Teaching Students Who Are Deaf-Blind and Cognitively Disabled To Effectively Communicate Choices During Mealtime.
Carol Gothelf
Director, Education Services, The Jewish Guild for the Blind.

Daniel B. Crimmins
Director, Department of Psychology, Westchester Institute for Human
Development and New York Medical College Cedarwood Hall.

Caren A. Mercer
Principle, Guild School, The Jewish Guild for the Blind.

Patricia A. Finocchiaro
Coordinator, Day Treatment Program, The Jewish Guild for the Blind.


Individuals who are deaf-blind and have a cognitive disability may not effectively communicate their desires and choices even when provided with the opportunity to do so, in part because of their frequently limited communication skills. The ability of these individuals to make choices may be further constrained by instructional staff and caregivers, who anticipate their wishes and make choices for them. These caregivers and instructional staff may be acting with only the best intentions for these individuals, perhaps in the belief that they are unable to make a meaningful choice.

Often, however, these individuals have not been taught how to make a choice.

For students who are deaf-blind and cognitively disabled to achieve valued life outcomes, it is essential that they are able to effectively communicate personal choices. Given the essential nature of the ability to communicate choice and the potential barriers to choice-making, it is necessary to focus on teaching students who are deaf-blind and cognitively disabled the process of making meaningful choices and to develop a flexible curriculum in which they have opportunities to practice making choices within the context of their daily routines. Mealtime is ideal for this instruction. It naturally occurs on a consistent, daily basis, in school, at home and in community environments.

The act of communicating what one wants to eat or drink and receiving what one has chosen results in natural consequences that are highly motivating, thus reinforcing the power of clear communication.

The table that follows offers a set of practical guidelines for teaching students who are deaf-blind and cognitively disabled to make choices during mealtimes. It is offered as an aid to instructional staff and caregivers to illustrate the ways in which a typical daily activity can be utilized to teach choice-making within the context of a natural routine. In addition, it has implications for how the skill can be increased in complexity as the student progresses. We offer this as an example that can be applied in other settings and activities, which include selecting something to do, choosing with whom to do it, choosing where to do it, choosing when to do i,t or choosing whether to do it at all (Brown Gothelf, in preparation; Crimmins Gothelf, in press).

Table 1
Choice-making Instruction

Guiding Principle.
People typically make choices in the environments in which the outcomes of their choice are available.

Choosing what to eat should take place where the student normally eats.
Teaching choice-making in an artificial environment removes many of the naturally-occurring cues to the event.

Administrative policies and procedures should ensure that the choice-making process can take place. This may involve working with the cafeteria staff or revising lunch-time schedules.

Guiding Principle.
The boundaries in which the choice-making activity takes place should be defined through the use of appropriate aids and cues. Providing boundaries minimizes the visual-motor and cognitive requirements of orienting and reaching.

A dycem placemat can be used to secure a cafeteria tray on a table, or on the lap tray of a student's wheel chair. A second dycem mat can be used to secure the plates and glasses on the tray. (Dycem is a non-slip plastic that is helpful in stabilizing objects on surfaces. It comes in reels or sheets that can be cut to size. It is portable, easily cleaned, inexpensive and available from adaptive aids catalogs).

If cafeteria trays are not available or necessary, the plates of food can be placed on a dycem mat directly on a table. For students with vision, the color of the dycem should be selected to provide contrast with the tray or table and the plates.

Guiding Principle.
Individual preferences play an important role in enhancing motivation for the activity.

The student is presented with two entree samples, one at a time. The items from which a student is choosing should be two things which he or she is likely to want to eat.

Administrators should work with cafeteria staff to ensure that appropriate alternatives are made available. (E.g., if two hot meals are not available, a choice between a hot meal and sandwich, or between two sandwiches should be substituted.) Be aware that food preferences are influenced by a student's cultural and family background.

Guiding Principle.
The student is made aware of the food through tactile-kinesthetic cues (guided or paired movements between the teacher and the student), visual, verbal, gestural and object cues. The teacher must assess the conditions that facilitate comprehension (e.g., with gestures, without gestures, etc.).

