and to achieve cognitive developmental milestones (Miles, 2003). 

Hand-under-hand instruction, as described above, will be the first necessary strategy for Antonjah’s development of functional hand skills and facilitating her progression from passive to active engagement (Larrington, 2009).  Using the coactive movement strategies also described earlier, and developing joint attention by engaging in shared experiences involving meaningful and interactive hand use will encourage Antonjah to extend her use of hands beyond her current self-stimulatory patterns.  The communication partners’ hands must be accessible by proximity in order to promote these interactions.  By modeling hand skills and repeating these examples many, many times, while providing tactile access to the hands and materials being used in routines, before using hand-under-hand instruction, Antonjah will begin to form understanding of hand use by observing and imitating – first through guided practice, then independently (Miles, 2003).  Using functional activities that develop hand sensitivity will also be an important method of encouraging meaningful use of hands.  Larrington in her “Fact Sheet” describes one such activity, in which skills associated with hand washing are developed through modeling the application of hand lotion.  This is a potentially useful technique for Antonjah if she will tolerate it, because it provides sensory and spatial awareness while presenting an opportunity for shared experience and engagement with a communication partner (Larrington, 2009).             

e.    Play            

Interactive play encourages communicative initiation, while providing opportunities for shared exploration of objects and participation in shared routines.  Play serves the primary purpose of

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increasing levels of engagement, which is a focal point for this plan in developing communication skills.  The responsive communication partner recognizes the need for playful interactions with the child, and develops play routines and activities that encourage social interaction.  The communication partner should use modeling strategies in combination with those co-active movement strategies described above, while labeling and providing access to language in various forms.  Miles and Riggio identify various contexts and content of play which may be useful for guiding the development of strategies and activities: play with toys, outdoor play, play with sounds (according to the individual student’s use of residual hearing), play with creative (“messy”) and tactual materials, and play with peers.  Extending the applications of playtime communication across routines and environments, and with a variety of responsive communication partners, the child has multiple and varied opportunities for communication and generalization.  Socially interactive play with peers is important, and children with multiple disabilities including dual sensory impairment, like their typically developing peers, require access to other children.  It is essential to promote play with peers and thereby encourage the development of positive self-concepts and concepts of others (Miles & Riggio, 1999).  

3. Assessment of Supports and Plan for Interventions 

“The success of any intervention depends on identifying appropriate goals.” (Light, 1997, p. 66)            

In order to create an effective communication plan and develop interventions to implement it, we must first assess the supports necessary to address the goals we have identified, defining the unique conditions of the individusl student’s communication environment (contexts) and possible barriers to a successful plan.  I have already emphasized the need for assessing the responsiveness of communication partners and of determining the form, function, content and context of communication goals.  An assessment must also be conducted to determine the current hand use of communication partners, the classroom and educational materials with regard to levels of accommodation and adaptation, and the support of administration and related services in developing meaningful and realistic intervention systems (Bruce, 2010).            

Janssen, Riksen-Walraven, and van Dijk have developed a clear and thoughtful, highly useful system for determining intervention needs.  In their study, eight core categories of behavior (initiatives, confirmation, answers, turns, attention, regulation of intensity of the interaction, affective involvement, and independent acting) were assessed in observing the interactions between children and their communication partners (educators).  Importantly, this study emphasized the behaviors of the educators and focused on assessing their responsiveness toward the child.  The findings of the study indicate that developing a limited number of aims of intervention is more effective in creating realistic and approachable goals.  By conducting thorough assessment of the student and the educator or communication partner’s communication in various routines, it will be possible to select the most needed areas for intervention.  The structure of the intervention is aimed at changing the behaviors of educators in order to better facilitate meaningful communication with the child (Janssen, Riksen-Walraven, & van Dijk, 2003).              

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In their follow-up study, Janssen, Riksen-Walraven, van Dijk, and Ruijssenaars emphasized the structural considerations for creating effective interventions.  The first step, “Determination of the Question,” is described as involving a more in-depth assessment of the functions and content of communication desired by the members of the educational team, including the parents or guardians of the child.  In the second step, “Clarification of the Question,” interaction coaches consult the parents to actually determine the relevant routines for which communication goals are being established, and the specific coaching needs for approaching goals.  In the final step, “Interaction Analysis,” the actual assessment of communication is conducted, and interaction coaches utilize video and observational analysis to determine strengths and weaknesses in interactions.  Analysis is with regard to function, form, content, and context (Janssen et. al, 2010).  

Interventions must be developed, as this wonderful research had shown, to improve communication with the family/caregivers, as well as between the multidisciplinary team.  In the above studies, the implementation of an interaction coach, and the expansion of support is clearly identified as a critical component to improving the facilitation of communicative development for children with dual sensory impairments.  In the absence of this possibility, we must do what we can within our limitations to encourage communication partners to expand their own individual roles and recognize the utmost importance of responsiveness.  Of course, teachers and other educators are often distracted by other responsibilities, either bureaucratic-administrative, or related to other students in the classroom.  It is useful to note, in prioritizing goals and strategic approaches for intervention, that the most significant effects for changes in the role of the communication partner were found in the initial study mentioned above by reducing the number of initiatives and improving regulation of the intensity of interactions with students (Janssen et. al, 2003).  These must be taken as direct suggestions for focusing our own often limited resources for intervention, in addition with a basic philosophy that training and constant development, and the demand for increased support, are necessary for fostering progress within the educational team in general.

 4. Transition Planning:

Legally and practically speaking, it is essential that any plan for skills development created for a student with severe and multiple disabilities including dual sensory impairment (legally speaking in New York, beginning at age 15) involve transition planning.  Effective models for transition planning are both person-centered and engage the entire educational trans-disciplinary team.  The Planning and Implementation Guide for Transition Services developed by the NY State Education Department has asserted, “Effective planning for transition services necessitates involving the student and family to the greatest degree possible in determining what the IEP should address.  Involvement is critical for developing transition services that truly meet the needs of the student” (NYSED, 1993, 34 CFR 300.345).  Any effective plan will look to the various environmental contexts in which the child exists, evaluating the child’s entire “Circle of Friends” and creating a Person-Centered Plan that utilizes input from all relevant parties.  Of course, the parent or guardian will provide the most useful input for such a plan and information packet, and the goals addressed by the parent or guardian for the student’s future must be addressed and included to the extent possible in creating this plan.

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 Using the models established by Person-Centered Planning and Personal Futures Planning, the team will create a detailed individualized plan which focuses on existing strengths and strategies for further development of the communication and other skills needed to achieve hopes and dreams set out by each member of the team.  This should be an active plan which can be added to and altered to reflect progress and personal development of the child as she approaches the transition from school age to the greater community in adulthood.  Many formats and structural approaches have been developed to create such a plan, yet all should provide similar information with a common approach, focusing on the special characteristics and strengths that make a child individual and unique.  The plan should address the child’s history and personal characteristics, giving voice to the child in expressing and sharing her past experiences and personality accomplishments, choices and rights, preferences and desires, what works/what doesn’t work in terms of environmental considerations and strategies for fostering interaction, skills competence, goals and spheres of influence and participation in the community.  Communication goals should be a focal point of a transition plan for students with dual sensory impairments, as communication and social interaction is the key to developing self-determination and active participation in any community.  A successful plan requires the input of all members, the development of concrete activity-based goals to address dreams and hopes, and the diligent implementation of selected strategies.  Review and reworking of the plan over time, again with maximum group input, is essential to its success in providing an effective transition (Mount & Zwernik, 1989). 

Transition planning should include an assessment of vocational skills in terms of experience/exposure and communication within pre-vocational routines.  Morgan, Boxler and McNamara have identified a strong connection between pre-vocational skills training/experience and the development of self-determination in young adults with deafblindness.  The opportunity to achieve a sense of responsibility and accomplishment of tasks is an essential part of self-determination, and pre-vocational experience should be a strong consideration in creating a plan for transition.  By assessing the management needs and participation levels of the student, as well as the goals and attitudes of family toward future planning with respect to vocation and placement, the team can begin to develop goals that fit the student individually (Morgan, Bixler, & McNamara, 2002).

 

 

 

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 Works Cited: 

Becker, S. (2009). Developing my classroom for secondary-aged students who aren’t actively engaging with people or objects. TX  SenseAbilities. 3(1), 19-23 

 Blaha, R., & Moss, K. (1997). Let me check my calendar. See/Hear. Retrieved October 20th,

2010 from http://www.tsbvi.edu  Bruce, S. (2010). Holistic communication profiles for children who are deaf-blind. AER Journal.

3(3), 106-114  Bruce, S. (2005). The impact of congenital deafblindness on the struggle to symbolism.

International Journal on Disability, Development and Education. 52 (3), 233-251  Bruce, S. (2003). The importance of shared communication forms. Journal of Visual Impairment

and Blindness, 97(2), 106-109 

Chen, D. (1999). (Ed.) Essential elements in early intervention: Visual impairment and multiple

disabilities. New York, NY: AFB Press

Downing, J., & Bailey, B. (1990). Developing vision use within functional daily activities for students with visual and multiple disabilities. Re:View, 21 (4), 209-218  

  Engleman, M.D., Griffin, H.C., & Wheeler, L. (1998). Deafblindness and communication:

Practical knowledge and strategies. Journal of Visual Impairment and Blindness. 92 (11), 783-798 

  Gaetano, Y.D., Williams, L.R., & Volk, D. (1998). The physical classroom environment.

Kaleidoscope: A multicultural Approach to the Primary School Classroom (pp. 68-89). Prentice Hall, Inc.: Upper Saddle River, NJ.  

 Goetz, L. & O'Farrell, N. (1999). Facilitating social supports for students with deaf-blindness in

general education classrooms. Journal of Visual Impairment & Blindness, 93 (11), 704-715

 Janssen, M., Riksen-Walraven, J.M., & van Dijk, J.P.M. (2003). Contact: Effects of an

intervention program to foster harmonious interactions between deaf-blind children and their educators. Journal of Visual Impairment and Blindness, 97 (4), 215-228 

 Janssen, M., Riksen-Walraven, J.M., van Dijk, J.P.M, & Ruijssenaars, W.A.J.J.M. (2010).

Interaction coaching with mothers of children with congenital deaf-blindness at home: Applying the diagnostic intervention model.  Journal of Visual Impairment and Blindness, 104 (1), 15-29 

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 Larrington, G.G. (2009). Fact sheet: Hand skills and more.  Colorado Services to Children With

Deafblindness. Retrieved October 20th, 2010 from www.cde.state.co.us/cdesped/download/pdf/dbHandSkills.pdf 

 MacFarland, S.Z.C. (1995).  Teaching strategies of the van Dijk curricular approach.  Journal of

Blindness and Visual Impairment, 89(3), 222-228   Marks, S.B. (1998). Understanding and preventing learned helplssness in children who are

congenitally deaf-blind.  Journal of Visual Impairment and Blindness, 92(3), 200-211  

Miles, B., & Riggio, M. (1999). Remarkable Conversations: A guide to developing meaningful communication with children and young adults who are deafblind. Watertown, MA: Perkins School for the Blind.

