Sini Peltokorpi
B 752
AN
N
ALES UN
IVERSITATIS
 TURKUEN
SIS
TURUN YLIOPISTON JULKAISUJA – ANNALES UNIVERSITATIS TURKUENSIS
SARJA – SER. B OSA – TOM. 752 | HUMANIORA | TURKU 2025
Promoting bodily-tactile 
interactions between 
mothers and their 
young children with 
visual impairment and 
additional disabilities
Four early intervention studies
Sini Peltokorpi
 
 
 
 
Sini Peltokorpi 
PROMOTING BODILY-TACTILE 
INTERACTIONS BETWEEN 
MOTHERS AND THEIR YOUNG 
CHILDREN WITH VISUAL 
IMPAIRMENT AND 
ADDITIONAL DISABILITIES 
Four early intervention studies 
TURUN YLIOPISTON JULKAISUJA – ANNALES UNIVERSITATIS TURKUENSIS 
SARJA – SER. B OSA – TOM. 752 | HUMANIORA | TURKU 2025 
University of Turku 
Faculty of Social Sciences 
Department of Psychology and Speech-Language Pathology 
Speech-Language Pathology  
Doctoral Programme of Social and Behavioural Sciences 
Supervised by 
Professor Minna Laakso 
University of Helsinki  
Helsinki, Finland 
Saara Salo, PhD 
University of Helsinki 
Helsinki, Finland 
Reviewed by 
Associate Professor Iris Nomikou 
University of Portsmouth 
Portsmouth, United Kingdom 
Docent Laura Kanto 
University of Jyväskylä 
Jyväskylä, Finland 
Opponent 
Docent Laura Kanto 
University of Jyväskylä 
Jyväskylä, Finland  
 
 
 
 
 
The originality of this publication has been checked in accordance with the University 
of Turku quality assurance system using the Turnitin OriginalityCheck service. 
 
Cover Image: Saara Waked 
ISBN 978-952-02-0446-4 (PRINT) 
ISBN 978-952-02-0447-1 (PDF) 
ISSN 0082-6987 (Print) 
ISSN 2343-3191 (Online) 
Painosalama, Turku, Finland 2025 
  
