From Rolling to Walking

1. From Rolling to Walking Therapeutic Living Centers for the Blind Eunice Lee, DPT, Physical Therapist Rosa Tu, MA, Teacher of the Blind and Visually Impaired

2. Outline • Discussion on the challenges parents face with early motor development for a child who is blind or visually impaired and who may also have multiple disabilities. • How to avoid long term impact by creating a stimulating space for learning. • How to facilitate children’s movement without interfering with their development, but rather designing opportunities for children to be active learners and learn through their own actions within the home or natural environment. • Make and take session with simple tools for families to use to improve motor planning, promote active listening and learning, and encourage social-emotional development.

3. Considerations • Remember that each child is unique • A severe visual impairment affects visual skills as well as other areas of development, and many infants who are visually impaired may have additional disabilities • Collaborating with the educational team to help the child optimize his/her skills in all areas is a crucial • Depending on the child’s areas of needs, the child will benefit from a multidisciplinary team approach to address the family and team’s concerns • Use of adapted equipment • Safety is a priority!

4. Vision in Early Motor Development • Newborns - Visually goal-directed movements: looking, reaching, grasping, head control, learning equilibrium, communication with gaze and reciprocating expressions and body language • Mobile - Moving is guided by vision for direction, for equilibrium and balance. • Objects that cannot be seen do not exist • Cause and effect • Seek independence • For those affected by a visual impairment, they learn about the world with different senses and then process it differently. It does not mean they are impaired. It just means when addressing and working with them, we have to be aware, they don’t learn like you learn.

5. Typical Pattern for Early Motor Development Cephalocaudal (Head to Tail progression) Proximal to Distal (midline out to extremities) Early large range movements to fine and precise small movements (random kicking to proper feet placements while walking) Core stability is essential to ALL movement

6. Impact of Early Motor Development due to Visual Impairment • Getz (2000) states that approximately 75-90% of all learning is facilitated via the visual pathways • Children may appear as uninterested or passive (First Steps, BCC, 1993) • Achievement of developmental milestones (e.g. acquisition of fine and gross motor skills) may be delayed or out of order (Kastein, Spaulding, & Scharf, 1980) • Purposeful and self-initiated movement may be delayed • Children may be fearful of open spaces

7. Motor Development with Visual Impairment Visible Traits: • Decreased muscle tone (First Steps, BCC, 1993) • Postural differences (Barraga, 1976) such as Deviated Head Position, with Stiff trunk and poor quality of movement • Wide base for stability • Self initiated vestibular system stimulating movements for a long time- e.g. rocking, swinging, eye poking, hand shaking and spinning. These inhibit acquisition of “normal” gross and fine motor skills • Diminished Static and Dynamic Balance • Fisted Hands • Diminished or altered self-image (low confidence) (Sonsken, Levitt, & Kitsinger, 1984)

8. Gross Motor Development (0-3 months) Without VI: With VI: Similar awareness of her body and movements by reflexes Delayed head control and may present with inability to focus on objects Muscle tone fluctuations – hyper or hypotonic Severe head lag during pull to sit Sitting – back arched excessively • Extension strength from flexed position • Tummy time – weight toward head without arm support due to being flexed • Gradual forward arm reach with straightening of body • Head up to look around • Sitting – rounded back with head lag. Falls forward • Standing – bears weight with legs and may step from reflex and not controlled movements

9. Gross Motor Development (4-6 months) Without VI: With VI: Less motivation due to lack of visual stimulation leading to less head lifting exercises. Because less opportunity to work on head strength, other postural stability achievements become delayed and more difficult. Very important to introduce different movement experiences during this time to provide sensory input to elicit motor output. • Improvements of head control while being held or held in sitting. • Tummy time: weight bear on their forearms with head up and shift weight. May push up on hands. Able to roll to side to free up hands. • Supine: Raise arms and legs up with kicking and hands to feet. • Sitting : back is more straight and needs less support.

10. Gross Motor Development (7-9 months) Without VI: With VI: Less variety of movement. Rounded postures due to decreased muscle tone, forward head. Self stimulating motions like rocking while on hands and knees but not moving outside base of stance. Wide base of support in various positions causing difficulty moving in and out of position. Decreased trunk segmentation. The stiffness reduces exploration and manipulation of their environment. • Sitting with arm support eventually to requiring no support. To challenging balance with reaching. • Tolerate hands and knees position (quadruped) and may rock forward and back. Eventually separate hands and knees and learn to creep. • Transitions: move in and out of positions from floor to sitting providing more freedom and opportunities to interact with environment. • Standing: weight bears better with support and may shift weight side to side. • May kneel, squat, and lower self to the floor and able to get in and out of position and has gained most of all components of movement.