Miles, B. (2003). Talking the language of the hands to the hands.  DB-Link, rertrieved October 24th, 2010 from http://www.dblink.org 

Miles, B., & McLetchie, B. (2004). Developing concepts with children who are deaf-blind. DB-Link.  Retrieved October 24th, 2010 from http://www.dblink.org 

 Mithaug, D. (1998). Your right, my obligation? The Journal of the Association for Persons with

Severe Handicaps, 23 (1), 41-43 Mount, B., & Zwernik, K. (1989). It’s never too early, it’s never too late: A booklet about

personal futures planning. Metropolitan Council: St. Paul, MN Morgan, S.M. (2009). Accommodations for sign language for individuals with low vision and

reduced visual fields.  Presented Fall, 2009, at Hunter College, CUNY, New York, NY.  

Morgan, S., Bixler, E., & McNamara, J. (2002). Self-determination for children and young adults

who are deaf-blind. NTAC Briefing Paper. NTAC: Monmouth, OR

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3. Present Level of Communication Skills          

 I. The Communication Matrix

Based upon results from the Communication Matrix, an assessment which relies upon extensive observation and the interpretation of motivational contexts of communicative intent, Antonjah highest level of achieved communication on the scales developed by Rowland and Schweigert is Level III: Unconventional, Pre-symbolic Communication.  Most behaviors are motivated by intent to refuse or obtain preferred objects or activities, but reach the level of intentional and unconventional pre-symbolic in her ability to initiate interactions and direct a communication partner’s attention to assisting her in obtaining or using a given object within a familiar routine.  At this point there do not seem to be social motivations for interaction, although this intent is not interpreted certifiably, and the request for attention may not always be solely for the purpose of obtaining.  In addition, behaviors resembling conventional displays of affection have been observed occasionally, although they are also not easily defined as such, due to simultaneous participation in self-stimulatory behaviors and steps within preferred routines. 

            Receptively, Antonjah does not display understanding of auditory information, including speech, although with hearing aids and an FM unit and when in an adapted auditory environment (such as a speech room or other quiet space) she apparently demonstrates brief reception of or interest in sounds by lifting her head or opening her eyes.  Moreover, Antonjah will often remove and discard her hearing aids when in a noisy environment, such as the gym or during a noisy period in the classroom.  She does not demonstrate auditory localization at this point.  Antonjah has receptive understanding of objects in visually recognizing them and applying purposeful usage, and demonstrates familiarity with selected, preferred routines and people.  At this point she does not show receptive language skills in identifying or using concrete object cues or any other more abstract representation. 

              The following description of expressive communication skills serves as an evaluation of the specific results of the Communication Matrix with regard to the motivation/intent of communicative competences, and an elaboration on interpretations, making use of example.  It is organized by motivational intent and level in development of symbolic language, as per the Rowland and Schweigert hierarchical scale.

1.    Refusing:

  Level I: Pre-Intentional behaviors (Expressing Discomfort):    

          Antonjah expresses discomfort on a pre-intentional level of communication primarily by grimacing, crying, vocalizing loudly, and engaging in self-injurious behaviors.  She may respond to minor discomforts with activities or situations by turning away or changing her posture (usually curling up into a ball while sitting on her chair).  This may be seen more as an unconventional display of rejection, but is difficult to interpret.  Antonjah’s more serious displays of discomfort at this level appear to be related to pain, and take the form of a sudden commencement of vocalizing, crying, hitting her head on both sides with her fists, and/or biting

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her wrists, ankles, or objects in her direct surroundings.  She may also at these points go to a person nearby and bite or dig her nails into their hands or arms.  When given a towel or other soft object during these episodes, she will bite the towel instead, but requires close monitoring as she often will throw the towel and return to biting herself or others.

Level II: Intentional Behaviors (Protesting)

Antonjah expresses herself in protesting unwanted routines, objects, or interactions generally by moving away from them, either by physically removing herself from the area, turning her head or body away, or curling up.  These protests typically coincide with self-stimulatory hand movements, the interruption of which she appears to be protesting, and she resumes following these diversions.  In this way, she is “not intentionally communicating,” and the behavior “functions to affect caregiver’s behavior, since caregiver infers intent” (Rowland, 1996).

 Level III: Unconventional Communication (Refuses or Rejects, Intentionally):

  Antonjah’s highest level of communicative behaviors in refusal, take the form of unconventional gestures which have the apparent intent of affecting the behaviors of communication partners.  These refusals or rejections manifest in Antonjah pushing away an object or person that she does not express preference for or desire for.  This is a more complex form of communication which requires a level of joint attention and interaction with a communication partner, and may present a key event for developing instruction to support future progress.  At this point, Antonjah does not display more conventional forms of communication such as using commonly understood (conventional) gestures, although with consistent support and close supervision, and additional gestural prompts (touch cues, directional deference of attention, modeling actions visually, using a flashlight to illuminate an object or area), she has begun in the past several weeks to give unwanted items back to a communication partner or to place them on the table in front of the partner (as of 11/8/2010).

 2.    Obtaining: 

Level I: Pre-Intentional Behaviors (Expressing Comfort):

              Antonjah displays competence at a pre-intentional level of communicative development in expressing comfort by smiling, laughing, and engaging in self-stimulatory behaviors described throughout this report.  These behaviors occur during preferred routines, or when she has obtained something she desires effectively (which may actually reflect a higher level of communication as discussed below), or when a stimulating or preferred object activity or person is introduced (such as a bright light).

 

Level II: Intentional Behaviors (Continuing Action, Obtaining More of Something):

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            Antonjah expresses desire to continue a preferred action or obtain more of something by approaching the object or activity, batting her arms, smiling or laughing, and physically taking the object or desired item.  Taking the object is seen as an intentional behavior because it does not involve joint attention or communicative intent deferred to a person in requesting.  These behaviors can be used to support meaningful and more communicatively complex interactions by providing proximity of communication partners, and sabotage of self-directed routines, as described in the justification of this plan.  For example, Antonjah will get up from her chair and go to the cabinet where her drink/food is kept, and will attempt to open the cabinet and reach for it on the top shelf.  If a communication partner is standing by her at these moments, she may reach out and seek assistance – which is a higher form of communication.

  Level III: Unconventional Communication (Requesting More Action, Requesting New Action, Requesting More Object, Making Choices, Requesting New Object): 

Antonjah’s use of unconventional communication in obtaining is expressed as described above, with scaffolding and proximity offered by competent communication partners.  She will, in these situations and responsive environments, reach toward the desired object without taking it, and guide the hand or arm of the communication partner to the desired item (if she either cannot use the object independently, or cannot reach it).  This occurs during mealtime, and in the gym while she is sitting on the trampoline, when she will pull the hand of a nearby communication partner to request more jumping (the partner will jump on the trampoline, providing kinesthetic stimulation, and will step off the trampoline to solicit her to request more).

  Level IV: Conventional Communication (Requesting):      

            Antonjah’s highest forms of communicative competence are expressed as conventional joint attention and “dual orientation” in giving an item to a person when she needs help with using it.  This, so far, has only been observed during mealtime when she wants more of her drink and needs it poured into her cup (that is, when the drink box is withheld from her and only small amounts are poured into her cup at each time, thereby sabotaging her self-directed routine).  Here, she will give the cup to the communication partner, usually after attempting to drink from the empty cup several times and reaching for the drink box.  It should be noted that Antonjah requires approximately 10 to 30 seconds of waiting time to request more each time. 

At this stage, Antonjah does not use more conventional gestures such as nodding her head, waving or holding her hand out to beckon or obtain, pointing to a desired object, or gazing back and forth between the partner and the object. 

   Antonjah does not currently engage in apparently socially motivated communication.  While she does express interest in other people, and attracts the attention of communication partners, at this point is appears to be wholly for the purpose of obtaining desired objects and preferred routines and activities.  In displaying what might be interpreted as affection, she will sometimes burrow into a communication partner, simultaneously engaging in self-stimulating hand movements and vocalizations (low frequency, guttural sounds).  This is generally following the

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acquisition of a desired item, or following a pleasurable experience such as bouncing on the trampoline or interacting jointly with a bright light.

 II.  Rate of Communication

An informal observation was taken on 12/10/10 over a period of an hour across daily activity routines to make an assessment regarding Antonjah’s rate of attempts at communication with a familiar communication partner.  The observation covered lunch time, clean-up after lunch (taking drink box to the trash and washing the cup in the sink), and leading Antonjah to another room for 1:1 turn-taking activity.  The communication partner (teacher) maintained physical proximity during each routine but did not initiate communication with Antonjah, waiting instead for her to initiate. 

A chart of this observation is attached on the following page.

 A. Description of Activities and Rates of Communication per Activity

In the lunch time routine, the communication partner sat facing Antonjah and within arm’s reach, holding her drink box as she held her cup.  During a period of 18 minutes, Antonjah initiated communication 28 times, following in a routine of passing the cup to the communication partner, he refilling it, and she taking the cup to drink, then passing it back to him to refill.  This shared routine activity had an average of 1.56 attempts per minute. 

 Following this turn-taking activity, the teacher passed Antonjah her clean-up cue and prompted her to stand up with a touch cue to her elbow and a gesture to stand.  She took his hand and walked with him to the sink area, pushing him away in refusal to take hand-under-hand guidance to throw away her drink box or wash the cup.  He stood next to her with his hand on her shoulder and forearm as she played with the water in the sink for about 6 minutes with no attempt at initiating communication.

 Following this, he led her out of the classroom to a quiet room for a 1:1 activity, a newly introduced but by now somewhat familiar turn-taking and joint attention routine involving shaking a tin can with a plastic lid inside which wooden sticks are placed to make a sensory toy.  During the first 9 minutes of sitting in the room with the familiar activity object introduced by the communication partner but no activity initiated by him, Antonjah only initiated interaction on an average of .67 attempts per minute.

 Once Antonjah initiated the turn-taking routine by picking up the toy and handing it to the teacher (first, shaking the tin can together, then Antonjah having her turn to shake it, then her passing it back to him to shake it together again, etc.), the average per minute over a period of 9 minutes was 2.67 attempts per minute.  A sabotage of the routine once it became fluid (hiding the sensory toy under the table) solicited a response of 7 attempts at initiating communication over a one minute period.

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 Finally, once Antonjah began to lose interest in the routine, the communication partner experimented by moving one chair further away from Antonjah to gain an informal evaluation of how her rate of communication is affected by lack of direct proximity.  Over the next 13 minutes, Antonjah averaged .15 attempts per minute, only once walking over to the teacher and pulling on his arm two times.

B. Evaluation Summary

 It can be informally surmised from these observations that Antonjah’s rate of communication is affected by: proximity of communication partner, preference-level of activity, quality of joint attention and turn taking, responsiveness of communication partner (when she tugged the communication partner’s arm in the final example, and he did not respond, she did not attempt to communicate again for the next 7 minutes), and familiarity of routine.

 The average rates of communication attempts per minute shown above can be seen as a general suggestion of the frequency by which Antonjah initiates communication with partners over a variety of contexts.  Importantly, it verifies that Antonjah requires proximity of communication partners, and preference-based (sensory) activity development in shared routines in order to increase her rates and levels of communication.  Furthermore, the sabotage of routine is seen here to have a direct affect on increasing the rate of communication and providing opportunities for interaction and problem solving.