 
To my brother Mikko 
4 
UNIVERSITY OF TURKU 
Faculty of Social Sciences 
Department of Psychology and Speech-Language Pathology 
Speech-Language Pathology  
SINI PELTOKORPI: Promoting bodily-tactile interactions between mothers 
and their young children with visual impairment and additional disabilities: 
Four early intervention studies 
Doctoral Dissertation, 220 pp. 
Doctoral Programme of Social and Behavioural Sciences 
October 2025 
ABSTRACT 
Children with visual impairment and additional disabilities (VIAD) may fail to 
perceive visual information from their parents’ facial expressions and gestures. In 
cases of congenital deafblindness (CDB), auditory information may also be limited. 
The parents of such children may experience challenges in detecting their child’s 
subtle bodily and gestural expressions. Such interactions indicate difficulties with 
accessibility, which may in turn compromise the child’s developmental outcomes 
and even the emotional relationship between the parent and child. However, the 
systematic use of bodily-tactile modality (touch and movement) during interactions 
could help to compensate for the child’s sensory loss. This thesis therefore 
investigates the effects of a bodily-tactile early intervention on the interactions 
between mothers and their children with VIAD or CDB, using a time-series design 
with a baseline, intervention, and follow-up; the follow-up spanned Studies II, III, 
and IV. 
In Study I, a mother was guided in the use of a bodily-tactile modality in which 
she imitated her three-year-old child with CDB. The results show that the mother’s 
tactile imitations increased during the intervention, that imitation exchanges became 
longer, and that the child began to respond more to her mother’s imitations through 
smiling and placing her hands on her mother’s face. Moreover, the child and her 
mother became more emotionally available to each other. 
In Studies II, III, and IV, four mothers were guided in the use of the bodily-tactile 
modality in interactions with their one-year-old children with VIAD. In Study II, we 
observed that the mother increased her use of the bodily-tactile modality in early 
social play routines and in tactile signing during the intervention. Her child 
developed new gestural expressions and imitated signs based on his bodily-tactile 
experiences. Their emotional availability was already good at baseline, yet there was 
still an increase during the intervention in the mother’s non-intrusiveness and the 
child’s responsiveness. The results of Study III suggest that the intervention 
increased reciprocity in the mother-child interactions, which was itself based on 
changes in the mothers’ interactional behavior. In Study IV, the mothers increased 
their use of bodily-tactile play routines, tactile anticipatory cues, tactile noticing 
responses, and tactile signs during the intervention. Moreover, the children and 
mothers were emotionally more available to each other during the intervention. 
 5 
Together, the results suggest that the bodily-tactile early intervention aimed at 
the mothers had a positive impact on the embodied participation and gestural 
communication of their children with VIAD. Positive changes were also seen in the 
emotional availability and reciprocity between the children and their mothers.  
KEYWORDS: Accessibility, bodily-tactile modality, early intervention, emotional 
availability, congenital deafblindness, multiple disabilities, visual impairment  
6 
TURUN YLIOPISTO 
Yhteiskuntatieteellinen tiedekunta 