For each sample of food, the student is moved through touching the plate, touching the food, smelling the food, and tasting the food. A staff member will say the name of the food, sign it, and shape the student's hands to sign the name of the food.

The student's receptive vocabulary may be limited. Natural routines should be maintained within the normal context of mealtime in order to help the student comprehend the expectancies for his or her behavior.

Guiding Principle.
Choices should be presented consistently in order to reinforce the physical structure within which choosing occurs. Placing the choices in the same locations in relation to the student's body each time they are presented helps the student to anticipate where the sample is likely to be.

The first sample is presented on the student's left, tasted with the left hand, and then removed. The second sample is then presented on the student's right, tasted with the right hand, and then removed. Care must be taken to ensure that the individual is not always choosing the sample on the right or the sample on the left.

The student's ability to reach, grasp, and manipulate utensils or the food itself, may be influenced by poor muscle tone, stability, or coordination, as well as limited visual functioning. Generally, proper postural alignment can be attained through the use of adaptive positioning equipment. Grasping and manipulating utensils can be assisted through the use of adaptive aids such as special spoons, plates with lips, or slant trays. (Campbell, 1987).

Guiding Principle.
Establishing routines within instructional sequences enables the student to anticipate the next step and encourages self-initiated choice-making. A pause or time-delay in a sequence (hands in the lap) may serve as a prompt to the student to initiate an interaction or make a selection (Siegel-Causey Ernst, 1989).

Both samples are then presented to the student. The student touches the left plate with the left hand, and the right plate with the right hand. As the student touches each sample, he or she is reminded of its name. The student is then directed to place both hands in his or her lap (using verbal and-or physical prompt as needed). The student is then instructed: It is time to pick what you want for lunch. Language input should be provided at a level and in a mode that the student can comprehend.

If a student does not respond when the question is repeated, the teacher communicates: That's OK, if you don't want the meat or the rice, I'll ask you again soon. Language input should be provided at a level and in a mode that the student can comprehend. The teacher should always return and provide the student with another opportunity and additional prompting if necessary.

Guiding Principle.
Reliable communication of preference depends upon a foundation of consistent responses to the student's non-verbal behaviors. Non-verbal behaviors need to be acknowledged by the teacher on the assumption that the individual is attempting to communicate meaningful dialog. This provides a basis for communicating shared meanings (Guess, Benson, Siegel-Causey, 1985; Williams, 1991).

The student chooses the desired food by touching one of the samples, by looking or facial gesture, by starting to eat, by vocal sounds and-or body movements, by signing or in any way indicating his or her preference. Considerations If the student reaches for both, or neither, the teacher must repeat the previous procedure, and reinforce that the student must choose one sample. The teacher must acknowledge any form of communication. If the student repeatedly reaches for both, he should be given some of each for lunch.

Guiding Principle.
Components of everyday routines should be utilized to establish correspondence between words and their meanings. Routines enable students to take an active part in the activity and to communicate with the teacher.

The staff signs finished for the undesired plate and moves the student through the sign finished and prompts the student to move the plate away.

Initially, the student may require the teacher to move his hands for him. Subsequently, the teacher and the student should cooperatively move their hands together, the student's hands riding on top of the teacher's. The teacher should pause in the pushing action, and allow the student to communicate a desire to continue by moving the teacher's hands.

Guiding Principle.
In addition to establishing correspondence between words and their meanings, the process of systematically using routines in the choice-making process must be established.

The teacher signs eat and the name of the desired food, and prompts the student to do the same.
This procedure must follow the previous one.

The teacher may choose other ways to communicate the same message, such as signing the student's name followed by the signs for wants to eat and the name of the food. Language input should be provided at a level and in a mode that the student can comprehend.

Guiding Principle.
Contingent communicative behavior is reinforced by getting the requested item.
The student communicates through an action or a signal to indicate his preference.

The student is served a full portion of the food that was selected.

The student must join the cafeteria line to obtain the full portion of food.

Table adapted from Gothelf, C.R., Crimmins, D.B., Mercer, C.A., Finocchiaro, P.A., (in press). Teaching choice-making skills to students with dual sensory impairments. TEACHING Exceptional Children; reprinted by permission of the editor.



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