Developmentally Appropriate Orientation and Mobility - Mount Sinai ...

DEVELOPMENTALLY APPROPRIATEORIENTATION & MOBILITYFACILITATING PURPOSEFULMOVEMENT IN YOUNG CHILDRENWITH VISUAL IMPAIRMENTSTanni Anthony, Ph.D.Deborah Hatton, Ph.D.Kevin A. Stewart, Ed.D.May 27-28, 28, 2008Ontario BLV Program

Learning Objectives• Define orientation and mobility and describethe developmental approach as it applies toyoung children who are blind/low vision,with and without additional disabilities.• Describe the components of early /developmentally appropriate orientation andmobility.

Learning Objectives• Describe the potential impact of blindness/low vision on motor development andmovement needed for orientation &mobility; and strategies for promoting thedevelopment of these skills using naturallearning opportunities.

“Children with visual impairment learndifferently, for no other reason thanthe fact that in most cases they cannotrely on their vision to provideinformation. The information theyobtain through their other senses isinconsistent, fragmented, , and passive.It takes practise, training, and time tosort all this out.”(Ferrell, 1997)

“Just think about how much childrenlearn by looking and throughobserving what is happening aroundthem. With reduced or absence ofvisual information children withsignificant visual loss are at risk inearly learning and development.”(Chen, 2002)

DEVELOPMENTALLY APPROPRIATEORIENTATION & MOBILITY

O&M for Young Children• Orientation can be defined as “knowing oneself as aseparate being, where one is in space, where onewants to move in space, and how to get to that place”(Anthony, 1993, p. 116).• “Mobilityrefers to motor development, including thenormal integration of reflexes, acquisition of motormilestones, refinement of quality-ofof-movement skills,and purposeful, self-initiated movement” (Anthony etal., 2002, p.328).

PurposeTo assist infants, toddlers and preschoolchildren ( (including children with multipledisabilities) in developing their sensory andenvironmental awareness to facilitatepurposeful and self-initiated movementpatterns through daily routines and playactivities.(Stewart, 2006)

Developmental O&M

Components of Early O&MDevelopmental O&M programs for young childrenshould include the following components:• sensory skill development,• concept development, and• motor development (including purposefuland self-initiated movement).Additional components for preschoolers include• environment and community awareness and• formal orientation and mobility skills.Anthony et al., 2002 ; Dodson-Burk & Rosen, 2002 ; Hill, RosenCorrea, & Langley, 1984

Components of Early O&M• Orientation—to to expand children’s s body concepts,daily settings, and locations within each environment• Mobility—to to encourage and refine independentmovement (including the use of mobility devices)• Purposeful Movement—to to reinforce children’sreasons to move in different environments• Environmental analysis for safety—to to assistthe family and transdisciplinary team in analyzingnatural environments, to ensure self-initiated andpurposeful movement(Anthony , Bleier, Fazzi, , Kish, & Pogrund, , 2002)

Analyze and build an environmentthat is supportive of sensorylearning.

Let’s Get Learning- Attachment- Concepts- Object Permanence- Cause/Effect- Means-endend- Imitation

What is learning?• Learning depends on cognition:Cognition is thought• Progresses beyond perception• Involves attachment, attention, body,object & space, communication /language• Developmental continuum

Cognitive development drivespurposeful movementChildren with severe visual impairments donot locomote—move move purposefully andindependently—until they acquire the objectconcept, the understanding that objects existeven though they may not be directlyperceived. (This is fair.)Bigelow, 1986, 1990, 1992; Fraiberg, 1977;Rogers & Puchalski, , 1988; Trösterster & Brambring, , 1993;Warren & Hatton, 2003

Attachment and Mobility• Secure attachment is believed to be relatedto the willingness of infants to venture outinto the environments to explore andexperience it.• Infants’ early social-emotional responseselicit and maintain proximity andinteractions with other people for protectionand survival, and facilitate development inall domains.

