How Sensory Impairments Affect Gross and Fine Motor Skills in Children with Multi-sensory Impairments - Essay Example

?Education “Movement is the foundation on which all learning is built”. Van Dijk, 6 Introduction: Children learn through action and engagement in any activity. This engagement involves movement and exploration of the child’s surroundings. Through movement, children develop their motor skills and an understanding of the physical world. Moreover, through their interaction with others, they also gain a basis for language and social rules. Children who are multi-sensory impaired (MSI) face many challenges, especially in learning how to move through their environment because their lack of sensory input removes the stimulus for appropriate corresponding sensory reactions. In effect, the lack of movement often hinders their natural learning processes (Groce & Issaacson, 1995). Multi-sensory impairment presents unique challenges to teachers who must make sure that the person with varying degrees of visual and hearing impairment, with associated learning and physical disabilities, has access to the world beyond the limited reach of his / her eyes and ears. These teachers must try to include them in learning and in experiencing the physical environments that surround them. If they do not, these children may not have the opportunity to achieve development milestones (Langham, 1995). This paper discusses and explores the complexity of needs experienced by the multi-sensory impaired children and whether these needs have a direct impact on their gross and fine motor skills and their daily learning. This assignment is divided into the following sections. Firstly, I have attempted to define the importance of movement on individual development and the effects of sensory impairment on the skills related to movement. Secondly, I have outlined the abilities of one particular pupil as I observed him over the period of two weeks in order to gain an insight into his learning. I have provided information about the child’s special educational needs based on references to information in the school class files, archived materials (medical reports) and my own observations. Thirdly, I have tried to point out the various challenges that were presented to me during the course of my observations. Finally, various strategies which would enable the pupil to access and improve his learning will be discussed at length along with a comprehensive reasoning behind the choices made and their effectiveness when implemented. My role in relation to this project was chiefly concerned with observing and working with a pupil. It was important to collaborate with the physiotherapist, the occupational therapist, and the support staff as they provided additional information about the pupil. It was also very fortunate that my colleagues fully supported this project and wanted to find a way to improve the learning opportunities of the pupil. The aim of this assessment was to facilitate teaching strategies and activities that would improve his movement experience within the learning environment. I wanted my pupil to develop a greater sense of autonomy in terms of what he could achieve with the support of adults, and what he could achieve independently. The implication of sensory impairments on child’s motor development: “Movement is a feature of all man’s activities. Through the movement of our bodies we can learn to relate the inner-self to the outer world” - Laban, 1948:13 A typical infant follows a known developmental progression that starts at birth. As the infant grows and his central nervous system matures, the gross motor skills develop in a head to foot progression (Gesell, 1940). The gross motor skills occur in a typical sequence. However, these skills can only develop as the infant also develops balance, coordination and the postural control needed to move his body in space (Shumway-Cook & Woollacott, 1985). An infant's desire to reach out and explore his surroundings is the primary motivator that eventually leads to gross motor development. When an infant's sensory systems (e.g. visual, auditory, tactile, motor, etc.) are impaired or when his brain does a poor job of processing, organizing, or integrating the flow of sensations, his natural motivation for movement is often severely affected (Rosen & Joffee, 1995). Children initiate independent movement and exploration because of what they see and hear. They observe the movement of others and learn to imitate them. In the case of the blind / visually impairment child, the primary mode of obtaining information is unreliable, so the child would likely utilize other means of gaining information that can be formulated into other sensory concepts. Hearing is the only distance sense available to the blind / visually impaired infant. Unfortunately, even with input from the hearing and other senses, there is no guarantee that the information would have meaning to the child. Barrage (1983) suggests that vision integrates all other sensory systems. He further explained that vision verifies information received through the other systems for sighted infants. For example, when the sighted infant hears the sound made by a favourite toy, the child would turn to look at it, and then smile in recognition. On the other hand, the blind / visually impaired infant may hear the sound and turn toward, but he would require touch to verify the object. His / her response is neither immediate nor assured. Selma Fraiberg (1968) noted that sound is not a substitute for sight. Between six and seven months of age, hearing and holding are two separate events for the child who is blind. Her research