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Visual Supports for Children with Disabilities: Adaptations to the Home Environment

By: Malkie Adler, MS, CCC/SLP and Linda Rosenfeld, MS, OTR/L 

Published in Building Blocks, December, 2009

All of us rely on visual supports to get us through our daily routines. They can be as small as a watch, as large as a landmark building or as common as a food-shopping list. They help to keep us focused and stay on task, and they are even more crucial to children and young adults with disabilities in helping them to communicate, express themselves, and live their daily lives as independently as possible. Here are some real-life examples of how children and young adults with disabilities use visual supports. Some identifying details and names have been changed to protect the privacy of those involved. 

Communication 
“I see a ball up on a high shelf. How can you help me tell you that I want it?” People can communicate in many ways, and children who are unable to communicate using oral speech can still be effective and efficient communicators. Sometimes the communication can be very subtle, such as when a child focuses on a desired object for a longer period of time than a non-desired object. Children who are unable to communicate using oral speech, can use various forms of augmentative and alternative communication (AAC) to communicate. AAC is any mode of communication that does not involve oral speech and is used to convey a message. Some of these modes of communication involve the use of gestures, sign, facial expressions, objects, symbols, photographs, written words, communication books or a speech generating device (SGD). An effective system includes multi-modal methods of communication. For example, a child may sign for more, use an SGD to request, and indicate no using a facial expression. Children should be encouraged to use any/or all means in order to communicate at any given time. There is no single method that is better than another.

To improve a child’s communication at home, and engineer the home environment, the school-based and home-based speech-language pathologists must work together. For example, if a child has learned the meaning of symbols, a symbol he recognizes as representing the kitchen can be placed on the door to the kitchen. Likewise, symbols that the child knows represent various actions (e.g., walk, go, stop, turn) can be affixed to a child’s walker.  A child who wishes to communicate that he wants to play with a ball can use a sign or gesture, look toward the ball or use a picture of a ball on a communication board. Remember, it takes two to communicate, so the child will always need a partner to communicate with and to model appropriate communicative interactions from. 

Schedules 
Visual schedules help us to get through our daily routines, remember important dates, and allow us to know what to expect at any given time. We use visual schedules like a personal planner, or desk calendar on a daily basis. Schedules can similarly help children and adults with disabilities to organize and manage their day. They can be created by writing a list, using pictures, symbols, or actual objects. 

“It’s Sunday morning and I have so many things to do that I don’t know what to do first. What can I do to help organize my day?” 

Allowing a child with a disability to participate in setting up his schedule gives him the opportunity to choose activities that will be part of his daily routine. A visual schedule will let him know what will be expected of him throughout the day, as it will act as a visual reminder for him. There are certain aspects of a child’s day where it may not be realistic for him to make a choice e.g. taking medication, or going to school, but he can still be given a choice as to who will give him his medication or help him get ready for school. For a child who cannot write and may not yet be at the level of understanding symbols or pictures, a visual schedule can be created using actual items (e.g., a spoon to represent mealtime, a paintbrush to represent an art activity). Taking pictures of the activities or using symbols that represent the activities that the child will be involved in can also be used. Visual schedules can be affixed to a wall in a central location of the house, or carried around by the child in a book for convenient reference. 

As each task is completed, the picture, symbol, or object can be placed in a separate section marked finished, or just checked off. Visual schedules eliminate the element of surprise as the child goes through his day, and makes transitioning between activities easier, because the child knows what to expect. This should help to reduce the child’s anxiety while keeping everyone involved with the child organized. 

Rachel is a non-verbal, ambulatory 12-year-old girl. She resides in a group home and loves to read books, listen to music, and play video games with the Wii. To communicate, Rachel uses facial expressions, gestures, sign language, an SGD, as well as a limited number of vocalizations. When Rachel gets home from school she creates a picture schedule for herself with the help of her counselors. One day, after coming home and eating dinner, she changed her mind about the next activity on her picture schedule, which was reading a book. She decided that she wanted to play a game on the Wii instead.

At first Rachel became upset, but then she realized that she all she needed to do was to let her counselors know what she wanted. She was not sure how to describe the Wii using her SGD. Since the Wii was not visible, she could not point to it and she did not know the sign for it. She did however have a photograph of the Wii that was part of her picture schedule. Rachel took her counselor by the hand, brought her over to the schedule, took the symbol for the Wii and then placed it next on the schedule. Her counselor then understood what Rachel wanted, and complied with her request to change her activity, putting Rachel in a good mood for the rest of the evening. 

