In October 2014 Suzanne Little, one of the trustees of the CVI Society and a Specialist Teacher at Meldreth Manor School presented a paper to the ISNA Multisensory World Conference at the Hamk University in Finland.
Her presentation - "A colour tent 'little room' as an optimal and meaningful sensory environment for children with multiple disabilities and cerebral visual impairment" is reproduced here.
The use of bright coloured tents can provide an optimal ' little room' visual experience for children with severe cerebral visual impairment. It can open a door to the mind, which gives pleasure and a meaningful sensory experience to increase awareness and engagement. This paper will highlight the impact of these tents upon two young people, over period of two years, who have multiple disabilities and visual impairment and how individual programmes were planned from this approach. The experience empowered their lives as they began to increase their visual awareness as never recognised before and their attention to their world enlarged as further sensory experience developed. Reference will be made to a paper co-authored with Professor Gordon Dutton who is a leading Ophthalmologist in the research of cerebral visual impairment who considers that these tents are valuable in promoting visual awareness in children with profound visual impairment. As co-authors we consider that the value of these tents for children with brain damage due to cerebral palsy is immense, and that this information needs to be disseminated and shared for the benefit of others with complex health issues and needs as a method to promote quality of life and enable learning.
Over stimulation of noise clutter and visual clutter can be a major barrier to experiencing pleasure and learning and a highly unpleasant sensory experience for anyone with complex needs. Whereas, an environment which is designed around the person and their responses is the key to unlock the door to communication and the means to overcome barriers of over stimulation or stimuli which is not appropriate for the individual.The tent can provide a visual stimulus that has been minimised by cutting out extraneous sounds and providing one uniform colour, it is a colour tunnel,which is distraction free and provides a one colour focus. It is a tent to involve child and therapist in interaction and/ or the means to give a child some quiet time to explore with vision and develop awareness and attention in a space that appears to create a sense of pleasure, security and calm.
How can a colour tent be produced?The simplest method is the hand held tent which can surround a child's head and envelope both child and therapist. All that is required are sheets of fluorescent or brightly coloured material of one colour.
A frame tent can be created by tying or clipping large sheets of material onto a floor standing frame, with these tents it is possible to place a wheelchair under the material.
A hoop tent with material sewn or clipped onto the hoop structure can by secured by a hook from the ceiling as is the case with projector nets.
Net and material tents for light and colour effects. These tents are also valuable in creating a focused, quiet and distraction free environment, such as using projection nets with slow moving colour wheels.
Material can be hooked to a ceiling and hung as sheets to form a tent and the slow moving colour wheel can be used as a light and colour effect visual experience.
Why are these tents valuable? For children with severe brain damage due to cerebral palsy the tent provides a valuable resource in observing visual responses often seen for the first time.
In the paper co-authored with Professor Gordon Dutton, published in the British Journal of Visual Impairment January 2015, we discuss two children's case studies and the possibility of Balint 'Syndrome' as the underlying cause of severe visual impairment as experienced by many children with profound disabilities. The children who benefited from the colour tent experience had a profound impairment in seeing more than one or two items at once (simultanagnosia) due to presumed brain damage related to cerebral palsy. The impairment of primary visual functions leads to low visual acuities, low contrast sensitivities and limited visual fields and damage to higher functions can lead to impaired recognition and limits to the use of vision to guide body movements. With the two case studies discussed in the paper the severity of the children's visual impairments are such that they have been registered as blind and in their previous educational settings they had not been given any meaningful visual stimuli. Children with severe cerebral visual impairment may experience sensory overload through excessive visual and auditory stimulation and then their response maybe to either shut down or become distressed. The positive effects and the outcomes of the use of colour tents, which created focused sensory sessions, will be explored in two case studies as the tent effect cuts out distractions in a way which enables limited visual function to be used.
Ali is 9 years of age and she has profound quadriplegic cerebral palsy and is registered blind. When Ali joined school she did not shown any visual awareness to the light and dark contrast equipment options in the multisensory room and was disinterested in visual stimuli. Ali greatly disliked noisy and busy environments and her response to these would be distress and engagement in self-stimulatory behaviours of banging her head violently with her fists and crying.
'When I first came to class I was unhappy and confused with the noises that I did not understand and in a space which seemed big and without meaning for me. I was surprised when I found a whole new experience that I had never known before as I discovered a lovely place where the noises disappeared and I felt safe and there seemed to be something interesting that I could see surrounding me and that was new to me. I liked this place it helped me feel calm and happy and I had fun listening to people sing my name and sing poems to me. I found they liked my happy vocalisations and we could chat together with my sounds. I also had time to explore by myself without anyone interfering with me and I liked finding objects which made interesting sounds which were in my special little room.'
When Ali first experienced a hand held bright orange colour tent her response was to immediately calm from her distress as she smiled and gazed around at the colour tent. The tent had the effect of creating a calm focused environment in the classroom. Ali's response from not showing any visual awareness changed to completely aware and attending to the tent and colour as she gazed with pleasure and concentration for several minutes at a time, for periods of up to twenty minutes. Ali's sensory visual threshold was meet and crossed as her capacity to become visually aware was awoken and facilitated by the tent 'little room' effect.
After a period of a few months of using the tent Ali changed from her use of shouting and biting her hand to using gentle sounds and claps in turn taking both within the tent and without it. The periods of time she uses the tent have decreased over the two years of monitoring as she appears to feel secure in other environments providing they are not crowded or noisy. Ali still uses the tent for some moments of calm when she is tired or unwell.