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4. Communication Goals:

Format:

1.Areas of Skill AcquisitionA. Long Term Objectives (LTO); Short Term Objectives (STOs)

Note: Increased partial participation, choice-making, concept development, functional vision and hand-under-hand skills are encouraged and implicit throughout the following goals, and are not addressed as separate goal areas.  These goals specifically target communication skills. 

Note: These goals address current intervention needs as determined by observation and informal assessment, which suggest that a preference basis is necessary for facilitating interaction and initiation.  Long-term goals attempt to include non-preferred activities and interactions within all daily routines, regardless of preference basis.  It will therefore be necessary to re-evaluate these goals and include more non-preferred routines as goals are achieved and rate of communication increases. 

Note: The goals which are directed at mealtime will for the time being use her current limited dietary preferences as noted in Student Description - drink/drinkbox refers to her Pediasure drink/food.  At this point intervention to address her gustatory aversions is being assessed and planned, and may include mixing pureed foods etc. into her current preferred drink.  Specific Short-Term Objectives may be changed to address changes in diet.

Note: Goals for communication skills addressed here should also be extended to other daily activities such as toileting; this will be addressed with appropriate communication partners for future development and practice for generalization across routines.

1. Initiate/Respond to Responsive Communication Partners

The following goals may include implicit joint attention skills; additional, more specifically focused skills in joint attention are included toward the end of this section.

A. LTO:

During a preferred activity and given sufficient wait time (10-30 seconds) between gradually fading prompts and physical proximity (within arms reach) of communication partner, Antonjah will initiate interaction with communication partner in order to request (1) an object/item (2) an activity/place (3) social engagement/play.

STOs:

Unconventional gestures:

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Prior to mealtime, given adequate physical proximity of a communication partner (in visual field), Antonjah will locate the preferred partner and take him/her by the hand and lead him/her to the cabinet where her drink/cup are kept 4/5 times in a given week.

Prior to mealtime, while standing with communication partner at cabinet with drink on top shelf out of reach, and given sufficient wait time (10-30 seconds), Antonjah will take communication partner by hand or tug on his/her arm or shirt to request her drink 4/5 times in a given week.

During mealtime, while sitting with communication partner at arm’s length, and given no prompt, Antonjah will request for her partner to open her drink container by giving it to him/her 4/5 times in a given week.

During mealtime, while sitting with communication partner at arm’s length, and given no prompt, Antonjah will request more drink by either taking her partner’s hand and directing it to the drink, or by giving the drink container to him/her to be poured into her cup 4/5 times in a given week.

During Gym class while sitting on the trampoline and given physical proximity of communication partner (arm’s length), Antonjah will request for the partner to jump on the side of the trampoline by reaching out and taking her/his hand or by gesturing the action of jumping with her hand or feet 4/5 times in a given week.

During Hearing Ed. therapy, given physical proximity of communication partner and presented visually and with a choice of two activities (objects/games/musical toys etc.) held out at arms length by the partner/Hearing Ed. instructor, Antonjah will request a preferred activity by reaching out and taking her choice when given a gestural prompt to do so 3 times during each of 3 30-minute sessions during a given week.  

In a functional vision activity, given physical proximity to communication partner and a choice of two visually stimulating tools (flashlight, light-up ball, light table with two objects, etc.) held apart by the partner, Antonjah will request a preferred item by reaching for it 3 times during a session 4/5 days of a given week.

Given physical proximity to a preferred communication partner and access to sensory objects and engaging environments during class activities or 1:1 work, Antonjah will request social engagement/play by taking his/her hand and directing it towards herself or an object to initiate playful activity once a day for a week.

In a communication group with her peers, given the choice of 2 objects for discussion by a classmate from the group’s selected discussion box, Antonjah will take the preferred item from her peer 3 times during a session 4/5 times in a given week.

Conventional Gestures:

Prior to mealtime, given adequate physical proximity of a communication partner (in visual

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field) and fading modeling prompts over time while at the cabinet containing her drink/cup, Antonjah will request her drink/cup by nodding her head, waving or holding her hand out to beckon or obtain, pointing to the desired object, or gazing back and forth between the partner and the object 4/5 times in a given week.  

During mealtime while sitting with a communication partner, and given fading modeling prompts over time and only a small amount of drink poured into her cup each time, Antonjah will request more of her drink by nodding her head, waving or holding her hand out to beckon or obtain, pointing to the drink/cup, or gazing back and forth between the partner and the drink/cup 4/5 times in a given week.

During Gym class while sitting on the trampoline and given physical proximity of communication partner (arm’s length), Antonjah will request for the partner to jump on the side of the trampoline by waving or holding her hand out to beckon or obtain or gazing back and forth between the partner and the trampoline 4/5 times in a given week.

During Hearing Ed. therapy, given physical proximity of communication partner and presented visually with a choice of two activities (objects/games/musical toys etc.) held out at further than arms length by the partner/Hearing Ed. instructor and visually accommodated as necessary, Antonjah will request a preferred activity by waving or holding her hand out to beckon or obtain, pointing to the desired item, or gazing back and forth between the partner and the item when given a gestural prompt to do so 3 times during each of 3 30-minute sessions during a given week.  

In a functional vision activity, given physical proximity to communication partner and a choice of two visually stimulating tools (flashlight, light-up ball, light table with two objects, etc.) held apart by the partner at further than arms length and visually accommodated as necessary, Antonjah will request a preferred item by pointing to the desired object, or gazing back and forth between the partner and the object 3 times during a session 4/5 days of a given week.

Given physical proximity to a preferred communication partner and access to sensory objects and engaging environments during class activities or 1:1 work, Antonjah will request social engagement/play by waving or holding her hand out to beckon or obtain, or pointing to a “play” activity or item 4/5 times in a given week.

In a communication group with her peers, given the choice of 2 objects for discussion by a classmate from the group’s selected discussion box held at further than arm’s length away and with necessary visual accommodations, Antonjah will point to the preferred item, wave or hold her hands out to beckon toward the preferred item, or gaze back and forth between her peer/communication partner and the preferred item 3 times during a session 4/5 times in a given week.

Object cues/tangible cues:

Prior to mealtime, given physical proximity of communication partner and her black felt board

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with object cues (drink box and no more than 3 others at a time, spaced equally apart with at least 3 inches between each cue), Antonjah will request to eat by touching or picking up the cue for her drink box 4/5 times in a given week.  

During mealtime, given physical proximity of communication partners and her black felt board with object cues, and without physical access to her drink box, Antonjah will request more drink to be poured into her cup by touching or picking up the cue for her drink box 4/5 times in a given week.

Prior to Gym class, given proximity-access to her black felt board with object cues, Antonjah will  request to go to the Gym by touching or picking up her Gym cue 4/5 times in a given week.

Upon entering Gym class and sitting on the padded bench, given a black felt board with object cues representing up to 4 different preferred activities and in direct physical proximity with the APE instructor and given a gestural prompt or sign to choose, Antonjah will select a preferred activity by touching or picking up the cue for the activity she wishes to do 4/5 times in a given week.

During Hearing Ed. therapy, given physical proximity of communication partner and presented with a black felt board with object/tangible cues representing three different activities (objects/games/musical toys etc.), Antonjah will request a preferred activity by touching or picking up her preferred choice when given a gestural prompt to do so 3 times during each of 3 30-minute sessions during a given week.  

In a functional vision activity, given physical proximity to communication partner and a black felt board with object cues representing a choice of three visually stimulating tools (flashlight, light-up ball, light table with two objects, etc.), Antonjah will request a preferred item by touching or picking up the cue for her preferred activity given a gestural prompt to do so 3 times during a session 4/5 days of a given week.

In a communication group with peers, presented by a peer with (concrete) partial object cues for preferred discussion items on a black felt board, Antonjah will request a preferred item for “discussion” by touching or picking up the preferred cue 4/5 times in a given week’s sessions.

B. LTO:

Given sufficient wait time (10-30 seconds) between gradually fading prompts and physical proximity (within arms reach) of communication partner, Antonjah will initiate interaction with communication partner in order to refuse (1) an object/item (2) an activity/place (3) social engagement/play.

STOs:

Conventional Gestures of Refusal:

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Upon arrival to the classroom in the morning and during a morning arrival routine when prompted gesturally and with accompanying ASL to participate in a part of the routine that she has skipped, Antonjah will express refusal to do so by giving the item (jacket, backpack, etc.) to the communication partner, or by shaking her head no (as learned by modeling/imitation) 4/5 times during a given week.

During an academic content area class period with her classmates (English Language Arts, Science, Social Studies, Math, Cooking) and presented with an unwanted item or activity by a classmate or instructor, Antonjah will express refusal to participate or rejection of said item by giving it back to the peer/partner or shaking her head no 4/5 times during a given week.  

During mealtime and given physical proximity to a communication partner, when presented with an unwanted food item or when finished with her meal, Antonjah will give the item/cup back to the partner or shake her head no with faded gestural prompting 4/5 times in a given week.

During Gym class when presented with the object cue to an unwanted activity by the APE instructor, Antonjah will express refusal to participate or rejection of said activity by giving the cue back or shaking her head no 4/5 times during a given week.

During Hearing Ed. when presented with an unwanted activity or item, Antonjah will give the item back to the Hearing Ed. instructor at least once per each of 3 sessions in a given week.

In a functional vision activity while in physical proximity with a communication partner, when presented with an unwanted activity/item illuminated by a flashlight or on a light table, Antonjah will give the item back to the communication partner 4/5 times during a given week.

During dismissal routine when prompted gesturally and with accompanying ASL to participate in a part of the routine that she has skipped, Antonjah will express refusal to do so by giving the item (jacket, backpack, etc.) to the communication partner, or by shaking her head no (as learned by modeling/imitation) 4/5 times during a given week.

In a communication group with her peers, given an unwanted object for discussion by a classmate from the group’s selected discussion box, Antonjah will give the item back to her peer or pass it to the next peer 3 times during a session 4/5 times in a given week.

2. Co-active Movement and Resonance-Building:

LTO:

In a resonance-building activity with a preferred communication partner, and given sufficient wait time (10-30 seconds) between prompts, Antonjah will attend to the partner’s imitation of her behaviors by pausing mid-perseveration and looking at her partner.

STO:

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Throughout the day during routines (morning arrival, academic content area activities, communication groups, mealtime, Gym, Hearing Ed, dismissal) while in close proximity with a communication partner and while engaging in a perseverating behavior, given an imitating behavior by the communication partner, Antonjah will pause mid-perseveration and look at her partner 4/5 times per day during a 5-day week.

B. LTO:

In a preferred activity and given sufficient wait time (10-30 seconds) between prompts, Antonjah will participate by taking turns in a functional routine with a communication partner.

STOs:

During morning arrival routines in close physical proximity of a communication partner and given sufficient wait time between gestural/modeling prompts (10 to 30 seconds), Antonjah will participate in turn taking with the partner to complete the steps of the routine (locate locker, open door, take off backpack, put backpack in locker, take off coat, put coat in locker, close locker door, etc.) with faded gestural/modeling prompts in all alternating steps of the routine 4/5 times during a given week.

