When it comes to treating mental disorders, psychologists have an arsenal of tools at their disposal. But that armament may need to be refined when the client has a physical disability as well as a psychological impairment. In addition to traditional techniques, psychologists need to draw upon creativity, hone communication skills and practice patience.
Mary Talbot-Fox, Ph.D., NCSP, school psychologist at Perkins School in Watertown, Mass. who works with students with vision impairments, explains that psychologists face two major stumbling blocks when working with this population: helping parents and other professionals understand that not every problem is related to the disability and the lack of valid assessment instruments.
“Families often attribute every problem to the blindness. It’s hard for parents to accept. As you follow a child, you can disentangle the situation,” Talbot-Fox says, noting that delays in mannerisms and social skills are to be expected in children with vision impairments.
Before deciding on a course of action, Talbot-Fox conducts interviews with parents and teachers and observes the child, preferably in the classroom setting. She assesses the cause of the vision loss, which may be the catalyst for explosive or aggressive behavior, anxiety, obsessive-compulsive disorder or other psychological issues. “Responses to loss of vision form a big part of the emotional response,” she notes. “Children who are blind from birth due to retinopathy of prematurity may also have a whole range of other problems. Some could be non-ambulatory or non-verbal. They may develop skills, but have difficulty with behavior regulation.”
Talbot-Fox explains that through standardized testing she tries to determine the behaviors that are separate from the vision loss. However, the tests themselves present the biggest challenge. “There are not a lot of good assessment tools. You have to rely on your own clinical experience,” Talbot-Fox says. “For ADHD, we use some standardized scales, but there are no norms for students with vision impairments. Those tests are not really appropriate or valid for our population. We don’t have instruments to gauge their emotional level.”
Parental involvement is critical in developing an appropriate treatment plan. Talbot-Fox says, “This takes a very big toll on families.” In addition to support and guidance from the interdisciplinary team at Perkins, parents have the opportunity to make contact with other parents. “This is very important,” says Talbot-Fox.
Pamela Ryan, MA, CAGS, one of four school psychologists at Perkins School, points out that regardless of age – the program serves ages three to 22 – the fundamental tool for effective treatment is communication. “The children need to have total communication, whether sign, speech, print or Braille. For some, we use pictures, sign language with typical hand-over-hand method or in the air signing,” she says. “There couldn’t be counseling, play therapy or evaluations until you have communication and a bond.”
Also, Ryan emphasizes the importance of teamwork. “Perkins has a very skilled social worker who does counseling. She also works a lot with parents, helping them understand how their child learns,” she says. “Some students have a consulting psychiatrist or a nurse who comes to the school with them.”
Talbot-Fox adds that occupational therapists help develop strategies to overcome sensitivities to touch and sound, which is common in people with impaired vision. On-campus resources, including a consulting neurologist, contribute to a child’s behavioral support plan.
At the Williams Center at the Austine School for the Deaf in Brattleboro, Vermont, Director Ray Stevens, Ph.D. explains that children with hearing loss have lived “disruptive lives” and have difficulty managing their own behavior. “They have a negative perception of the world and have less fortitude in applying themselves,” he says. In some cases, these children are conflicted, becoming angry and insulting and violent, while inwardly feeling gratitude for others’ willingness to help them.
Children who have hearing loss see life through a different lens than those with the ability to hear. Their condition comes with anger and paranoia, which is usually socially induced, so psychologists need to practice “rational detachment,” Stevens emphasizes. “You can’t take things personally. You have to be able to put your emotions aside and maintain a good professional relationship with the kids,” he says.
Communication also plays a key role for those with hearing loss. “These children have poor management of their impulses. Communication affects their condition, but doesn’t create the condition. Someone who is deaf often fails to get rehabilitation due to inadequate communication skills,” he says, citing the importance of teaching parents how to communicate effectively with their child.
“A child who is deaf is accustomed to a world of silence. If a couple who is deaf signs to their child, the child acquires language and emotional strength from his signing parents,” Stevens says. “These children overcome obstacles we’ll never understand.”
While books in Braille are available to those with vision impairment, no such resource exists for individuals with hearing loss, Stevens notes. “Language is a barrier to acquiring historical scientific facts,” he says. “Finland has a library of rewritten books for children who are deaf. We don’t have that in America.”
As a resident, Sandra B. Coleman, Ph.D., treated a ten-year old boy diagnosed with affective psychosis on a daily basis, but had no precedent for treatment. “Although I had the support of staff, there were no real guidelines at the time,” she says. Since the boy was non-verbal, Coleman had to devise some effective means of communication. Using a self-designed sign language, the two were able to make some progress. She found that storytelling was one of the most effective means of reaching the boy.
Working with this child taught Coleman that therapy for an individual with both physical challenges and psychological impairments requires experimentation and creativity in order to find the right approach. She notes that during the course of treatment the therapist learns about the patient and can tailor the most appropriate treatment. “You need dedication, patience and a non-threatening approach,” she says.
Coleman subsequently became director, Behavioral Medicine Department and faculty member in the Family Medicine Residency Program at Eastern Maine Medical Center (EMMC), retiring after 20 years and now has a part-time private practice in Bangor, Maine.
By Phyllis Hanlon