noted that the beginning of search behaviour occurred between seven to nine months of age. Sensory input that is absent has a cumulative effect on the interpretation of the blind / visually impaired child. The child also has no control over the presence or absence of sound in the environment (Stephens & Grube, 1982; Stephens & Simpkins, 1974). Sounds can be very confusing when not paired with clear visual information. Only after much tactile, motor, and auditory interaction does sound acquire meaning. Only then can sound provide information about location, cause, or source. Without these essential pieces of information, the ability of the child to develop effective problem solving skills, which is a cornerstone of cognition, would be seriously challenged. For example, object permanence may not be obtained by the blind / visually impaired child until he / she has the ability to reach for objects using sound cues. The child may not be motivated to reach for objects since the results of his/her actions cannot be seen. He / she may not understand his ability to cause things to happen or his ability to retain pleasurable stimuli (Barrage, 1992). Vision impairment / loss will likely result in delayed gross motor and fine motor development. For example, lying on the stomach is frequently a position that children would not like due to lack of limited visual input from this position. However, this position is necessary for a young child in order for them to develop adequate head, trunk control, as well as trunk control in their arms. In addition, when the child has hearing impairment, they also lack visual and auditory cues, which may then cause fear or defensiveness about being touched or moved (McLinden & McCall, 2002). Careful attention has to be provided to gain the trust and comfort level of the child. A gentle touch to a specific body part may serve as an anticipatory cue and may help the child be better prepared for a motor activity. In effect, a gentle pulling upwards on the shoulder of a child may serve as an indication that they are about to be picked up. Although vision does not affect muscle use, lack of vision can indirectly affect a child's motor skills. The development of these motor skills requires interaction with the environment and where there is no visual interaction, development milestones like crawling and walking may be delayed. If a child is unable to see a desired object / observe other people walking, there is no motivation to reach it / imitate them. In effect, the child becomes less interested in learning or moving independently. These skills can therefore be slower to develop as compared to other motor skills that are more static, such as learning to sit in one place (Ray, et al., 2012). There is also evidence of delayed movement postures among children with visual impairments. This may be due in part to the presence of low postural tone, and the interdependent relationship of movement, as well as the acquisition of true object permanence and localization skills. Brown and Bour (1986) report that the reason many visually impaired babies have low postural tone is because they lack experience in the prone position. Limited opportunities in this position ultimately deny the child the needed proprioceptive stimulation for motor development. Low postural tone will often compromise the integrity of their motor skills, as well as their balance and strength. Balance reactions, trunk rotations, and actual motor milestones may also be influenced. In these instances, a child may be able to sit independently, however, the actual sitting posture may be compromised. A rounded back with legs situated far apart may be the only way the child can achieve independent sitting. Due to low trunk tone, the child may need to establish a wide base of support to maintain an upright sitting posture. These compensatory patterns may sometimes become habitual. If repeatedly used over time, the child is often vulnerable to physiological changes in his/her muscles; some of these muscles may lengthen and some may shorten to accommodate for compensatory posture (Campbell, 1983). Fine motor development requires movement of the small muscles in the fingers and wrists, usually in coordination with the eyes. Infants who have good vision explore their environments from the very beginning by using their sight. They learn to coordinate their eye and hand movements so they can manipulate a variety of toys. The beginning of "reaching" starts off with the visual stimulus. Children who are visually impaired must learn to coordinate the movements of their hands and arms with their functional hearing. They need to learn to use their hands in ways which would be functional, motivating and enjoyable. It is often assumed that tactile development is more highly developed in infants with visual impairments because they are dependent on it for their daily learning (Cutsforth, 1951). However, many children can be easily overwhelmed by, and become fearful of experiencing the world through touching, feeling, exploring, and manipulating objects. They are likely to manifest sensory dysfunctions, as well as abnormal responses to sensory stimuli e.g., hypersensitivity to touch, pressure and temperature (McLinden & McCall, 2002). Fine motor development does not occur in isolation, but is related to all aspects of development. Many infants with visual impairment do not receive sufficient opportunities in the prone position and, consequently, miss the experience of weight bearing on the hands, subsequent refinement of grasping objects as well as the chance to develop gross motor activities, like pushing to roll over or sit (Kitzinger, 