Psykologian ja logopedian laitos 
Logopedia 
Sini Peltokorpi: Pienten näkömonivammaisten lasten ja heidän äitiensä 
välisen kehollis-taktiilisen vuorovaikutuksen tukeminen: neljä 
varhaiskuntoutustutkimusta 
Väitöskirja, 220 s. 
Yhteiskunta- ja käyttäytymistieteiden tohtoriohjelma 
Lokakuu 2025 
TIIVISTELMÄ 
Näkömonivammaisten lasten voi olla vaikea havaita heidän vanhempiensa kasvojen 
ilmeitä ja eleitä. Mikäli lapsi on syntymästään kuurosokea, hänen on lisäksi hankala 
vastaanottaa kuulonvaraista tietoa. Myös vanhempien voi olla vaikea tulkita 
näkömonivammaisten tai kuurosokeiden lastensa hienovaraisia kehollisia ilmaisuja 
ja eleitä. Ilmausten saavutettavuuteen liittyvät vaikeudet voivat heikentää lasten 
kehitysmahdollisuuksia ja lasten ja vanhempien välistä tunneviestintää. Kehollis-
taktiilisen modaliteetin (kosketuksen ja liikkeen) systemaattinen käyttö vuoro-
vaikutuksessa voi kompensoida näkö- ja kuuloinformaation puutetta. Tämä väitös-
kirjatutkimus selvittää kehollis-taktiilisen varhaiskuntoutuksen vaikutuksia näkömo-
nivammaisten lasten ja heidän äitiensä väliseen vuorovaikutukseen. Aikasarja-
asetelman mukaisesti aineistoa kerättiin ennen varhaiskuntoutusta, kuntoutuksen 
aikana ja sen jälkeen. Seurantavaihe sisältyi tutkimuksiin II, III ja IV.  
Tutkimuksessa I äitiä ohjattiin käyttämään kehollis-taktiilista modaliteettia 
hänen kolmevuotiaan syntymästään kuurosokean lapsensa ilmausten jäljittelyssä. 
Ohjauksen aikana äiti alkoi käyttää enemmän kosketusta jäljittelyssä. Äidin ja lapsen 
väliset jäljittelydialogit pitenivät, ja lapsi alkoi vastata äidilleen enenevässä määrin 
hymyilemällä ja asettamalla kätensä äidin kasvoille. Lisäksi heidän emotionaalinen 
saatavillaolonsa vahvistui.  
Tutkimuksissa II, III ja IV ohjattiin neljää äitiä käyttämään kehollis-taktiilista 
modaliteettia vuorovaikutuksessa heidän yksivuotiaiden näkömonivammaisten 
lastensa kanssa. Tutkimuksessa II havaitsimme, että varhaiskuntoutuksen aikana äiti 
alkoi käyttää enemmän kehollis-taktiilisia vuorovaikutusleikkejä lapsensa kanssa. 
Lisäksi äiti otti käyttöön taktiileja viittomia. Hänen lapsensa alkoi tuottaa kehollis-
taktiilisten kokemustensa pohjalta uusia eleilmaisuja ja jäljitellä viittomia. Sekä äiti 
että lapsi olivat emotionaalisesti saatavilla jo lähtötilanteessa. Kuntoutuksen aikana 
tapahtui vahvistumista äidin ei-tunkeilevuudessa ja lapsen responsiivisuudessa. 
Tutkimuksen III tulokset viittasivat siihen, että kehollis-taktiilinen varhaiskuntoutus 
lisäsi vastavuoroisuutta äitien ja heidän näkömonivammaisten lastensa välisessä 
vuorovaikutuksessa, mikä puolestaan johtui muutoksista äitien vuorovaikutus-
käyttäytymisessä. Tutkimuksessa IV havaittiin, että kuntoutuksen aikana äidit 
lisäsivät kehollis-taktiilisten vuorovaikutusleikkien ja taktiilien viittomien käyttöä. 
He alkoivat myös ennakoida tapahtumia ja vastata lapsilleen kosketuksen ja liik-
 7 
keiden avulla. Lisäksi näkömonivammaisten lasten ja heidän äitiensä välinen 
emotionaalinen saatavillaolo vahvistui.   
Väitöskirjatutkimuksen johtopäätöksenä voidaan todeta, että äideille suunnattu 
kehollis-taktiilinen varhaiskuntoutus vaikutti myönteisesti näkömonivammaisten 
lasten keholliseen osallistumiseen ja kommunikointiin eleiden avulla. Positiivisia 
muutoksia havaittiin myös lasten ja äitien välisessä vastavuoroisuudessa ja 
emotionaalisessa saatavillaolossa. 
ASIASANAT: Saavutettavuus, kehollis-taktiilinen modaliteetti, varhaiskuntoutus, 
emotionaalinen saatavillaolo, synnynnäinen kuurosokeus, monivammaisuus, näkö-
vamma 
  