During mealtime, given physical proximity of communication partner, sufficient wait time (10-30 seconds) between gestural and modeling prompts and presented with her cup, drink, and felt board with object cues, Antonjah will follow initiation/request for more by taking turns with the communication partner to pour the drink into the cup independent of physical assistance 4/5 times during a given week.

Following mealtime, given physical proximity of communication partner and when presented with/directed visually by pointing to the object cue for clean up on her felt board, Antonjah will take turns in the clean up routine by taking either her cup or drink, with the communication partner taking the other, to the trash can/sink 4/5 times in a given week.

During Gym class while engaging in an activity involving two or more peers (i.e. throwing a ball) and given gestural and modeling prompts by a communication partner, Antonjah will take turns to participate in the activity by waiting for her turn and following prompts to engage in said activity 4/5 times in a given activity throughout a given week of Gym class.

During Hearing Ed. therapy, given a preferred musical toy or such activity and given modeling prompts to use it, Antonjah will take turns with the Hearing Ed. instructor or communication partner to use the instrument or activity-item 4/5 times per session for 3 sessions of a given week.

During a functional vision activity with a flashlight or lightbox and given modeling prompts to complete a task (i.e. placing items in a box, or sorting to one side or the other), Antonjah will

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take turns with a communication partner to do so 4/5 times per session each day for a week. C. LTO:

During a turn-taking routine with a preferred communication partner, and given sufficient wait time (10-30 seconds) and physical proximity (within arm’s reach), Antonjah will respond to a “sabotage of routine” by protesting, laughing, or requesting a solution from the partner.

STOs:

During morning arrival routines in close physical proximity of a communication partner and presented with a sabotage or disruption of the understood routine, Antonjah will respond by protesting, laughing, problem solving to complete the routine step independently, or requesting a solution from the partner 4/5 times during a given week.

During mealtime, given physical proximity of communication partner and a sabotage of or disruption of the understood routine, Antonjah will Antonjah will respond by protesting, laughing, or requesting a solution from the partner 4/5 days of a given week.

Following mealtime during clean-up routine, given physical proximity of communication partner and presented with a sabotage or disruption of the understood routine, Antonjah will respond by protesting, laughing, problem solving to complete the routine step independently, or requesting a solution from the partner 4/5 times during a given week.

During Gym class while engaging in a preferred activity (i.e. walking on the treadmill or sitting on the trampoline while partner bounces it), and presented with a disruption of routine, Antonjah will respond by protesting, laughing, or requesting a solution from the partner 3 times during a session 4/5 days of a given week.

During Hearing Ed. therapy while engaging in a preferred turn-taking activity routine (i.e. playing with a resounding mirror, musical toy, etc.) and presented with a sabotage or disruption of the understood routine, Antonjah will respond by protesting, laughing, problem solving to complete the routine step independently, or requesting a solution from the Hearing Ed. instructor or communication partner 3 times per session during the 3 sessions of a given week. 

3. Joint Attention:

LTO:    Given proximity of communication partners and while engaged in daily routines involving a variety of functional materials and sensory items, Antonjah will allow a communication partner to direct her hands with hand-under-hand guidance to touch a given item or engage in a given activity without pulling away or engaging in perseverating behaviors.

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STOs:

During morning arrival routine while engaged in turn-taking routines with a communication partner, Antonjah will accept the hand-under-hand guidance of the partner to direct her to explore her tactile/visual name cue on her locker 4/5 times during a given week.

During an academic content area class period with her classmates (English Language Arts, Science, Social Studies, Math, Cooking) and when presented with an item or object relating to that activity, Antonjah will accept hand-under-hand guidance to explore the activity materials 4/5 times a day for a week.

During communication groups while participating in a discussion box activity with her peers, Antonjah will accept hand-under-hand guidance to explore a new or unwanted item 3 times per session 4/5 days during a given week.

Following mealtime, presented with her felt board with object cues and given sufficient wait time following a gestural/modeling prompt (10-30 seconds), Antonjah will accept hand-under-hand guidance to explore the cue for clean-up 4/5 times during a given week.

During Gym class while engaging in a preferred routine in close physical proximity with a communication partner (or APE instructor), Antonjah will accept hand-under-hand guidance to explore the entire space of the activity (i.e. different parts/components of the trampoline, the treadmill, etc.) for the purpose of attending to labels or learning to operate said activity device more independently 3 times during a gym lesson 4/5 days during a given week.

During a free time or art activity, in close proximity with a communication partner, Antonjah will accept hand-under-hand guidance to explore the materials needed for a given creative activity (sensory/tactile collage materials, glue, colored pens, etc.) 4/5 times during a given week.

During dismissal routine while engaged in turn-taking routines with a communication partner, Antonjah will accept the hand-under-hand guidance of the partner to direct her to explore her tactile/visual name cue on her locker 4/5 times during a given week.

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5. Activities

As stated throughout this communication plan, it is critical that activities be centered in Antonjah’s preferences.  This can mean using preferred activities as a platform for addressing communication goals through responsive interaction and explicit instruction.  It can also mean using preferred objects/materials within not necessarily preferred routines to encourage participation and extension of goal-oriented practice across domains and environments.  While this plan is centered in preference-based activities, it is important to recognize that this foundation is meant for intervention purposes as determined by observations and informal assessments of current interactional management needs (scaffolding).  In the future it will be necessary to shift the focus toward increasing communication in all activities, preferenced-based or not, and as such it is important to consider developing positive shared experiences in all daily activities. 

As we think about creating a meaningful person-centered transition program for Antonjah, it is important to develop activities that address transition goals.  The most important goals for current focus have been identified previously as largely interactional-responsive, in terms of increasing communication skills to include higher symbolic language development (conventional gestures, object cues), participation in coactive movement routines and the strengthening of joint attention through allowing more generalized and instruction-focused contact with communication partners.  It is the hope that through addressing these goals Antonjah may more comfortably approach social environments, engage with peers, and explore transition options with more independence of movement and exploration, and more meaningful engagement with others.  It is important here to identify the importance of developing both independence of self and interdependence with others in creating the foundation for a successful life.

The following activity areas are a framework for addressing Antonjah’s current goals in communication, and are designed to provide challenging yet realistic environments for participation and skill development.  Antonjah is a student in a 12:1:4 classroom with students with visual impairments and additional disabilities, and each student in the class has unique needs and accesses the curriculum at an individual level.  The class is organized to include academic subject areas (English Language Arts, Math, Science, Social Studies) as well as Cooking/Shopping, and Communication Groups; Gym, Art, Music, and related services take place in separate classrooms.  These areas will be discussed below as relevant to Antonjah and her classmates.

Each skill area per long-term goal (LTO) is presented specifically in each activity; the general description of each activity will only be presented the first time it is mentioned.

1. Initiate/Respond to Responsive Communication Partners:

 As presented in the “Goals” section of this plan, these skills are organized into levels of symbolic communication being addressed (unconventional, conventional, and object cues).  Antonjah will be practicing these skills in hierarchical progression throughout the school year; that is, instruction will be designed with increased emphasis on modeling and explicit instruction

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of these skills as they progress.  However, multimodal communication will be present in activity instruction throughout, object cues accessible and use of them modeled and taught straightaway.

The object cues used in this section are introduced as either pertaining to an anticipation calendar or as a field of choices, as described in both the justification for this plan and in the goals and objectives.

LTO 1: During a preferred activity and given sufficient wait time (10-30 seconds) between gradually fading prompts and physical proximity (within arm’s reach) of communication partner, Antonjah will initiate interaction with communication partner in order to request (1) an object/item (2) an activity/place (3) social engagement/play.

LTO 2: Given sufficient wait time (10-30 seconds) between gradually fading prompts and physical proximity (within arms reach) of communication partner, Antonjah will initiate interaction with communication partner in order to refuse (1) an object/item (2) an activity/place (3) social engagement/play.

Morning Arrival: is a consistent daily routine which provides much opportunity for interaction and participation.  The student lockers are located immediately to the right of the door, and each one has a unique name cue or label, designed to accommodate the individual student’s mode of sensory access, affixed at the appropriate level for access by the individual student.  As students are escorted into the classroom by assistants and aides from other classes in the school who are inconsistent and may not be aware of each student’s goals and current levels of communication, it is important for a responsive communication partner to be present when each student enters the classroom to make sure that the students are allowed to participate as fully as possible in steps of the arrival routine.     

Mealtime (lunch): is a consistent daily routine during which Antonjah has shown the most motivation to initiate communication with familiar communication partners, and has demonstrated strong preferences in communicative forms, content, and contexts.  Antonjah has a definite consistent sense of timing for lunch, and generally stands up from her chair at around 11:15 every day and walks to the cabinet where her drink and cup are kept.  The drinks have been moved to the top shelf of the cabinet, slightly out of reach, to encourage Antonjah to initiate communication in order to complete the prior-to-lunch routine.  The cup is kept on the middle shelf of the cabinet, where Antonjah can locate it easily.  The activity routine preceding lunch is structured to provide opportunities for communicating requests and refusal, as well as participation in joint attention and coactive movement routines involving turn-taking and explicit instruction of the complete task analysis.  In addressing the goals of increased levels of symbolic communication, Antonjah will require proximity-based facilitation of a responsive communication partner who does not step in to complete steps of the routine for her unnecessarily.

Gym: is a consistent daily routine during which Antonjah has expressed strong preferences for movement activities, and is therefore a great starting point for focusing on

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encouraging meaningful interaction with communication partners for the purpose of requesting, exploring environments coactively and engaging in social play.  Antonjah’s primary current preferences in Gym class are the trampoline, a large wooden rocking boat (which is not encouraged due to age-inappropriateness, an adapted bicycle, and a treadmill.  As in the lunch routine, Antonjah will focus on increasing symbolic levels of communication to use both conventional gestures and object cues to request preferred activities or more input from a partner, in addition to mastering her current use of unconventional gestures (which still require proximity and facilitation), and to refuse unwanted activities or materials.

Hearing Ed. Therapy: is a mandated related service which Antonjah participates in for 3 x 30 minute sessions per week.  Sessions have been scheduled during the teacher’s prep. period and while her classmates are in Music or Dance class (which she has shown much refusal to participate in).  Prior to going to the room in which Hearing Ed. sessions take place, the teacher will put on Antonjah’s hearing aids if they are not presently on.  Since these sessions take place after Gym class, generally Antonjah takes her aids off during Gym (possibly due to the noisy environment there).  Hearing Ed. is a focused language environment during which Antonjah can receive 2:1 support from responsive communication partners.  She is generally presented with a choice of activities, many of which are musical toys or instruments.  This is an opportunity for Antonjah to develop skills in requesting, refusing, and to initiate social interaction with scaffolding developed to explicitly address language goals.  These routines, as they become more familiar, will be extended to include object cues addressing the short-term objectives.