1980). When neurological processing is impaired, difficulties with grasp, eye-hand coordination, and balance will be particularly noticeable. Muscles lose stiffness of movement and function because of the inability of the central nervous system to integrate fixed muscle patterns with brain signals. This also results in abnormal coordination of muscle activity. Abnormal muscle coordination then interferes with the child's ability to mobilize, and they become afraid to maintain balance and shift position or body weight while sitting. Many children find fine motor tasks challenging and will sometimes avoid participating in this task due to the resulting frustration, fatigue, and fear of frustration (Gallahue, 1985). The ability to use all the sensory systems simultaneously is critical in early development. Equally important is the ability to take information obtained through one sensory system and apply it to another. Children with multiple disabilities have unique needs due to the combined effect of several impairments that present unique challenges. The combination of the characteristics of the multiple impairments causes each individual child to have a unique response to different situations and different ways of learning. Different influences, both environmental and psychological, will cause a child to react and respond differently to a specific situation. Differences due to personal stamina, cognitive and motor abilities can create varying outcomes for children with the same multiple disabilities (Heller, Alberto, Forney, & Schwartzman, 1996). Therefore, it is important for the teacher to take into account each child's specific needs when considering and planning education. My observations: “Our pupils’ experience of the world may be very different (…). They may have limited awareness of the world around them because of sensory impairment or may be limited in their ability to explore what they can see, touch or hear because o restricted physical movement”. - Pease, 2011:4 In agreement with the above quote, I believe that sensory impairment poses unique challenges for children. These challenges imply much more than just the visual and/or hearing impairment they may possess. Many children have additional problems related to balance and the proprioceptive (sense of motion or position) system. They also have issues related to sensory integration as well as abnormal responses to sensory stimuli of any form. Along with various other learning and developmental setbacks, they also experience failure in effectively communicating and interacting with those around them, and these failures in interactions often affect their day-to-day learning. Hence, I believe that it was crucial for me to provide strategies for my pupil to support and develop any intentional movement already demonstrated. Such strategies would help him establish a greater sense of autonomy and assist him in experiencing and understanding the world around him. Illustrations of a pupil recently worked with Child Age Description of the problems faced Z 11 years delayed developmental issues, dystanic athetiod cerebral palsy, spasticity bilateral sensory neutral hearing loss, visual impairment, dysphasia, epilepsy Pupil Z entered my class as a pupil who was recognised as functioning at the very early stage of development. He has been following the Pre-formal Curriculum, which aims to address the needs of pupils working at developmental levels well below the National Curriculum standards. Recent results in the National Curriculum Assessment indicate that Pupil Z has achieved P-Level 2, which implies that he was functioning at a very early developmental level (Appendix 1). “Before arranging a specific environment, it is necessary to observe what the child is able to do (…)”. - Neilsen, 1997:65 From my observations of Pupil Z, it is evident that there were some inconsistencies in the comments made in the statement, in the multidisciplinary reports, and my personal experience working with the pupil in class. In terms of medical concerns, Pupil Z, on a daily basis, would receive ‘baclofen’ medication, which is used to manage and treat his physical condition, including his: muscle rigidity, muscle spasticity, and seizures. Pupil Z did not appear to suffer any side effects from his medication. Moreover, regular communication among the school nurses, the pupil, his parents, and myself, meant that his health and well-being was carefully monitored. Due to the poor function of his nervous systems, he also manifested difficulty in controlling muscles responsible for swallowing; moreover, he also suffers from “significant oral and pharyngeal stage of swallowing difficulties on both eating and drinking’ (Appendix 3). Due to swallowing difficulties, he could only eat pure food and pre-thickened drinks (Appendix 3). His weight and eating behaviour has been carefully monitored and assessed by the nurses and by the speech and language therapist. There was much concern raised about his daily nutrition intake and energy level due to optimum time needed (e.g., an hour at dinner time) to eat safely. Due to the poor functions of his nervous systems, particularly areas which control “automatic” functions, he also has problems in regulating body temperature. As a result, he often becomes hot easily, often putting him at risk for seizures. Adults who have worked with him commented that he has not had any seizures in the last year, although he still had problems in controlling his body temperature. In effect, constant monitoring of his body temperature had to be carried out by the nurses and teaching staff. In terms of mobility, Pupil Z does not have independent