8 
Acknowledgements 
I became interested in communication using the tactile modality when I studied 
Finnish Sign Language at Rovala Folk High School in Rovaniemi. During that time, 
I had the chance to provide assistance to a man with acquired deafblindness during 
a weekend course. When I observed ongoing interactions, I was overwhelmed by the 
beauty and fluency of the Finnish Tactile Sign Language and by the fact that complex 
conversations can be realized through the sense of touch. Later, I wrote my master’s 
thesis in logopedics on interactions between children with CHARGE syndrome and 
their mothers. That study raised the question of how early interactions between 
parents and their children with sensory impairments and additional disabilities can 
be enhanced. My doctoral thesis is an attempt to answer this question. 
This study was conducted at the Department of Psychology and Speech-
Language Pathology, Faculty of Social Sciences, University of Turku. I warmly 
thank all the children and their families who participated in the study. You are the 
heart of this research! The financial support from the Eino Jutikkala Fund of the 
Finnish Academy of Science and Letters, the Emil Aaltonen Foundation, the Finnish 
Cultural Foundation, the University of Turku, the Otto A. Malm Foundation, the 
Pediatric Research Center, the Turku University Foundation, and the TOP 
Foundation is gratefully acknowledged.   
I express my deep gratitude to Professor Minna Laakso, my supervisor in 
logopedics, for her expertise and guidance during my study. Her thoughtful 
comments and experience were highly valuable throughout. Likewise, I express my 
warmest gratitude to Saara Salo, PhD, my supervisor in psychology, for providing 
her psychological expertise and knowledge to the research and clinical work for this 
study. I owe my respectful gratitude to all the co-authors. I feel privileged to have 
had Anne Nafstad, Cand.psychol., a pioneer in the deafblind field, as a collaborator. 
I am grateful for her support, availability, and advice throughout this journey. 
Similarly, I wish to thank Paul Hart, PhD, an expert in the deafblind field, for his 
creative ideas and inspiring discussions. I warmly thank my master’s thesis 
supervisor, Marlene Daelman, PhD, for her contribution to Study I. I am grateful to 
Elsa Tuomikoski, BHC, for her time, skills, and dedication in conducting the 
reliability tests for the studies. I wish to thank Anu Kajamies, PhD, for her technical 
 9 
assistance, patience, and important contributions to Study III. I am grateful to 
Professor Zeynep Biringen for acting as a co-author. As a developer of the Emotional 
Availability (EA) Scales, her contribution was essential to Study IV. I thank Hetti 
Lahtela, PhD, for her important work in this study.  
I express my deep gratitude to Associate Professor Iris Nomikou and Docent 
Laura Kanto for reviewing this thesis. I appreciate their encouraging feedback and 
helpful comments that supported me in finalizing this work. I warmly thank Docent 
Kanto for agreeing to serve as my opponent during the public defense. 
I wish to express my gratitude to all the people who helped me during my 
research. I extend my deepest thanks to Leena Vikkula, Lic. Phil., for her flexibility 
and for making the necessary arrangements related to my work at Helsinki 
University Hospital. I thank Professor Elina Mainela-Arnold for her wise comments 
as a follow-up group member. I am also grateful to all the people who helped me in 
contacting the families: Dr. Tuire Lähdesmäki and Heljä Salminen at Turku 
University Hospital and Dr. Päivi Lindahl and my colleagues at the New Children's 
Hospital in Helsinki. My thanks go to the IT Services at the University of Turku for 
their help in solving technical problems, especially Jani Pöyhönen and Peter Dahl.  
I warmly thank my colleagues, fellow doctoral students, fellow workers, and 
researchers for their thoughtful insights into the discussions related to this study. 
Especially to An for the laughter and inspiration, to Sirpa for the in-depth discussions 
and encouragement, to Silja for sharing this PhD journey, and to Julia for your help 
and thoughtful conversations. Thank you, Helena, for the updates with the literature 
and for lending your material. 
My heartfelt thanks to my wonderful friends and family: To Outi for your 
friendship, support, and in-depth discussions, and for being a great example. To 
Saara for your friendship and beautiful drawings. To Saskia for always reminding 
me of the importance of this study. To Tiina for your companionship during my 
world travels. To Anne, Teresa, Pia, Mika, and Riitta for your company and 
encouragement. I also thank my relative Vuokko Saarenpää for her interest in this 
study.  
I want to express my loving gratitude to my parents Aila and Markku and my 
sister Satu and her family. Your love and support have been unshakable. My deep 
appreciation and love go to my husband Luis Angel. The sparkle of life in you makes 
me shine.   
My deepest gratitude belongs to my Heavenly Father, who gave me everything 
I needed on this journey. Thank you for your faithfulness. Proverbs 8:14 
October 2025 
Sini Peltokorpi 
10 
Table of Contents 
Acknowledgements ......................................................................... 8 
Table of Contents .......................................................................... 10 
List of Original Publications ......................................................... 15 
1 Introduction ............................................................................. 16 
2 Review of the literature .......................................................... 18 
2.1 Children with visual impairment and additional disabilities ...... 18 
2.1.1 Visual impairment ........................................................ 18 
2.1.2 Motor, intellectual, and hearing impairments ............... 19 
2.1.3 Congenital deafblindness ............................................ 22 
2.2 Early interactions between children with VIAD and their 
parents ................................................................................... 23 
2.2.1 Primary and secondary intersubjectivity ...................... 24 
2.2.2 Emotional availability ................................................... 28 
2.2.3 Early social play routines as an intervention context ... 30 
2.3 Communication and language development of children with 