Functional Vision Activities: Antonjah has shown interest in bright lights including flashlights, CCTV screens, TV screens, computers, light balls, and light tables.  At this point she does not participate in functional use of materials with enhanced visual quality.  Functional vision skills can be worked into any activities, whether academic content areas, daily living routines, etc.  However, it is important to create 1:1 space for focusing instruction, particularly for a student such as Antonjah who presents management needs in proximity of a responsive communication partner.  For Antonjah’s development of functional vision skills, it may be useful to actually bring her into a separate “vision room” where she can use a light box and other materials.  This is an opportunity for Antonjah to work 1:1 with a partner to request desired items and refuse unwanted materials or activities, and again to focus on increasing symbolic levels of communication and generalizing skills in these levels across environments and domains.  Many of the skills addressed in these activities will then be extended throughout the daily routines and class periods.   

Communication Groups: is a class period activity designed to encourage meaningful social interactions and facilitated/guided discussions.  Students are split into small groups, ranging in size as appropriate; each group is facilitated by a class assistant, and the teacher either goes from group to group helping to facilitate discussion, or works 1:1 with a student or a small group.  Discussions range in content and form/mode, and can take the form of discussion boxes, verbal conversation, sign language, AAC device

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usage, or combined forms.  For Antonjah, this is an opportunity to interact socially with peers and to practice forms of communication under the facilitation and instruction of the teacher and assistant.  At this point, Antonjah’s participation in Communication Groups tends to be limited to either 1:1 discussion with the teacher, or limited participation in a very small group with the assistance of a teacher or assistant.  Further development of skills in this goal area require Antonjah’s increased exposure to this activity, with meaningful encouragement to participate, and increased opportunities to communicate at various levels of symbolic representation.

Academic Content Areas: These classes take up a significant part of the daily schedule, although they are structured in small groups facilitated by the teacher and the assistants, and involve multilevel instruction an adapted content.  Antonjah generally requires 1:1 facilitation to engage in activities that are out of her general preferences, and it is therefore particularly important to include opportunities to explore these activities utilizing preferred materials, such as flashlights.  Antonjah generally pushes away or throws any item presented to her in these contexts, so instruction must be closely facilitated here to allow practice of higher levels of communication for requesting and refusing, as well as in general participating.  These are also potentially meaningful opportunities for Antonjah to engage with peers, which at this point also requires 1:1 support of a responsive communication partner.

Dismissal : is a consistent daily routine which Antonjah tends to participate in with some level of engagement.  Like lunch, in this routine she has a keen sense of timing, and generally stands up from her chair and walks to the locker area at approximately 2:15 every day.  As she has the consistent habit of removing her socks and shoes upon entering the classroom and refusing to put them back on until the end of the day, it is at this time that, given proximity of shoes/socks and a familiar communication partner, she will sometimes pick up her shoes/socks and present them to the partner in anticipation of dismissal.  This is an important time of day for a responsive partner to work closely with Antonjah to respond to attempts at initiating communication. 

2. Co-active Movement and Resonance Building, Turn Taking Activities:

LTO 1: In a resonance-building activity with a preferred communication partner, and given sufficient wait time (10-30 seconds) between prompts, Antonjah will attend to the partner’s imitation of her behaviors by pausing mid-perseveration and looking at her partner.

LTO 2: In a preferred activity and given sufficient wait time (10-30 seconds) between prompts, Antonjah will participate by taking turns in a functional routine with a communication partner.

LTO:  During a turn-taking routine with a preferred communication partner, and given sufficient wait time (10-30 seconds) and physical proximity (within arm’s reach), Antonjah will respond to a “sabotage of routine” by protesting, laughing, or requesting a solution from the partner.

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Morning Arrival : provides many opportunities for engaging in resonance-building interactions and turn-taking to complete the steps of the arrival routine.  When Antonjah enters the classroom with the escort who has brought her from the bus, the communication partner should greet her at the door and allow for her transition into the classroom environment by providing passive proximity for encouraging interaction and initiation of the first step of the arrival/locker routine, while blocking her from going directly to her chair and passing by the routine.  Using the assessment developed for task analyzing level of independent participation in the arrival routine, the partner should engage to the appropriate level with the student in coactive movement and turn-taking, fading prompts and creating “sabotages” of the routine once it is known and developed.

Mealtime : being a consistent routine in which Antonjah participates with engagement and determination, is a great opportunity for creating resonance and coactive movement routines and encouraging turn-taking in the steps necessary to complete the preparation for lunch and the actual eating of lunch.  The normal routine can also be sabotaged to provoke a response as mentioned in the short-term objectives.  Clean-up is a part of lunch during which coactive movement may be highly applicable for explicit routine instruction, while improving upon the interactive status of relationships of communication.

Gym : provides ample opportunity for coactive movement and turn-taking, as many of the activities in Gym implicitly involve active participation by two or more individuals.  In order to access the treadmill, for example, Antonjah will have to work with the APE instructor or another present communication partner in order to turn it on; in order to access the trampoline as she currently does, sitting on it and waiting for a partner to bounce on it with his/her feet, she will need not only to request that assistance, but in the development of a more meaningful activity, to take turns and coactively explore the activity.

Hearing Ed. : being a focused language environment with 2:1 communicative facilitation, is a full 30-minute session 3 times per week which encourages the development coactive movement routines involving the teacher or Hearing Ed. instructor imitating her movements and attempting to engage her attention beyond perseverating behaviors.  As routines develop in these activities, turn-taking skills can be practiced in more focus.

Functional Vision Activities : provide opportunities for taking turns to complete a task which may be selected based on preferences with the intent of encouraging development of concepts, such as sorting, labeling, etc.  In these activities, Antonjah will work with the teacher or other communication partner in a 1:1 environment and will practice not only these specific communication skills, but also have increased opportunity to improve upon attending skills in general.

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3. Joint Attention:

Note: As mentioned in the section “Goals,” skills in joint attention are implicit throughout many of the short-term objectives in other areas of skill acquisition; the LTO presented below is more specifically targeting explicit instruction of joint attention skills.

LTO:  Given proximity of communication partners and while engaged in daily routines involving a variety of functional materials and sensory items, Antonjah will allow a communication partner to direct her hands with hand-under-hand guidance to touch a given item or engage in a given activity without pulling away or engaging in perseverating behaviors.

Morning Arrival/Dismissal : provides opportunity for joint attention, particularly in the exploration of her locker name cue, which should become generalized over time.

Gym:   provides opportunity for joint attention in the coactive movement routines described above and in the hand-under-hand exploration of the wider environmental space of the gym itself and the specific preferred activities which Antonjah has selected.

Mealtime: allows for the practice of skills in joint attention, particularly in the hand-under-hand exploration of object cues and materials, in all three stages of lunch (prior-to/preparation, during lunch/eating, and after/clean-up). 

Hearing Ed. : opportunities for practicing joint attention include the exploration of various musical toys and activities, as well as in the extension of joint attention skills from objects to people in the 2:1 communication partner ratio described above.  Antonjah will have many chances to engage in joint attention between communication partners, and with objects.

Academic Content Areas: present multiple daily activities in which Antonjah may have the opportunity to explore new materials and subject matter with her peers and the classroom staff.  With close proximity of a responsive communication partner, who may in time become a trained peer buddy (as aggressive behaviors continue to disappear in Antonjah’s routines), Antonjah can explore new materials increasingly with hand-under-hand guidance.  Functional vision tools and skills can also be integrated into this and other activities to facilitate joint attention.

  Communication Groups: during discussion box activities in a small group or 1:1 discussion, Antonjah can practice skills in joint attention by allowing hand-under-hand guidance for exploring objects for conversation.  This may also be extended in time to include the facilitation of peer buddies, with increasingly less reliance on the teacher and assistants for 1:1 facilitation.

 

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6. Strategies

Intervention aims center on improving the quality of responsive interactions and making use of evidence-based strategies for developing meaningful communication as per the individualized goals and skill areas described throughout this plan.  As previously justified, responsiveness of the communication partner involves recognizing, interpreting, and responding to communicative attempts of the student, as well as providing opportunities for communication and concept development by structuring the learning environment and using strategies that support initiation and response in the four main areas of communicative intent.  As Janssen et. al found in their 2003 study on the effects of interventions promoting harmonious interactions between deafblind children and their educators, the two significant intervention effects were “decreases in the number of initiatives and improved regulation of intensity of the interaction” (Janssen et. al, 2003, p. 224).  With this in mind, general strategies for this individualized plan are identified below, followed by specific strategies in the context of activities:

General strategies which apply to all activities and interactions:

Note: these strategies may be elaborated upon when additional specific descriptors are deemed necessary for individual activities, but should otherwise be applied as described to all activities.

Strategy #1: promoting self-efficacy and preventing learned helplessness: limit the extent to which tasks are done for the student; involve the student in tasks and activities as much as possible

Strategy #2: proximity of communication partner:

a.   provide physical access to the communication partner for shared forms and general participation in routines and activities,

b.   for requesting preferred activities or items, communication partners should strategically remove themselves from direct physical access, while remaining in visual field in order to encourage Antonjah to increase her efforts in requesting (i.e. partner will stand at least a few feet away from her and within her visual field prior to meal time so that she has to stand up and go to him/her in order to initiate the routine)

Strategy #3: providing sufficient wait time for response: depending on the familiarity of the routine as assessed, provide from 10 to 30 seconds, or more, between prompts, allowing Antonjah to process information and respond/initiate interaction or participate in steps of routines and activities

Strategy #4: support preferred routines and provide opportunity for stimulating experiences: encourage engagement through preference-based activities and provide materials which are stimulating

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Strategy #5: increase communication partners and provide interaction coaching: train staff and involve parent in generalizing efforts at facilitating harmonious interactions, train peer buddies in the classroom and involve in activities as described below

 

Activities: 

A. Morning Arrival (locker routine):

•   initiate/respond to communication partners:

Strategy #1: promoting self-efficacy and preventing learned helplessness: allow Antonjah to take off her coat and backpack (as assessed in discrepancy analysis); support her as described in other parts of the routine, with faded support as she learns to participate more in these steps.

Strategy #2: proximity of communication partner: communication partner should be within physical proximity for all steps of this routine from entering door to sitting down in seat.

Strategy #6: "sabotaging” the routine: communication partner will illicit response from Antonjah by changing the routine at sections where she is familiar with the procedure (i.e. modeling putting her jacket back on once she has taken it off to illicit her response in redirecting the routine to its correct next step).

•   resonance and coactive movement strategies, turn-taking skills:

Strategy #7: hand-under-hand exploration/guidance: upon entering the classroom, the instructor will guide Antonjah’s hand to follow along the lockers to find her name cue and open the locker door.  Remove hands from under her when she is touching the object of focus, and decrease support as she learns the routine.  This strategy should be used in coactive movements, wherein the communication partner follows Antonjah’s movements to share in the interaction (MacFarland, 1995).