Choice Making
The ability to make choices allows children with disabilities to exercise greater independence and increased control over their environment. 

“Everyone in my family is making decorations for the sukkah. I am sitting in my wheelchair and watching them. How can I participate?” 

It is important to give children with disabilities every opportunity to make choices when participating in various activities using the methods that work best for them. These methods include using eye gaze, touching or swiping at an object, pointing to a symbol or picture representing their choice, and/ or vocalizing. 

For example, when dressing in the morning, a choice of two different shirts can be held in front of a child, and he can make his choice by touching the desired shirt, looking at it, or verbalizing. Similarly, when doing an art project for the sukkah, two different colored paint bottles can be held up and the child can indicate his choice via eye gaze, touching one of the bottles or vocalizing. If the child understands the use of symbols, a board with a choice of colors can be provided, or created using a computer program. Even if the child is not able to physically point to the desired color, they may have other ways to indicate a choice, e.g., through a yes/no response, smiling or vocalizing.

Activities of Daily Living 
Activities of daily living (ADLs) are activities that one is involved with as part of a daily routine. They may be as simple as washing hands and brushing teeth or as complex as doing the laundry or preparing a meal. “I got my hands dirty when I was eating dinner. I now need to wash my hands and I want to do it by myself but it is difficult for me. I don’t know where to start. How can I learn to be more independent in this area?” Activities of daily living can be modified or adapted so that people with disabilities can be as independent as possible. The ADL can be broken down into steps, objects, pictures, and/ or symbols representing each part of the activity, which can be assembled into a task strip. For example, when sequencing the ADL of hand washing at the sink, a task strip can be created to visually break down the activity into simple steps, i.e., turn on water, take soap, wash hands, turn off water, take towel, dry hands, put in garbage. A task strip for any ADL can be as simple or as complex as necessary. These task strips act as visual cues or reminders to help the child complete the task. The task strip also encourages consistency. The language on the task strips does not change, and therefore, the child will learn to complete the task the same way each time, regardless of who is helping him. This will help the child to learn the proper sequence of steps to complete it successfully. Other visual supports, such as checklists, symbols, and/ or actual objects, can be used modify an ADL and guide a child through a task. Any ADL can be broken down or built up to meet a child’s needs and help to make him as independent as possible. The following anecdote illustrates how an ADL can be modified through the use of a checklist as a visual support. 

Ezra is a 19-year-old boy who is ambulatory and verbal. He tries to be helpful around the house, and has gotten his parents’ permission to learn how to do his own laundry. However, when he first tried to do it, Ezra became overwhelmed with all the directions and lost his focus on the task. His parents helped him by breaking the task down into two separate parts, each with its own list of tasks. The first list told Ezra all of the things he would need in order to do his laundry. The second list contained the exact steps he would need to follow. The lists were then laminated so that Ezra could check off each step with a wipe off marker. This has allowed Ezra to do most of his laundry by himself and be successful. 

The proper use of a visual supports system requires prior consultation with the child’s speech-language pathologist or occupational therapist. It is important that the school and home teams work together to meet the child’s needs. The use of a visual system takes time to create and learn for both the caregiver and the child who will be using the system. Consistency across all environments is fundamental to success. Through the use of visual supports (symbols, pictures, lists etc.), providing choices, using different modes of communication, and modifying ADLs, children with disabilities can become more effective communicators and can participate in daily activities to the bet of their abilities.

Malkie Adler, M.S., CCC/SLP, TSSLD is a licensed speech and language pathologist who works in a schoolbased program and in an Ohel Bais Ezra residential program with children with varying disabilities using augmentative and alternative communication. Linda Rosenfeld, M.S., OTR/L is a licensed pediatric occupational therapist who works in a schoolbased program and in an Ohel Bais Ezra residential program. She works with children who have physical and/ or cognitive limitations to improve their performance in daily living and school-based tasks. OHEL Children’s Home and Family Services, which incorporates Bais Ezra and The Lifetime Care Foundation, provides programs and services for individuals and families at risk, and individuals with developmental or psychiatric disabilities, in both residential and out-patient settings. OHEL’s professional services are available throughout New York, New Jersey and South Florida. For more information, please call 718-851-6300 or visit www.ohelfamily.org.

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