Attachment and Mobility• Social referencing provides children with theself-confidence to move and explore.• Severe visual impairments may impedeexploration and movement– by making attachment more challenging,– by possibly decreasing motivation to move outinto the world to explore it, and– by making it difficult or impossible to glace backat the caregiver (social referencing) during earlyexploration.(Warren & Hatten, , 2003)

ConceptsConcepts are mental representations ofimages and ideas and, for orientation andmobility, can be categorized as• body concepts,• object concepts,• environmental concepts, and• spatial and positional concepts.Long & Hill, 1997Skellenger Orientation & Hill, & Mobility 19973J

Concept Levels• Concrete—knowledge of specificcharacteristics• Functional—understanding understanding purpose orfunction• Abstract—understanding of characteristics andpurposes and ability to generalize to otheruses and situationsSkellenger & Hill, 1997

Body Concept / Image• Body concept describes theability to perceive andunderstand the positions orpotential positions of one’sbody.• Children with some usefulvision and with highercognitive abilities tend toLong & Hill, 1997have better body concepts.

Anthony, Bleier, Fazzi, Kish, & Pogrund, 2002Development of BodyConcepts• Awareness of touch, posture, and body movement(i.e., mapping of the immediate body)• Awareness of body parts through movement• Identification of body parts• Identification of body planes• Understanding relationship of body parts andplanes to movement• Identification of self in relation to objects and space• Laterality of self and objects

Facilitating Body Image inInfants and Toddlers With VI• Provide consistentnurturing, responsivecare with appropriatesensory cues• Encourage infantmassage• Play interactive, turn-taking games involvingwhole bodymovements• Play body movementand naming gamesduring daily routines• Provide sensoryexperiences that helpchildren become moreaware of their bodyparts and relationshipsamong body parts• Encourage purposefulmovement whilenaming body partsbeing moved.

Object Concepts• Object concept refers to understanding what anobject is and, later, its function and meaning.• Through repeated and meaningful experiences withobjects such as bottles, rattles, and rubber squeaktoys, infants begin to recognize the sensory featuresof objects.• Objects used in daily routines and natural learningopportunities help children to anticipateand participate in daily routines.

Object Permanence• The understanding that an object continuesto exist even if it is not providing currentsensory stimulation. (Warren, 1994)• Sighted infants develop this skill around 9months.

Strategies for PromotingObject Permanence• Recognize signalsthat convey interestin items recentlyremoved fromtouch.• Provide tactile and,later sound cues toencouragereaching.• Provide organizedand consistent playspaces.• Involve children inthe retrieval ofdesired objects.

The child learns that objectshave permanence.When interacting with the child, try to:• Let the child be an active participant inacquiring objects from their specific location• Let the child be an active participant inreturning objects to their specific location• Return to the location of a favorite ornecessary object frequently

Use of TraysMetal cake pan or wooden trayCardboard box top coveredwith contact paper and heldon with a clamp

Object SchemesDeliberate actions that involve objects arecalled object schemes. Examples of objectschemes include• bringing a ring to mouth,• playing with paper,• banging objects,• putting on a shoe, and• peeling a banana.

Object Constancy• Ability to perceive an object as unchangingeven under different conditions ofobservation.• Children acquire object constancy throughmultiple, hands-on experiences with objects.

Comparative Learning• Different objectsrequire differentactions.• Objects in the samecategory may havedifferent characteristics.• Objects have different sizes, shapes, textures,etc.Anthony et al., 2002

Objects differ from one another.When interacting with the child, try to:• Provide the child with enough time tomanipulate the objects.• Encourage the child to compare twoobjects.• Start with objects which vary greatlyand move to more similar objects.• Point out similarities and differencesbetween two objects.

Cause and Effect• Children learn that they can make thingshappen and control the environment.• Use hands to reach for items and to makethings happen.• Bounce up and down to signal “more”• Vocalize or gesture to secure “more” of afavourite food or activity.

Strategies to FacilitateCause and Effect• Arrange environment to entice movement tolocate desired objects.• Encourage use of gesturesor vocalizations beforethey receive “more”• Provide activities thatprovide sensory feedback from movement.