Strategy #8: communicative starting and stopping cues: in turn-taking interactions within the routine, communication partner will provide cues to start and stop, exchanging roles to complete the task and encouraging meaningful, resonance-building interactions (i.e. partner will gently tug at Antonjah’s jacket sleeve to let her know it is her turn to take the jacket off, then will model the gesture of giving the jacket to him/her with a light directional touch to her hand holding the jacket, before using hand-under-hand guidance to put the jacket away in the locker)

Strategy #9: modeling conventional gestures/distancing: communication partner will model gestures of participation (i.e. pointing to the locker/name cue/hook/jacket/etc.) and/or refusal (when Antonjah refuses to participate in steps of the routine: i.e. when Antonjah refuses to put her jacket away in her locker by throwing it on the ground and walking away, partner will  model giving the jacket to the communication partner/shaking head no)

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•   joint attention-specific:

 Strategy #10: coactive manipulation: in addition to using hand-under-hand techniques as described above in mutual exploration, communication partner will use hand-over-over hand to provide direct instruction only when Antonjah has established rapport with him/her and she is deemed to be defiantly refusing participation in a targeted skill that she has not demonstrated full ability to perform.  In this routine, coactive manipulation may be utilized to engage Antonjah in attending jointly to the name cue, locker door and latch, hook, and individual actions (as she may be easily distracted by self-stimulatory hand movements, or may directly refuse to participate or attend).

•   strategies for developing functional visual skills:

-“accentuating visual characteristics of the task” (Downing & Bailey, 1990, p.214): provide a name cue on the locker which is visually enhanced in order to maximize visual input (as described in adaptations section).

-use a flashlight to direct attention to an object or action: communication partner will use a flashlight to direct Antonjah’s attention to the name cue and to his/her own hand when necessary to show Antonjah visually how they perform a step in the routine.

B.   Mealtime (Lunch): 

•   initiate/respond to communication partners:

Strategy #1: promoting self-efficacy and preventing learned helplessness: communication partner will allow Antonjah to obtain her cup from the cabinet, while encouraging communication by storing the drink too high for her to reach; allow Antonjah to hold her cup and drink independently; encourage Antonjah to participate partially in pouring her drink into the cup, taking her cup to the sink and washing it out, and throwing away her apron and the empty drink container; do not pour drink until she requests it as described.

Strategy #2: proximity of communication partner: partner should stand away from Antonjah but within visual field prior to mealtime to illicit her initiating the routine’s first steps and requesting assistance; during mealtime, physical proximity of communication partner is necessary for Antonjah.

Strategy #6: "sabotaging” the routine: communication partner will change or disrupt a known part of the routine to illicit response/provoke communication (i.e. move the placement of the cup in the cabinet as Antonjah has already developed consistency and predictability in this part of the routine)  

•   resonance and coactive movement strategies, turn-taking skills:

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Strategy #7: hand-under-hand exploration/guidance: communication partner will use hand-under-hand technique to assist Antonjah in picking up the drink box and coactively pouring it into the cup.  No assistance necessary to help her drink.  This strategy will also be used to explore object cues during the initial learning period, and to take the cup and drink box to the sink and garbage bin respectively following lunch.  Also use hand-under-hand for mutual exploration of the tactile qualities of various areas and objects of the lunchtime routine (cabinet, drink box/lid, sink and trash bin rim).

Strategy #8: communicative starting and stopping cues: communication partner will develop personalized cues to initiate turn-taking role changes, which fit into the natural routine of lunchtime and gradually decrease in dependence and prompting. 

Strategy #9: modeling conventional gestures/distancing: communicative starting and stopping cues will take the form of modeling conventional gestures: pointing (to the object cue for drink and clean-up, to the drink box in the cabinet, to the sink and trash bin), pushing items away when finished, requesting more by reaching for an object will be faded into using more conventional and more symbolic forms of communication (using object cues, attending to ASL).

•   joint attention-specific:

Strategy #10: coactive manipulation: direct instruction with either hand-over-hand or hand-under-hand as necessary at this point will be used for modeling use of the object cues and the steps of cleaning up after eating (which at this point Antonjah does not attend to or participate in actively).  Coactive manipulation of hand skills may also be necessary for modeling pointing gestures and picking up objects (as Antonjah requires this assistance to redirect from persistent self-stimulatory hand movements).

Strategy #11: representational reference: communication partner will engage student by following her movements in spontaneous movement activities within the routine (i.e. following lunch, when Antonjah is at the sink washing her cup out and begins splashing with the water, communication partner will also splash, sharing the playful activity with Antonjah and subsequently moving toward mutual exploration of the attributes of the sink area).

•   strategies for developing functional visual skills:

-“accentuating visual characteristics of the task”: provide contrast with object cues against black felt background and highlight when necessary.

-use a flashlight to direct attention to an object or action: illuminate the object cues with a flashlight, use flashlight to direct Antonjah to specific areas of concentration throughout the steps of the lunch routine.

-   “presenting the stimuli within different visual fields and planes” (Downing & Bailey, p.214): communication partner will present the materials in different areas view (i.e. the drink box while helping Antonjah to pour with hand-under-hand), in conjunction with illuminating the

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object with a flashlight when necessary to direct attention further; this will encourage meaningful development of visual tracking. 

C.   Gym:

•   initiate/respond to communication partners:

Strategy #2: proximity of communication partner: communication partner will maintain proximity of visual field and within arm’s reach but not directly touching Antonjah while on the trampoline or other preferred activity to allow Antonjah opportunity to request with increased active role (she will have to make a larger effort to request, thereby engaging her more in the interaction).

Strategy #4: support preferred routines and provide opportunity for stimulating experiences: communication partner will make sure that movement-based preferences are available in gym activities, in conjunction with selected current preferences and assessment of sensory preferences (vestibular, proprioreceptive, etc.).

Strategy #12: provide opportunities for choice-making: communication partner will not lead Antonjah to an activity area upon entrance to the gym, but will rather allow her to explore known areas (and introduce new areas and activities in tandem with labeling) and decide upon her choice of activity.  As she becomes more familiar with object cues within the gym environment, expand the symbolic involvement of the choice-making interaction by providing a black felt choice board with object cues upon entrance to the gym, and allow Antonjah to choose an activity from the list – note: this is a long-term activity goal and strategy which will have to develop naturally with her use of object cues and the anticipation calendar)

Strategy #5: increase communication partners and provide interaction coaching: teacher will work with gym instructor to provide Antonjah with consistent strategies for interaction across domain environments throughout the school day.

Strategy #6: "sabotaging” the routine: while Antonjah is engaging in a preferred activity in the gym, communication partner will sabotage the routine to illicit response (i.e. walking a few away in the middle of bouncing on the trampoline, or introducing a novel item from a different activity such as a ball or lifting weight to engage Antonjah in a change of routine or protest).

•   resonance and coactive movement strategies, turn-taking skills:

Strategy #7: hand-under-hand exploration/guidance: communication partner will use hand-under-hand with Antonjah in mutual exploration of the whole components of preferred activities in the gym (i.e. the springs of the trampoline, the buttons and rails of the treadmill, etc.)

Strategy #8: communicative starting and stopping cues: communication partner will provide cues for turn-taking routine changes, such as jumping enthusiastically off the trampoline to provoke response and further request for more.

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Strategy #9: modeling conventional gestures/distancing: communication partner will use conventional gestures such as pointing to a given activity, and to the object cues as they are introduced in the choice field; extend conventional gestures to use simple ASL such as “jump” for requesting more on the trampoline.

Strategy #5: increase communication partners and provide interaction coaching: teacher will work with Antonjah’s peers to develop turn-taking activities such as throwing a ball back and forth, with another communication partner working closely with Antonjah to provide communicative stopping and starting cues and modeling the activity.

Strategy #13:  imitation (parallel and deferred): communication partner will imitate Antonjah’s behaviors within a turn-taking routine such as bouncing on the trampoline or engaging in self-stimulatory behaviors and hand movements to illicit response or parallel imitation.  Communication partner will develop imitation routines in order to transfer roles and provoke Antonjah to imitate him/her, as in turning on the treadmill by pressing the button, turning it off, and in playful gestures throughout preferred activities.

•   joint attention-specific:

Strategy #10: coactive manipulation: only necessary in this activity area for exploring and instructing use of the object cues, as Antonjah is motivated to use all other activity objects and areas with minimal assistance and maximum shared interactions.

Strategy #11: representational reference: communication partner will share in the experience of preferred activities by joining Antonjah and completing exploratory steps together (i.e. exploring the parts of the adapted bicycle before, during and after helping Antonjah to use it)

•   strategies for developing functional visual skills:

-“accentuating visual characteristics of the task”: highlight the switches/buttons on the treadmill with yellow tape, provide contrast in presenting the object cues for choice-making.

D.  Communication Groups:

•   initiate/respond to communication partners:

Strategy #2: proximity of communication partner: For these new and relatively unfamiliar routines involving social interaction, Antonjah will require physical proximity of both teacher/assistant as communication partner, and physical proximity of peer buddies and group members.  The initial goal in this activity is proximity and attending to focused language environments, and introducing concept and language development is reliant on this proximity.

Strategy #4: support preferred routines and provide opportunity for stimulating experiences: materials developed in communication groups (including discussion box items) to complement Antonjah’s preferences and provide access to stimulation of sensory needs.

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Strategy #5: increase communication partners and provide interaction coaching: Peer buddies will require instruction and training in helping Antonjah to participate more actively in this activity, including allowing sufficient wait time and working with the communication partner to work coactively with Antonjah using discussion boxes and other items for interaction with language etc.

•   resonance and coactive movement strategies, turn-taking skills:

Strategy #7: hand-under-hand exploration/guidance: Communication partners will work with Antonjah to coactively explore items in discussion box and other novel materials with peer buddies, and to accept tactile interactions with peer buddies (touching hands, etc.).

Strategy #8: communicative starting and stopping cues:  In discussion boxes and other interactive lessons within the communication group, communication partner will use established cues, focusing on conventional gestures, to facilitate Antonjah’s active participation with peer buddies (passing an object around in a turn-taking scheme).

Strategy #12: provide opportunities for choice-making: In developed communication group routines (discussion boxes, adapted books, shared movement activities), Antonjah will be given choices using whole objects, with the goal of moving toward using more symbolic forms of language.

•   joint attention-specific:

Strategy #11: representational reference: Communication partners, and eventually peer buddies, will mutually explore materials for discussion to share experiences, including movement around school and in classroom learning centers.

Note: This is not a preferred or familiar routine at this point, for which reason coactive manipulation and hand-over-hand instruction has been ruled out in favor of creating comfortable new experiences and environments.

•   strategies for developing functional visual skills:

-“accentuating visual characteristics of the task”: materials in communication group activities will be developed to provide contrast and to accentuate focal points.

-use a flashlight to direct attention to an object or action: Communication partner may use a flashlight to direct Antonjah’s attention toward a given object or movement, or toward a peer buddy.

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E.   Academic Content Area Activities:

•   initiate/respond to communication partners:

Strategy #2: proximity of communication partner: Communication partner will maintain physical proximity at all times possible during academic lessons in order to engage Antonjah more directly in accessing materials which are not yet preferred.

Strategy #3: providing sufficient wait time for response: sufficient wait time for response is absolutely necessary when dealing with the novelty of materials and activities in academic content areas, as they are not preferred or familiar to Antonjah.