mobility. He is fully dependent on others for all his physical needs. He actually required specialized seating and support from the experienced staff in order to ensure access to class activities. He displayed a lot of involuntary movements which meant that it was difficult for him to control his gross and fine motor actions, even when his statement read ‘upper limbs are more effective then his lower limbs’ (Appendix, 2). His progress reports read that his attention to objects and activities continue to be limited due to his complex needs. Contrasted to this, I have observed him reaching for objects (e.g. on a side of his chair) and making attempts to explore or activate equipment with physical prompting. I have also noticed that the muscle tone in his upper limbs increased with mild to severe tone with activity. Difficulties in performing tasks often hindered his ability to explore and/or activate the task (e.g. pressing the switch to activate something). He did seem to be motivated by activities, however this motivation primarily depended on his interaction with an adult, with sensory stimulation, and with other resources which motivated and stimulated his interest. In addition, he appeared to be relatively good at feet reaching, however, he struggled with other motor skills, e.g. hands reaching. He communicated particular pleasure in using his feet rather than his hands in exploring different objects, materials, and substances. My observation of Pupil Z has confirmed that his communication skills were variable throughout the day and was often related to his positioning. For example, he was able to communicate his likes and dislikes to objects and activities by reaching out with his feet, by vocalizing, and by smiling (Appendix 4). In terms of his vision, he has ‘no visual distinction’, although his eyes are anatomically normal. ‘He has visual processing difficulties due to his brain damage’. His statement read that ‘he wears a hearing aid and seems to respond well to sounds’. However, adults who have worked with him commented that he did not tolerate wearing his hearing aid and often kept moving his ear forcefully until he worked the hearing aid off. In addition, his statement read that his ‘auditory results were poor and there is some doubt as to how much sound is getting through’ (Appendix, 2). Members of staff have reported that he is very curious about the sounds around him and that he uses his hearing well to make sense of the world around him. When travelling, he is known to use his hearing well to orientate himself with his environment, e.g. when hearing the sounds of school automatic gates, he will vocalize in protest. My observations have confirmed that he was aware of sounds in the environment and has responded to them through facial expression and body movements, e.g. stilling - when hear loud sound and smiling in recognition – and when hearing the same sound again (Appendix 4). The combination of information from the Pupil Z’s statement, information indicated in the school class files, archived materials (medical reports), and my own observations gave me a basis for my investigation. I now needed to evaluate how the pupil’s learning through movement can be improved. I felt that in line with school policies and procedures, the use of the team approach (support staff, the physiotherapist and occupational therapist) was also necessary to support a better working environment for Pupil Z. Implications of the study: The major barrier that I faced while collaborating with the school physiotherapist and occupational therapist was the lack of time available to discuss issues. Moreover, there were different points of view seen in relation to a variety of issues, including how to organise Pupil Z within the physical environment. The physiotherapist and the occupational therapist stressed the importance of good posture in order to prevent spinal deformities. They indicated that this posture can be ensured by keeping activities and objects in front of Pupil Z within his tactile field. However, when it came to accessing activities on his tray (sitting and standing position) the effort it had taken him to move his arms into this forward position had been at the root of my concern. From my observations, it was evident that he found it very difficult to access objects on his tray and the intervention of the adults played a significant factor in enabling him to reach for objects on his tray (Appendix 4). What I wanted was for Pupil Z to focus on reaching with his hand without being distracted by individuals guiding his hand. I wanted adults to support him to a comfortable position. Difficulties in controlling his movements meant that the adult supporting him had to overreach to position his hands back on tray. I observed that the pupil was able to access objects himself on the side of his chair and communicate his pleasure in exploring them, however, the physiotherapist commented that these activities encouraged bad posture. There were also moving and handling issues to contend with when considering using movement / different positioning within activities for Pupil Z., e.g. his weight, muscle forts, etc. There was the issue that Pupil Z was becoming increasingly heavy and strong; and at times he was difficult to move due to his strong involuntary movements. Sometimes it could take up to three adults to move him safely through a manual hoist. My colleagues were concerned about how to manage facilitating activities when there were only three of us to manoeuvre six pupils. I felt this problem could be easily overcome in the long term, if we had access to special adaptive equipment, such as a ceiling track