Means-End RelationshipsWhen children problem solve to identify amethod for securing a desired object oraccomplish a task.– Wiggling body to move closer to object– Reaching with mouth when holding object– Pulling blanket so that the toy moves closer– Unwrapping a snack– Opening a container to obtain an object

Imitation• Children with visual impairments may nothave the benefit of observing others andmay not be able to acquire as manyconcepts through imitation.• Need assistance in developing concepts andmotor skills that sighted children acquirethrough observation and imitation.– Rolling a ball back and forth– Pedaling a tricycle– Putting shapes in a form board

Environmental ConceptsAllow children to explore environments in asystematic manner without intruding.– Provide simple descriptions– Identify landmarks– Identify sensory features of areas– Keep furniture and toys in predictable positions– Task-analyze analyze daily events and have childparticipate as independently as possible.– Repeat experiences often

EnvironmentalConcepts

Development of SpatialConcepts• Mapping of body-toto-object object relationships• Mapping of size and shape relationships• Mapping of part-toto-whole relationships• Mapping of temporal space• Mapping of distant space

Strategies for Young Childrenwith Additional DisabilitiesStrategies that may facilitate cognitivedevelopment:– Engaging materials,– Repetition,– Consistency/routines,– Guided and independent experiences, and– Immediate positive reinforcement.

“Let’s Get Moving”- Developmental Principle- Challenges & Strategies

The Process of MotorDevelopment• Directionality– Cephalo-caudal:Infants’ musculardevelopment proceeds from head to toe.– Proximo-distal:Infants improve control ofmuscles starting at the midline of the bodyand moving toward extremities.– Gross to fine: Infants gain control overtheir larger muscles before their smallermuscles.Alexander, Boehme, , & Cupps, , 1993

The Process of MotorDevelopment• Sequence: With each developmental step,the next skill missed or not fully masteredwill affect children’s s abilities to achievesubsequent skill mastery.• Mobility and Stability: The acquisition ofcontrolled movement or of postural controlrequires both stability (maintaining aposture) and mobility.Alexander et al., 1993Gilfoyle, , Grady, & Moore, 1981

The Process of MotorDevelopmentSensation: Sensoryinformation is used tomotivate and direct allmotor behaviors.

Four Variables InfluencingMotor DevelopmentVariables that affect the rate andquality of motor development of youngchildren include• healthy brain maturation,• healthy central nervous system,• unaffected input from sensory systems, and• opportunities to practice skills.Allen & Marotz, , 1994

Early Reflexes• Involuntary responses to specific sensoryinput.• Newborns’ reflexive behaviours dominatemovement.• Become integrated into voluntary motorresponses within the first year.

Postural ReactionsAutomatic movements and adjustments inresponse to, or in anticipation of, changesof position in relation to the center ofgravity.– Righting reactions– Protective and supportive reactions– Equilibrium (Balance)(Brown, 1988)

Postural Tone• Postural tone refersto the readiness of themuscles to respond tostimuli from the brain.• Postural tone can betoo high (hypertonia(hypertonia),too low (hypotonia(hypotonia),or fluctuating betweenhigh and low (athetoid(athetoid).

Postural Tone• Children who have motor dysfunction canpresent with abnormal postural tone.• Postural tone is changeable and can beinfluenced by movement, handling,positioning, or the task itself.

