Makaton is a sign and symbol language added to spoken language to aid communication, when this is needed. The name "Makaton" comes from the first letters of the names of three speech and language therapists who together devised the programme in the 1970s: a researcher Margaret Walker, Katharine Johnston and Tony Cornforth, colleagues from the Royal Association for Deaf people.

Whilst Makaton has proved extremely beneficial in developing language and communication skills for many children and adults, for a child (or adult) with cerebral visual impairments (CVIs) it may prove inaccessible for several reasons:

Makaton requires language to be spoken at the same time as 'signing'. This creates problems for a person with CVIs as they are often unable to handle two senses at once. To look at something whilst listening creates particular difficulties. Makaton uses movement of the hands to create the relevant sign. Some people with CVIs require very slow movement to gain visual awareness, because for many with CVIs, movement is processed more slowly than it takes place, and so the movement may not be seen. This difficulty processing movement applies to anything which moves, be it water, a ball, a car or moving hands, such as in Makaton.

Makaton is often used as a 'joint' activity in classrooms, with several people speaking or singing and signing simultaneously. The need to process this extra information can add another barrier to learning for children with CVIs. For some, what may be seen, understood and responded to in optimum conditions, may not be possible to perceive in a group while in a visually 'busy' area.

The visual background against which the signing takes place, can add another layer of difficulty. Is the person who is signing wearing patterned clothing, badges or jewellery? Or is that person seated in front of a visually 'busy' background?

Do we have accurate information about the affected person's visual fields? Our experience is that undiagnosed visual field deficits are common, particularly in children who are nonverbal. For those in wheelchairs, visual field deficits are less likely to be detected, because there are no collisions or falls to raise suspicion of their presence.

So any combination of difficulties with seeing movement, or with visual crowding and clutter (due to varied degrees of simultanagnosia), low visual acuities or reduced contrast sensitivity perception, or visual field deficits can render pictures and hand signing invisible.

This means that all these issues need to be evaluated in all young people whose "learning difficulties" appear to render them unable to access these methods of communication, so that appropriate measures can be taken to make sure they are visible.

It is easy to attribute any lack of response to cognitive difficulties, rather than the fact that the person being signed to hasn't 'seen' and has not been able to process what is required of them, because the means of communication used does not take into account the range of cerebral visual impairments that might be present and their impact. It is essential to remember that at present many children and adults have undiagnosed cerebral visual impairments and are therefore at risk of being inadvertently excluded from communication because the methods being used are not accessible to them.

The person may also have cerebral auditory impairment, causing difficulty locating or recognising sounds. Just as visual 'clutter' may mean that something which a person may recognise and respond to when in optimum conditions and good health, they may find distressing in an environment filled with auditory and/or visual 'clutter', such as a busy classroom.

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