hoist and positioning devices (e.g. rising bed) which could reduce the issues of timing and reduce the number of adults needed to move / support motor-impaired pupils safely. We needed more recourse to keep pace with the rising population issue. After discussions with my colleagues, I realized that their main concern was on how to prevent any further deterioration of Pupil Z’s physical well-being, and how to improve his education through movement. I agree that Pupil Z was a very vulnerable young person and it was necessary to respect his right to education; moreover, any deterioration of his health and well-being was equally important. I also felt that it was also necessary that I continue to look for ways to modify and adapt the environment, making it accessible and safe for him to independently experience his environment. Despite the shortcomings of the collaborations, the whole experience has increased my sensitivity towards the needs of Pupil Z and has also paved the way for improving his learning. Based on my findings, I have drawn the following intervention plan for pupil. Intervention plan: “(…) it would be of benefit to the child if teachers would exclude from their educational methods the approach of guiding his hands. The only strategy (…) of value (…) is his own”. - Nielsen, 1996:31 I recognise that pupils with physical impairments can benefit from adult support. However, I also believe that adults can support them in reaching objects without being too intrusive. Where adults are more intrusive, children would lose motivation for learning and for movement. I agree with Lillie Nielsen’s notion that if we provide too much direction (hand-over-hand assistance), we would teach children that only adults direct learning. In these cases, we are teaching them to be extremely passive or to expect physical assistance all the time. I have witnessed through my observations and in working with one particular pupil in my class that it is best to be less intrusive in the child’s development. I accept Lillie Nielsen’s notion that it is our role to help children learn by creating an environment which would encourage them to use their bodies and minds to explore learning independently and to reinforce what they have learned based on their priorities (Nielsen, 1977). When I reflect on the amount of movement that the pupil experienced in a week, it seemed that there were too many occasions when the pupil was in fact in a ‘static’ position. My lessons were often carried out by guiding his hands, feet, or body to perform the movements necessary for the task, or by persuading him to smell or to listen. When I looked at my timetable schedule, there was little flexibility left for him to engage in facilitated activities that would have given him learning opportunities for imitated tasks and for independent explorations. Consequently, he often rejected / withdrew when approached with tasks, apparent in him closing his eyes and/or sleeping. In some cases, he would perform a simple skill (e.g. activating the Big Mac switch) but most often, he only displayed initiative and independence when he was prompted or persuaded by an adult. His lack of motivation detrimentally affected the quality of his school life. His poor comprehension in school made me question the efficacy of his education. After sharing same concerns with my teaching staff, I decided to carry out a two-week observation plan in order to determine his existing skills (what he can do) and preferences (activities, positioning, objects). I felt that the first step I needed to take in the program involved knowing Pupil Z’s preferences. I felt that these preferences can then guide me in choosing objects and activities that would motivate him to learn. Then, I knew that I could implement these activities in order to establish change and improvement in the long term. Winnicott (1980) pointed out the importance of the ‘transitional object’ in human development. He discovered that by observing the early interaction with primary care givers that every child has a favourite object which almost always forms part of his experience. This special object helps in the transition from old to new objects and experience. I feel the notion of ‘transitional object’ is very apt in light of the observations I have made. It was therefore necessary, for motivational purposes to observe which objects Pupil Z liked to play with and to include these when introducing him to new objects and activities. My observations have confirmed that he has a good repertoire of activities and objects that could engage his interest. He has also the ability to explore independently as well as to participate in activities for a prolonged period of time when he is given opportunities to freely move his limbs on a mat / bed. His most preferred ways of exploring stimuli was with his feet while lying on his back. During his explorations, he often made contact with, reached, and modified the form of his legs by kicking mobile parts (e.g. bells to ring, mirror to spin, etc.). My observations have also confirmed that most of the time, he found it extremely difficult to access stimuli (e.g. tactile mat) or a position appropriately on his tray (Appendix, 4 & 5). “The hands are the eyes of the blind (…) an irony in the case of a large number of infants whose hands may be blind to”. - Fraiberg at el., 1968:133 I agree that our hands are an incredible tool. They play a leading role especially in the first months of an infant’s life, but for some blind / visually impaired children these hands are a crucial tool for learning and therefore, their use should be encouraged and supported. Even if a child’s