Strategy #4: support preferred routines and provide opportunity for stimulating experiences: as much as possible, adapt materials to Antonjah’s preferences in all academic content activities.  Provide sensory stimulation according to preferences, including movement-based activities.  Adapt areas and environments to support these sensory needs in order to engage Antonjah more fully in accessing novel materials.

Strategy #5: increase communication partners and provide interaction coaching: Train peer buddies to work with Antonjah in academic environments and activities, designating tasks and items that are appropriate to Antonjah’s engagement levels and sensory preferences.

•   resonance and coactive movement strategies, turn-taking skills:

Strategy #7: hand-under-hand exploration/guidance: communication partner will use hand-under-hand techniques to attempt to mutually explore novel academic content area activity materials.  This may start at the first level of hand-under-hand, in shadowing Antonjah in accessing materials, and Antonjah simply allowing the proximity of the communication partner’s hand touching hers.

Strategy #8: communicative starting and stopping cues: Facilitate active participation in the routines of lessons by indicating with gesture and by physically giving Antonjah materials to show her that it is her turn (i.e. in a cooking lesson, the communication partner will stir, modeling the action and taking the first turn, then will tap Antonjah and give her the wooden spoon for stirring, further modeling and including hand-under-hand at first, then fading prompts as she learns routines).

•   joint attention-specific:

Strategy #11: representational reference: communication partner, and eventually peer buddies, explore the components of novel materials together, sharing the experience.  

Note: This is not a preferred or familiar routine at this point, for which reason coactive manipulation and hand-over-hand instruction has been ruled out in favor of creating comfortable new experiences and environments.

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•   strategies for developing functional visual skills:

F.   Hearing Ed. Therapy 

•   initiate/respond to communication partners:

Strategy #2: proximity of communication partner: Communication partners (hearing ed. Instructor, teacher, etc.) will provide physical proximity during activities in Hearing Ed. Therapy.

Strategy #3: providing sufficient wait time for response: When presenting Antonjah with choices and activity-based materials, and following modeling of use of musical/vibrational instruments and other sensory materials, communication partners will allow Antonjah sufficient time to respond.

Strategy #4: support preferred routines and provide opportunity for stimulating experiences: activities will reflect sensory preferences, and choices will be offered that include sensory preferences (vibrational instruments, mirrors, lights, movement activities etc.). 

Strategy #5: increase communication partners and provide interaction coaching: Teacher will work with Hearing Ed. Instructor to generalize interactional strategies and activities across domains of the school day, including modeling hand-under-hand techniques and creating a dialogue about progress and preferences.

Strategy #12: provide opportunities for choice-making: activity choices will be presented for Antonjah to select preferred activities; i.e. communication partners will present whole objects on the table in a clutter-free arrangement with respect to contrast and spacing, allowing Antonjah to explore each of 3 choices of musical instruments or games before selecting one.  Black backdrop/felt board may be useful placed behind choices.

•   resonance and coactive movement strategies, turn-taking skills:

Strategy #7: hand-under-hand exploration/guidance: communication partners will use hand-under-hand techniques to mutually explore instruments in Hearing Ed.,

Strategy #8: communicative starting and stopping cues: in turn-taking activities (i.e. playing drum, engaging in imitation of sensory-seeking behaviors – rocking back and forth, vocalizing vibrational sounds, hand and finger movements, etc.), communication partners will model conventional stopping and starting cues to allow Antonjah to take her turn in the activity or exchange. 

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Strategy #9: modeling conventional gestures/distancing: In these preferred activities, communication partner will model conventional gestures (pointing, giving an item to Antonjah that she has requested, and taking it back when she is refusing it or finished – as opposed to her throwing or dropping it) and will complement conventional gestures with ASL to label and describe activities and interactional exchanges.

Strategy #6: "sabotaging” the routine: within familiar turn-taking routines using preferred materials in Hearing Ed. Therapy (i.e. playing the resonating drum), communication partners will introduce disruptions in order to illicit response from Antonjah.

Strategy #13:  imitation (parallel and deferred): communication partners will imitate Antonjah’s behaviors (both self-stimulatory and externally interactive with activity materials) in turn-taking exchange and with the purpose of engaging a response in connection with the routine of the activity, and provoking parallel imitation over time.

•   joint attention-specific:

Strategy #11: representational reference: communication partner and Antonjah will explore the components of musical toys and other materials in Hearing Ed. Therapy together in shared experiences.

Note: coactive manipulation has been ruled out for use in these activities because the instructional value is more geared toward engaging in mutually enjoyable experiences involving joint attention and coactive exploration, rather than direct instruction of tasks.

•   strategies for developing functional visual skills:

-“accentuating visual characteristics of the task”: choose materials and items that are visually stimulating, and accentuate visual qualities by providing environmental contrast (i.e. black felt board behind choices presented).

-use a flashlight to direct attention to an object or action: communication partners may use a flashlight to direct attention, especially in place of using more physical prompting to attend to materials

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7. Materials

Materials are arranged by activity, and where applicable by category (preferred items, novel/non-preferred, etc.).  Materials are not organized by strategic usage, as each activity generalizes strategies and combines goals using the same materials except where previously described specifically.

A. Morning Arrival:

student lockers:

individual name tag cue

large hook

handle / latch of locker

student personal items: backpack

coat / sweater / gloves etc.

B. Mealtime / Lunch hearing aids and FM unit, glasses cord

preferred items:

preferred chair (blue padded chair)

adapted cup (cut-out, green)

milk formula (may add yogurt or other pureed food to it in small amount)

Communication Board:

black felt board

object cues: drink (drink box), trash / clean up

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(drink box cue, trash cue, fold-out felt board with drink cue illuminated by flashlight, preferred adapted cut-out cup in foreground)

finished box

flashlight

unpreferred items / routine areas

aprons (white plastic disposable)

sink

trash bin

shelved cabinet (where drink boxes are kept)

C. Gym

preferred activity items/materials:

treadmill (with magnetic block switch to turn on - move magnet to side to activate switch)

trampolines (one adapted rectangular trampoline with rails for standing while jumping, one small regular circular trampoline)

large wooden rocking boat (adapted)

adapted bicycle

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non-preferred / novel activity items

adapted foam balls (with holes for holding and bells inside)

adapted arm weights

yoga balls / peanut balls

gym mats

floor scooters

balance boards

hand crank bicycle pedals

stationary bicycles

object cues: gym, bring next activity cue to gym (music/hearing ed.); develop cues for individual activities

black felt board on wall of gym for cues

D. Hearing Ed. Therapy

hearing aids and FM unit, glasses cord

sensory materials / preferred and novel toys for joint attention and turn-taking routines

musical instruments

tambourine

xylophone

chimes

handheld drums

rainmaker

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vibrating toys (stuffed animals, pens, balls)

light balls

flashlights

thin plastic sheen mirror built like resonance board (with thin wooden rim)

light table and translucent cubes, APH light box material books

tin containers with plastic lids: wooden blocks/sticks, buttons, and other novel items to put inside and shake    

1.    2.  

       

1. (tambourine and toy xylophone on resounding mirror)  

2. (tin container with plastic lid filled with resounding items - shown in joint activityturn-taking activity routine)

E. Communication Groups / Academic Content Areas:

hearing aids and FM unit, glasses cord

discussion boxes (topics and materials to be developed according to selected groupings; may include such categories as “found in the park” i.e. sticks, leaves, acorns, grass, rocks, etc.)

adapted tactile books and pre-braille materials (APH, etc.)

object name cues

other novel items related to current daily/seasonal activities and curricula (i.e. items from class shopping trips, personal items from home for show-and-tell/sharing activities and home/cultural perspectives)

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flashlight

preferred chair

Note: Academic content area lessons involve class curricular materials which may come in adapted form to accommodate individual students including Antonjah; her preferred seating, flashlight, and other sensory needs will be assessed and provided according to the individual lessons and unit activities).

F. Concentrated Functional Vision Activities

hearing aids and FM unit, glasses cord

light balls

light table and APH materials (translucent blocks, overlays with colors, shapes, pictures etc., translucent gel pads)

flashlights / penlights

CCTV and novel/preferred items (and pictures)

novel items: toys, games and activity objects for joint attention and play

preferred items as selected from observation in Hearing Ed. and communication groups for tracking and attending to

musical, vibrational and visual/light cause and effect toys

concept development tasks: stacking rings, pegboards, blocks, etc.

flimsy mirror built like resonance board

crayons/pens and paper

G. Music

hearing aids and FM unit, glasses cord

preferred chair

object cue for music

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musical instruments:

large resounding drum

smaller drums / congas etc.

xylophones (wooden and metal with sticks)

tambourines

shakers / maracas

electric mini-harp

chimes

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8. Adaptations

 A. Visual Adaptations (Enhancing the Visual Environment):

 As Antonjah is a visual learner and her primary mode of access is visual, it is critical that a plan to encourage communication development focus on enhancing the visual environment with respect to accessibility and maximizing opportunities for interaction with materials and communication partners.  Visual adaptations, like all instructional-environmental considerations, are highly individualized for students with severe and multiple disabilities including dual sensory impairment.  Preferences, as reiterated throughout this plan, must be included in these arrangements.  However, some general visual adaptations can be taken from the literature on specific conditions of low vision, and environmental adaptations for the general classroom environment and for individual student should focus on lighting/glare, contrast, visual clutter, and distance of presentation (materials and people).    

 Antonjah’s visual diagnosis of coloboma involving the macula and optic disc infer a low visual acuity.  Informal assessments of functional vision and preferences have indicated functional use of peripheral and lower visual fields (locating her shoe on the floor while walking, and picking it up) and visual ability to attend to and pick up (hand-eye coordination) an object presented within arm’s reach.  Recommendations for presentation of objects according to literature on adapting sensory and visual environments, in conjunction with observational information, suggests that materials should be presented from “a few inches to a few feet away” (Silberman, 2009). 

 For students with severe disabilities in general, and particularly for students with low vision, materials (for activities, choice-making, etc.) should be presented with sufficient spacing between each item (3 to 6 inches, depending on visual condition).  Glare should be reduced in presenting materials and arranging lighting.  Materials should be selected to increase contrast and reduce visual clutter, both in the design and decour of the classroom, and in the use of individual activity-based materials.  In addition, clothing choices for communication partners can reflect individualized visual needs of students, such as wearing a long-sleeved black shirt while signing (ASL, or gesturing, for that matter) in an accommodated visual field (Morgan-Morrow, 2009).  This enhances the contrast and reduces the visual clutter that might be present in other clothing.

For Antonjah, the use of a flashlight to both redirect her attention when she is engaging in perseverating eye-to-hand motions (which, although fulfilling a sensory need that must be respected, limit her ability to recognize and respond to opportunities for communication) and to illuminate materials (as seen in the photo in the previous section on materials showing an illuminated object cue on a contrasting felt board during the lunch routine).  Due both to Antonjah’s low vision condition and to her sensory and learned behaviors that create boundaries between herself and interaction with others, it is necessary for visual adaptations to consistently make materials clear and simple (not cluttered), highly contrasted, preference-based, and individually illuminated.  Specific color preferences can also be a part of the visual adaptations in selecting and providing materials, such as the use of her green cup and blue chair (which

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contrast with the visual environment of the room, and, exchanged with similar materials of less contrasting colors, have been rejected by her). 