Postural Stability• Stability refers to the ability to maintainbody posture as weight is shifted.• Young children may use certain positionsthat provide mechanical stability toperform a new movement (e.g., widebase of support).Alexander et al., 1993

Postural Stability• Another method infants may use to providestability is to fix or hold parts of the bodythrough muscle contraction.• Through maturation and the practice ofmovement, the muscles will be capable ofproviding dynamic stability.Alexander et al., 1993

BVI and Postural Development• Research results suggest that motor developmentis delayed and that infants who are blind/visuallyimpaired often have atypical patterns of motordevelopment.• The impact of visual impairment on early motordevelopment depends on a complex set ofinteractions between children’s s characteristics andthe characteristics of the social and physicalenvironment.Adelson & Fraiberg, , 1974; Ross & Tobin, 1997;Sonksen, Levitt, , & Kitsinger, , 1984; Warren, 1994

Child Characteristics ThatImpact Postural Control• Multiple disabilities• Prematurity• Amount of functional visionWarren, 1994

Influences of BVIon Postural ControlChildren who are blind/visually impaired may display• low postural tone;• decrease in head-righting responses tomovement;• lack of head and trunk rotation;• delays in the development of protective,righting, and equilibrium reactions; and• paucity of movement and decreased explorationof the environment.Adelson & Fraiberg, , 1974; Brown & Bour, , 1987; Hart, 1984;Prechtl et al., 2001; Sonksen et al., 1984; Tröster& Brambring, , 1993

Goal-Directed MovementCaregivers and earlyinterventionists shouldencourage goal-directedmovement, which involvespurposeful and self-initiatedmovement.Anthony, 1993

Transitional MovementAlthough children who are blindmay be able to sit and standindependently within the agerange of sighted children, theymay not move into, out of, orforward from these positionsat the same ages as sightedchildren. Adelson & Fraiberg, 1974

Crawling• Some children who are blind/visually impaireddemonstrate delays in crawling; othersnever crawl.• Developmental lags in crawling might berelated to the fact that reaching to objectsby sound alone occurs later in infantswho are blind.Adelson & Fraiberg, , 1974Fraiberg, , 1977Trösteret al., 1994

Strategies toEncourage CrawlingProvide opportunities to• reach while in the prone position andon all fours, and to• play on all fours, especially toencourage side-toto-side weight shifts todevelop the balance needed to shiftweight and free one side for movement.

Strategies toEncourage CrawlingFacilitate movementtransitions from sittingto all fours, as well asearlier transitions(prone to supine,supine to sit) to develop theunderlying components ofmovement needed for crawling.

Strategies toEncourage Crawling• Provide opportunities for childrento increase understanding of objectpermanence.• Use sensory informationto become familiarand to motivate themto move purposefullyin space.

Defined SpacesThe use of definedspaces with meaningfulobjects in predictablepositions can expandchildren’s s understandingof the environment andpromote independence.

Defined Spaces• Defined spaces are areas in whichmeaningful objects are kept inpredictable positions.• Defined spaces can be used across acontinuum of activities in a wide rangeof locations.• Highchair trays and cribs can serve asdefined spaces to encourage reaching

Creating Defined Spaces• The size of the area should be establishedinitially, and increased very gradually.• Heavy furniture, walls, or cabinets shouldborder at least two sides.• Toys and objects in the play space shouldbe highly meaningful and motivating.• These toys and objects should be kept inpredictable positions.

Fine Motor Skills• Fine motor skills include discretehand skills, or prehension.• Awareness of hands and theunderstanding that hands canbe used purposefully is an earlyfine motor milestone.

Strategies to PromoteEffective Use of the Hands• Helping infants findtheir hands• Facilitating hand-toto-handplay in midline• Facilitating thedevelopment of grasp• Providing multiple and variedopportunities for grasping

Strategies to PromoteEffective Use of the Hands• Provide firm proprioceptive input intothe hands.• Promote hand-to-handplay, hand-to-mouth play,and hand-to-foot play tofacilitate an awarenessof the hands and midlineorientation of the body.

“ It is not important to look at the ageat which a child achieves certainmilestones as it is to assess how thechild’s development is proceeding and thequality of that development.”(Nagaishi,, 1993)

Summary of Strategies• Active Participants• Experiencemovements• Positions• “Tummy” play• Movements• Interpret senses• Safe space• Encourageindependence• Positioning• Use of hands

Most ImportantEnjoy the successes, learn from themistakes, and have fun in theexperience of “ “Learning with yourChild”.(Anthony, 1993)