opportunity to access the world through the use of touch is also affected due to motor problems, it is still important for the development of this child to encourage active hand behaviours (McLinden & McCall, 2002; Nielsen, 1977). Various issues are apparent in the case of Pupil Z, who is suffering from extreme muscle spasms that affected his ability to control and explore the physical world through hand movements. I believe that we must step back and carefully observe a child’s behaviour in order to determine his developmental milestone rather than continuing to impose teaching strategies that may be age appropriate but are actually inappropriate to their developmental level. Fraiberg at el., (1968) note that spontaneous kicking is one of the most common behaviours seen in the first month among infants, and by kicking their legs several hundred times per day, infants are learning about the properties of their limbs and how they can eventually control their bodies. If a child will not have enough stimulation or opportunity to perform this task, he / she may stay on that very early developmental level for a prolonged period of time. I feel it is important to provide Pupil Z with as many opportunities each day to release the energy from his legs by offering him a wide variety of objects to explore. It is also important to treat his feet as tactile tools from which he can experience, explore and learn basic concepts, e.g. cause and effect, etc. (Appendix, 4 & 5). I agree with Fraiberg at el., (1968) that learning is possible if the child is given opportunities which are appropriate to his developmental level. Only then can he discover, experiment, and explore a wider range of materials and objects; and only then can he be given sufficient time to explore, repeat and carry out actions as many times as necessary. I believe that in helping a child to learn, it is possible to create environments that build on skills which the child already has. In the short term period, I observed that the Pupil Z not only used his feet consistently to explore objects but that he has also used his feet to examine areas outside his bed/mat. For me it was a first sign that the pupil is beginning to grasp the concept that there is a physical world beyond the reach of his legs. “The environment must be rich in motives which lend interest to activity and invite the child to conduct his own experiences”. - Montessori, 2012:1 I agree with Maria Montessori (2012) and Lilli Nielsen that the philosophy behind the approach of creating environment and activities for learning is that, if a young child at the earliest developmental level is given an opportunity to learn from his own active exploration and examination, he will achieve skills that become part of his personality. These skills, then, become natural for him to use in interaction with others and to use for the fulfilment of his own needs. They will gradually make him ready to react relevantly to instructions and education. In other words, he will learn to be as independent as possible. The choice of materials in both approaches is both cost-efficient and logical. Children are more attracted to great colour contrasts (e.g. black and white). Household items that are often rich in sensory features are inexpensive and the range of items available is almost unlimited. Lilli Nielsen (1979) advocates that with repetition, the necessary conditions for the beginning of experimentation keeps alive the sense of curiosity, and it gives the child the opportunity to experience more patterns. Favourable environments provide feedback and support for the learner, prompting them to take action based on their own initiative. My observation and working with Pupil Z has confirmed that these strategies can best support pupils’ learning when there is a concerted effort on the part of the team, when there is additional time given for the presentation of tactile information, and when there is a systematic evaluation of adaptations. A teacher’s instructional style certainly influences what a pupil learns. For this reason, we should be even more careful when planning activities and using strategies. The teacher must convey his or her instructional expectations and information through physical contact with the student. Conclusion: This assignment was initiated by a description of my growing interest in this subject. It then proceeded to discuss the importance of movement on individual development and the effects of sensory impairment on the movement skills development of Pupil Z. My aim was to observe Pupil Z and based on my findings, I have come up with strategies which could be used to support the pupil in his learning. Through collaborations and a number of observations I planned, carried out, and evaluated with Pupil Z, key issues arose- how to organise Pupil Z within the physical environment in line with school policies and procedures, how to ensure the health and physical well-being of pupil and the staff supporting him. Through my one-on-one observation of Pupil Z, I concluded that he seemed to be more motivated to use his feet rather than his hands to explore his physical environment. I discovered that he had the ability to concentrate, participate in activities, communicate, and stay alert throughout a school day for longer periods of time when his environment was modified and adapted. In the short term, I was able to highlight the reason why Pupil Z lacked the motivation to learn and in the process, I was able to come up with a few ideas on how to facilitate better the learning environment for him. Overall, I feel the issues which arose from this assignment need further investigation. Read More