 Although the lighting in the classroom cannot be easily changed from the highly irritating fluorescent bulbs and skylight (there are no windows in the classroom), lighting can be used in specific activities (such as during 1:1 activities in a separate room, with a light box or flashlight) to further enhance the environment for developing functional vision skills.

Morrow, S.M. (2009). Accommodations for sign language for individuals with low vision and reduced visual fields.  Presented Fall, 2009, at Hunter College, CUNY, New York, NY.  

Schwartz, Antonjah. (2010) Causes of visual impairment: pathology and its implications. In Corn, A. & Erin, J. (Eds.)  Foundations of Low Vision: Clinical and Functional Perspectives, 2nd Ed (pp. 137-187). New York: AFB Press

Silberman, R.K. (2009).  Adapting sensory environments.  Presented Fall, 2009, at Hunter College, CUNY.

 B. Auditory Adaptations (Enhancing the Auditory Environment):

At present, as previously mentioned, there is no definitive information regarding Antonjah’s functional hearing with hearing aids.  There has also been no definite observation of Antonjah localizing auditory sources, with or without hearing aids.  However, until this fall, there has been apparently no consistent use of hearing aids and FM unit in the past 10 years.  It is necessary to provide adaptations to the auditory environment in order to provide structure and a basis for Antonjah to potentially access auditory information for the purpose of learning and communication. 

 As in visual adaptations, there are both general and student-specific adaptations that can and should be made to enhance the auditory environment for learning and accessing/encouraging opportunities for interaction and communication.  These adaptations of the general environment include the reduction of noise clutter (background noises) within and outside of the classroom and the actual placement of the student in the classroom (elaborated in “Positioning and Seating”).  Physical adaptations can be made to the classroom itself to enhance the auditory environment, such as “carpeting on floor, noise-reducing draperies and ceiling tiles, cork room dividers, and wall panels”(Silberman, 2009).  The actual structure of the classroom should be considered as well in creating an auditory environment that is conducive to learning, and the choice of arrangement of furniture and decorations.

 For Antonjah, as observed over the past several months while wearing hearing aids and the communication partner using an FM unit across various activities and environments, there is a direct relationship between the increase of noise clutter and Antonjah’s action to pull out and throw/discard her hearing aids.  Since discovering this, and because Antonjah does not typically tolerate wearing her aids for more than an hour at a time, a schedule has been developed for Antonjah’s use of hearing aids that focuses on making use of them in structured and noise-

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reduced environments.  Therefore, they are taken out before Antonjah goes to gym or group music class, which tend to be extremely noisy environments due to the other students present and the respective activities of each locale.

Moreover, instruction can be focused on accessing and utilizing the auditory learning environment while Antonjah is wearing her aids, also encouraging concept development and joint attention.  This is the basis for creating a structured Hearing Ed. Therapy room for Antonjah during her 3 weekly sessions with the instructor and the classroom teacher, including the reduced noise clutter provided by the small soundproof room and the 2:1 focus of communication partners, and the selection of musical instruments and auditory-visual cause-and-effect toys.  The environmental adaptations and activities of this environment can be extended throughout the week in scheduled 1:1 time with the teacher to further promote skill generalization and provide more opportunities for focused communication.  It is essential that the classroom environment (and other learning environments, to the degree possible) be regulated to reduce unnecessary auditory noise or clutter, such as the chatting of professionals.

Silberman, R.K. (2009). Auditory adaptations.  Presented Fall, 2009, at Hunter College, CUNY. 

 C. Tactile Adaptations (Enhancing the Tactile/Sensory Environment):

 Tactile adaptations should also focus on both general evidence-based strategies and individual preferences.  Tactile adaptations are particularly important in the development of object cues, and materials selected should most naturally represent the object, activity or concept addressed.  For Antonjah, the object cue for her drink box is a partial piece of the box itself, glued onto a piece of cardboard to reflect the standard Texas School for the Blind cues used at the school (a requirement of the classroom set by administration).  Similarly, the cue for “clean up” is a piece of the trash bag used in the classroom, which is placed directly next to the sink so that Antonjah and other students may learn a consistent functional routine of throwing away their trash, then washing their cup/bowl/etc. when they are finished eating (the trash can is to the left of the sink, to mirror literacy’s left to right process).

 Antonjah does not demonstrate tactile defensiveness per say, although she often rejects input in general (that is, she pushes away when communication partners attempt to introduce objects/materials to her, or to use hand-under-hand guidance.  Upon observation of this behavioral characteristic, as well as upon view of her heavily caked and calloused hands, tactile modifications must be presented with minimal intrusiveness of interaction, with sufficient wait time, and in quality they should be visually preferable (see use of flashlight).  The use of puff paint, wikki sticks, or other such tactile graphic adaptation tools should be used with this in consideration, as well as in light of her still developing functional hand use. 

Downing, J.E. & Chen, D. (2003). Using tactile strategies with students who are blind and have severe disabilities.  TEACHING Exceptional Children, 36 (2), p 56-60

Silberman, R.K. (2009). Tactile adaptations.  Presented Fall, 2009, at Hunter College, CUNY.

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D. Positioning and Seating, Classroom Arrangement Environmental Adaptations:

 Antonjah’s positioning and seating should be adapted to her preferences (her favorite blue padded chair) and with respect to enhancing the quality of interactions with communication partners and peers.  Positioning and seating should therefore vary by activity, and should be developed in conjunction with all other adaptations described above, upon which a successful environment for communication development is contingent. 

 Antonjah’s positional placement in the general classroom environment is with her chair’s back against the side wall on which a wall-length black felt board is hung, with each student’s individual object cues and calendar systems, as well as folders and other school work and information is held, with the least possible amount of visual clutter.  Antonjah prefers this area of the classroom, and if her chair is moved to another area, she will push it (holding it like an AMD) back to this location.  From here, she can see most of the classroom, with her back to the wall, and can attend to anything or anyone that comes into her view.  Behind Antonjah’s chair is her section of the board, vertically divided from other students’ sections by a neon orange line of tape.  At her accessibility level (that is, directly behind her chair at eye/hand level) are her classroom object cues (placed equally apart, and available for use).  Above these, out of her reach, is a small notepad also attached to the board by Velcro, upon which the teacher or other classroom staff may write progress notes.  Above this is a folder of other teacher-access materials, including a flashlight, and past notes and work samples.

 During 1:1 activities and group work involving 1:1 attention, the teacher/communication partner should sit directly next to her, and her chair should be facing him/her.  During certain hand-under-hand instructional activities and routines such as cleaning up after lunch or participating in the morning arrival/locker routine, it may be necessary for the communication partner to shift between standing directly in front of Antonjah to model and take turns, and directly behind her to model and provide hand-under-hand with both hands (i.e. washing hands, washing a cup in the sink).  In the gym positioning with regard to communication partners should be assessed and adapted according to each activity with regard to communication goals and routine steps and in providing only the amount of assistance necessary to encourage self-determination.

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9. Evaluation

A. Tracking Progress and Ongoing Assessment

Ongoing assessment and re-evaluation of the current plan is essential to guiding progress and developing instruction; this involves creating organized systems to keep track of individual goal achievement and specific levels of communication in terms of rate/frequency of communicative attempts and responses of communication partners.  It is important to assess both the student and the environment, including the role of communication partners and the progress of intervention aims. 

 The Communication Matrix utilized in this plan as the key assessment will be re-administered every three months as directed, providing a general indication of progress towards symbolism in areas, modes, functions, and contexts of communication.  Informal observations should also be added to complement this assessment, which may take the form of notes organized into sections of goal area as indicated in this plan.  Two in-class notebooks have been created to track progress informally (by observation), and are kept within easy access of all classroom and school staff.  In addition, a small notebook has been created by the teacher and Hearing Ed. Instructor to record dates, times, and observations regarding Antonjah’s use of hearing aids (when were they put in, for how long did she keep them in, what activities took place in this time, and what were the contexts and contents of interactions between communication partners and Antonjah).  Assistants and aides have been briefed on the presence of and use of these informal collection tools, and have begun adding observational input which may be helpful to understanding broader contexts of Antonjah’s interactive daily experiences beyond that which is seen by the teacher. 

 Further assessment tools have been developed, and should continue to be developed in order to more accurately and acutely track progress of individual goals.  The task analysis provided below serves as an example of an activity routine-based informal assessment tool, which should be used on a weekly basis to evaluate progress in participation and communication within functional daily routines.  A similar tool can be developed for other activity routines, such as lunch, toileting, etc.

 It is not currently necessary to keep weekly track of specific vocabulary (expressive/receptive) for Antonjah, although in time the use of a gesture dictionary may be useful.  For the time being, this type of information should be kept in a notebook tracking use of object cues and gestures, informal notes to complement the Communication Matrix.

  Communication goals must be worked into the next IEP, and weekly progress sheets should address each goal.  Long-term goals and short-term objectives per activity are printed individually and kept on a teacher/staff board in the classroom with space to write comments on what was observed physically and contextually, and the date of observation and name of

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observer.  Other continued assessments include the assessment of preferences, which should grow with the introduction of strategies and activities which are conducive to creating responsive communication partners and meaningful opportunities for Antonjah to interact.  In effect, her world should grow bigger if this plan is appropriately addressed, and this must be tracked and recorded in order to maximize the affect it may have on developing future goals and improving upon the plan.  Only through this effort will it also be possible to expand the sphere of influence of the plan to include a wider world of domains and environments for accessing opportunities for communication.

 An organizational system will be created to keep materials for assessment and progress of communication goals in order, taking the form of a divided binder which will be accessible for the entire collaborative trans-disciplinary team.  Sections of the communication binder will represent goal areas of the communication plan and include assessment, development, and observational notes.  Meetings, both formal and informal, will be scheduled appropriately to discuss new information and general progress of goals, as well as to develop new goals across skill and environmental domains.

B. Transition Planning

 As discussed, transition planning is and will increasingly become more of an essential component of Antonjah’s educational plan, which includes this plan to develop communication goals, activities, materials, strategies, adaptations and assessments/evaluations.  The creation of a successful transition plan relies upon cooperation and communication between all members of the collaborative team, including the parents/guardians, and to the extent possible, the student herself.  Relevant contents of the communication binder and the practical results of ongoing assessment tool must be included in the creation of Antonjah’s Person-Centered Plan.  The assessment of preferences is easily adapted into a “What I like/What Works for Me” section of the template of a Person-Centered Plan, as are strategies and materials.  Goal progress should also be included in such a plan, providing information to new communication partners in the future as to what Antonjah is capable of, and what progress she has made in reaching goals in the past.  Antonjah’s mother should be made to feel a part of the team that creates this plan, which should go with her in her future transition beyond school, and this plan also should have space for further development.

 Progress in transition planning must be coordinated by the teacher and the school social worker with maximum participation encouraged in extension to other members of the collaborative team.  An organizational system is already in place for the school social worker’s use, and active participation by the teacher will be focused on using these resources to the benefit of the student by involving the entire team, and including ongoing development of communication profiles in this process as much as possible.