11. Gross Motor Development (10-12 months) Without VI: With VI: Due to fear while standing, arms may be “W” and feet are positioned wide. Slowly, but able to learn to transition from horizontal to vertical position using less area for base of support. With parents to encourage and O&M to teach how to make environment safe and use sensory cues, child learns to initiate movement. • Higher level of movements with various speed, coordination, adjustments and refined balance control. • More use of hands with accuracy and coordination. Hands are used purposefully for daily functional activities.

12. Orientation and Mobility • Per Anthony (Pogrund & Fazzi, 2002, p. 330), there are four main areas to focus on: • 1. Continue to expand the child’s understanding of his or her own body, daily settings and location in various environments; • 2. Encourage, then help refine the child’s means of movement; • 3. Reinforce the child’s purpose to move within his or her environment so that he or she is motivated to explore and is capable of accomplishing a goal which requires having to move as the means to achieve that goal; and • 4. Assist the family and service providers in analyzing the child’s daily environments for safety and possible modifications that will maximize self-initiated and goal-oriented movement.

13. Strategies to Help Your Child Move and Explore! • Strategies for families to support movement and exploration • Support the child’s orientation by maintaining the placement of objects in the house in a consistent manner and using spatial terms to describe locations (e.g. “Your toy box is next to the tv”) • Provide additional time for your child to look at, listen to, and explore new objects or actively participate in household tasks to promote hands-on experiences in a functional manner so that they can expand in their understanding of their environment (and be independent as well!) • Provide a safe home environment for the child to encourage the child to explore on his/her own (e.g. using electrical outlet covers, keeping blind cords out of reach) • Positively accept the use of low vision and mobility devices in the child’s natural environments (i.e. home, school, community) • Optimize lighting and the use of color and contrast in the home to facilitate ease of movement and exploration for young children

14. Strategies to Help Your Child Move! • Strategies for families to support movement and exploration (continued) • Using objects with multi-sensory qualities • Tactual (e.g. chains of beads with a bead in between each one, combs, whisks) • Auditory (e.g. bells, measuring spoons, metal teaspoons) • Stand in front of the child instead of behind him/her or on the side to orient the child to move forward in movement and through space • Use tactile markers to help and motivate a child • Tummy Time

15. Strategies to Help Your Child Move and Explore! • Individualized Adaptations include but are not limited to: • Number of items used • Size of objects used • Distance of visual target from the child (e.g. within the child’s grasp to promote reaching) Source: Everyday Activities to Promote Visual Efficiency (Trief & Shaw, 2009), pg. 27, 398

16. Strategies to Help Your Child Move and Explore! • Vividness of color Source: Everyday Activities to Promote Visual Efficiency (Trief & Shaw, 2009), pg. 27, 398

17. Strategies to Help Your Child Move and Explore! • Vividness of color (continued) Source: Everyday Activities to Promote Visual Efficiency (Trief & Shaw, 2009), pg. 27, 398

18. Strategies to Help Your Child Move and Explore! • Contrast or simplicity of the background Source: Everyday Activities to Promote Visual Efficiency (Trief & Shaw, 2009), pg. 27, 398

19. Strategies to Help Your Child Move and Explore! • Complexity of the visual target Source: Everyday Activities to Promote Visual Efficiency (Trief & Shaw, 2009), pg. 27, 398

20. Strategies to Help Your Child Move and Explore! • Presentation method Source: Everyday Activities to Promote Visual Efficiency (Trief & Shaw, 2009), pg. 27, 398

21. Strategies to Help Your Child Move and Explore! • Illumination (e.g. natural lighting) • Familiarity with the materials • Preferred area of vision • Position of the child Source: Everyday Activities to Promote Visual Efficiency (Trief & Shaw, 2009), pg. 27, 398

22. Encouraging Children with Multiple Disabilities to Move and Explore! • Attach toys using suction cups or elastic to sturdy equipment (e.g. table, highchair) • Place safe materials in an area that is easily accessible to the child who may not be able to move independently (e.g. solid, high contrasting bins to store toys) • Create positive experiences when exploring various objects and textures (e.g. being held by a caregiver, lying on top of a comfortable blanket) • Describe everything in the child’s environment along a route while providing additional time for the child to process the information and explore • Use real objects • Have children participate in daily living activities using accommodations that are appropriate for the child Source: Early Focus (Pogrund & Fazzi, 2002), p. 373

23. Lilli Nielsen and Active Learning • What is Active Learning? • As the name implies, Active Learning revolves around the learner being active. • “Since I am unable to come to the room, the room must come to me.” (Nielsen, 2003) • Please Note: Dr. Nielsen’s approved equipment and books in the United States is through the LilliWorks Active Learning Foundation. Also, remember that safety of materials is a priority! www.lilliworks.org