The outcomes from using the colour tent are positive as Ali has increased her willingness to interact with others and explore the environment outside the tent and she has begun to use her visual awareness with one piece of equipment in the multisensory room; in keeping with the assessment of her visual awareness and sensory responses in requiring one item of appropriate stimulus at a time. Ali has discovered that it is possible for her to work slowly and quietly and the colour tent has provided a meaningful experience.
Tom is 17 years of age and has profound quadriplegic cerebral palsy with cerebral visual impairment and he is registered blind. Past education reports state that Tom very rarely lifted his head to use his limited vision. This was partially considered to be caused through his poor head control. However, with the use of colour tents Tom improved his head control dramatically with and without the tent as he is motivated to discover new found visual stimuli. This has had positive outcomes in his engagement with others senses, such as touch, providing the stimulus is one thing at a time and time allowed for Tom to respond.
'I find it tiring to look up especially when there is no reason to lift my head. I have found a new experience which I enjoy and people comment on my smile as being in a colour tent is one of my favourite activities. I have made choices of my favourite colours and my most favourite colour is orange. I like to move my head to gaze around at the colour and I can't help myself but giggle at this new found pleasure. I have also found that it's good to keep my head up to use my vocalisations to chat to people who come close to me so I know they are talking to me. The multisensory room interests me now as I find I can track colours and light movement. I do not like being offered more than one thing at a time as this is confusing, but when I have time to explore I really concentrate on reaching out to touch sound objects which I can have on my tent frame. My favourite time is when I am free to look at the colour surrounding me then I leave that activity and explore a new one of reaching out to touch an interesting object, this is not an easy task for me as my arms are quite stiff but I do it and feel proud as I smile and vocalise to let people known what I have achieved.
The fluorescent orange colour material was the first hand held tent experience for Tom. This met and crossed his visual awareness threshold as he became attentive and motivated to lift his head to look around at the colour that surrounded him. From this engagement with a motivating stimulus a sensory programme was planned for Tom to have regular tent sessions. He used the tent frame in a daily routine for 15 -20 minutes at a time in which he remained involved with the pleasure of using his limited vision. Even whentired Tom appeared to enjoy the tent as it had the effect of reviving his interest in sitting upright in his wheelchair to use his vision and his facial expressions and smiles clearly demonstrated the value of this experience. The outcome after only a few weeks was that Tom began to keep his head up with or without the tent and in different environments. He was eager to join in with his helper in using his vocalisations in interaction and began to demonstrate visual awareness and attention in using a communication aid to say hello which he located when it was 30 cms from his line of vision. Tom widened his sensory experiences to explore and locate a tambourine which was placed on the tent frame to enable him to reach with his limited arm movement and he was able to track it's movement from right to midline and a little to the left. This was achieved with determined concentration and total involvement. He also used his vision to scan the light and colour effects in the multisensory room and in the projector tent area in the classroom.
The overall outcome over the two year period for Tom is that he remains able to focus upon single items within the tent, but not more, indicating that he doesn't have the ability to experience more than one visual stimulus at a time, or profound simultanagnosia. Tom appears to enjoy being left alone in silence to explore his tent and find single items that he recognises such as a red tambourine. Following on from using a colour tent Tom has gained a better posture and is able to hold his head up to scan his surroundings, as well as being more involved in interaction with others. Even after a long period of ill health when Tom returned to school he responded with a vocalisation of delight and recognition when given his favourite orange tent.
Neurones that fire together wire together:
With reference to this famous quote from neuroscience and relating this to severe brain damage due to cerebral palsy; it is possible to see evidence of increased awareness from Ali and Tom's consistent responses in processing information. Ali and Tom have severely limited visual awareness but this evolved from their colour tent experience, to new responses of visual awareness and attention. It appears that the bright coloured material used to create the tents really motivated Ali and Tom and this has been evident with other students with multiple disabilities and cerebral visual impairment. The children were motivated in expressing their preferences when offered one colour choice at a time and the tunnel effect of the tent appeared to create a pure experience allowing and enabling visual engagement by creating a 'little room'experience and avoiding sensory overload. Providing that the sensory experience is given slowly and time given for an individual to find their own level of response, then further sensory experience can be added one at a time. These could be the sound of one word which is pronounced slowly with varying pitch and tone, or massage, reaching out to touch a sound object or with a music cue. In this way it is possible to find other sensory thresholds and cross these to increase awareness and attention and create new and meaningful learning experiences related to the child and their capabilities and interests.
he brain injury of children with multiple disabilities and cerebral visual impairment limits what can be seen and visual guidance of movement is profoundly impaired. Therefore, the tent effect provides a novel way of stimulating and assessing functional vision and offers the possibility to create meaningful sensory activities The tent eliminates distractions and being surrounded by colour acts as a motivator to children with complex needs to use their potential vision for the first time.
As stated by Tom's parents:"It's beyond our wildest dreams that the door to our son's mind has been unlocked,and you can now see what we know he is capable of."
How many more people with severe brain damage could benefit from this simple tent 'little room' experience?
References:Paper: Some children with multiple disabilities and cerebral visual impairment can engage when enclosed by a "tent": is that due to Balint's Syndrome?
British Journal of Visual Impairment, January 2015.
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Paul Pagliano (2012) The Multisensory Handbook:Multisensory Communication 5-51
Atiken, S & Buultjens M (1992) Vision for Doing: Assessing Functional Vision.
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