24. Strategies to Help Your Child Move! • Head Control – Back, Tummy, Sitting • Rolling - Back to Tummy, Tummy to Back • Sitting – Supported, Weight bearing through arms, Unsupported • High Kneeling to Pull to Stand • Cruising • Walking Source: Snell, R. (1997) http://www.csun.edu/~hfedu009/innovations/html/motordev.html

25. Case Studies • Our parents have provided us permission to share videos and photographs of their children • Release of information and photographic release forms were obtained

26. Parent Panel • Tatiana • Aishling

27. Household items are inexpensive yet stimulating and fun educational toys/activities that may improve motor planning, promote active listening and learning, and encourage social-emotional development! Cardboard Tube Penny Can For additional copies of these hand-outs as well as other great resources for parents and educators, please visit the Braille Institute’s Child Development Center website: http://www.brailleinstitute.org/documents/index.php/ category/child-development Make and Take!

28. References • Anthony, T. L., Bleier, H., Fazzi, D. L., Kish, D., & Pogrund, R. L. (2002). Mobility focus: developing early skills for orientation and mobility. In R. L. Pogrund,& D. L. Fazzi (Eds.), Early focus. Working with young children who are blind or visually impaired and their families (pp. 326-404). New York, NY: AFB Press. • Blind Children’s Center. (1993). First steps. A handbook for teaching young children who are visually impaired. Los Angeles: Blind Children’s Center. • Getz, D. J. (2000). Comments on attention deficit disorder (or attention deficit hyperactivity disorder) and vision therapy. Retrieved from http://www.add- adhd.org/attention_deficit_disorder.html • Lilliworks. (2014). 10 Principles. Retrieved from http://www.lilliworks.org/sample-page/10-principles/ • Lilliworks. (2014). About AL. Retrieved from http://www.lilliworks.org/sample-page/ • Nielsen, L. (2003). Space and self. Active learning by means of the little room. Copenhagen, Denmark: SIKON. • Orel-Bixler, D. (1999) Clinical vision assessments for infants. In D. Chen (Ed.), Essential elements in early intervention. Visual impairment and multiple disabilities (pp. 107-156). New York, NY: AFB Press. • Pogrund, R. L., & Fazzi, D. L. (2002). Early focus. Working with young children who are blind or visually impaired and their families (2nd ed.). New York, NY: AFB Press. • Shumway-Cook, A., & Woollacott, M. H. (2001). Motor Control; Theory and Practical Applications. Maryland: Lippincott Williams & Wilkins. • Snell, R. (1997). Gross motor development in infants with multiple disabilities. In D. Chen (Ed.). Effective practices in early intervention. Infants whose multiple disabilities include visual impairment and hearing loss (pp.167-176). Northridge, CA: California State University, Northridge, Department of Special Education (ERIC Document Reproduction Service No. ED 406-795). • Trief, E., & Shaw, R. (2009). Everyday activities to promote visual efficiency: a handbook for working with young children with visual impairments. New York, NY: AFB Press. • WeeWaterways, LLC. (2014). Water-based method to improve your child's physical and mental development. Retrieved from http://www.waterwaybabies. com/ contact-us-order/

29. LilliWorks is dedicated to the Active Learning principle that “Everyone Can Learn” Source: http://www.lilliworks.org/sample-page/

30. Braille Institute will be hosting a special Active Learning Conference! The 2014 Southern California Active Learning Conference will provide information on Active Learning with special focus on a budget friendly approach. No childcare will be provided. Presenters: Trisha Borg, Special Education Teacher, Narbethong State Special School, Australia Lori Enroth, LilliWorks Active Learning Foundation Board Member & Educational Outreach Coordinator Debbie Zimmer, Active Learning Advocate & Parent Deadline to register for this FREE event is on Friday, 4/18/14

31. In Summary… We aim for success no matter how small or how big the movement is!

32. Questions? Eunice Lee - eunicelee012@gmail.com Rosa Tu - Rosa.Tu.117@gmail.com Thank you for attending our presentation! A warm thank you to all of our TLC families who gave us permission to share their wonderful children and unique stories and experiences with you all. A special thank you to our parent panel, Tatiana and Aishling, for participating in today’s presentation and sharing their children with us! We would also like to thank: - Diana Dennis and TLC for their unwavering support and providing us this wonderful opportunity to share stories of our beautiful children and families. Sue Strafaci and The Braille Institute for granting us permission to use the wonderful Child Development Center’s resources. Lori Enroth for sharing information pertaining to Active Learning. Nikki Blackburn for her knowledge and thoughtfulness.