VIAD ...................................................................................... 31 
2.3.1 Communication development during the first year ....... 32 
2.3.2 Communication and language profiles ........................ 34 
2.3.3 Bodily-tactile expressions of children with congenital 
deafblindness .............................................................. 35 
2.3.4 Augmentative and alternative communication ............. 38 
2.4 Early intervention ................................................................... 39 
2.4.1 Participation as a right of the child ............................... 40 
2.4.2 Accessibility ................................................................ 41 
2.4.3 Tactile strategies ......................................................... 43 
2.4.4 Early interventions focused on parent-child 
interaction and communication .................................... 47 
2.4.5 Early interventions focused on parents’ sensitivity ....... 48 
3 Aims of the study .................................................................... 50 
4 Methods ................................................................................... 52 
4.1 Participants ............................................................................ 52 
4.1.1 Study I ......................................................................... 52 
4.1.2 Study II ........................................................................ 53 
 11 
4.1.3 Studies III and IV ......................................................... 54 
4.2 Study design .......................................................................... 55 
4.3 Data collection ........................................................................ 57 
4.4 Tactile imitation guidance (Study I) ......................................... 59 
4.4.1 The theoretical framework ........................................... 59 
4.4.2 Content of tactile imitation guidance ............................ 59 
4.5 Bodily-tactile early intervention (Studies II–IV) ........................ 60 
4.5.1 The theoretical framework ........................................... 60 
4.5.2 Main principles ............................................................ 61 
4.5.3 Discussion and video feedback ................................... 62 
4.5.4 Triadic play session ..................................................... 63 
4.5.5 Free play session ........................................................ 69 
4.6 Data analysis .......................................................................... 69 
4.6.1 Imitation coding procedure .......................................... 70 
4.6.2 Bodily-tactile coding procedure .................................... 71 
4.6.3 Multimodal conversation analysis ................................ 75 
4.6.4 Emotional Availability Scales ....................................... 79 
4.6.5 Reliability ..................................................................... 81 
5 Results ..................................................................................... 84 
5.1 Study I .................................................................................... 84 
5.1.1 Postural and behavioral changes ................................ 84 
5.1.2 Frequency and length of imitative bouts ...................... 85 
5.1.3 Communication modes used in imitations .................... 85 
5.1.4 Emotional availability ................................................... 86 
5.2 Study II ................................................................................... 87 
5.2.1 The mother’s use of intervention-based and  
non-intervention-based tactile strategies ..................... 87 
5.2.2 Robin’s expressions .................................................... 89 
5.2.3 Contextual emergence of new gestural expressions .... 90 
5.2.4 Emotional availability ................................................... 94 
5.3 Study III .................................................................................. 95 
5.3.1 Thea and her mother ................................................... 95 
5.3.2 Sara and her mother ................................................... 98 
5.3.3 Alex and his mother ................................................... 102 
5.4 Study IV ............................................................................... 105 
5.4.1 The mothers’ use of tactile strategies ........................ 105 
5.4.2 Emotional availability ................................................. 109 
5.5 The mothers’ evaluation of the intervention .......................... 110 
6 Discussion ............................................................................. 111 
6.1 Summary and discussion of the results ................................ 111 
6.1.1 The characteristics of the mother-child imitations 
after the tactile imitation guidance ............................. 111 
6.1.2 The mothers’ use of the bodily-tactile modality .......... 113 
6.1.3 Children’s participation and reciprocity of the 
mother-child interactions ........................................... 116 
6.1.4 Emotional availability ................................................. 118 
6.2 Discussion of the methods ................................................... 120 
6.3 Theoretical significance of the study ..................................... 123 
6.4 Clinical implications .............................................................. 124 
12 
6.5 Future research .................................................................... 126 
6.6 Conclusion ........................................................................... 129 
Abbreviations .............................................................................. 130 
List of References ....................................................................... 131 
Appendix ...................................................................................... 148 
Original Publications ................................................................... 149 
 
  
 13 
Tables 
Table 1.  The participants, interventions, and analyses used in 
the studies. ........................................................................ 70 
Table 2.  The categories of the mothers’ bodily-tactile behaviors 
in Studies II and IV. ............................................................ 72 
Table 3.  The categories of Robin’s expressions in Study II. ............. 75 
Table 4.  The analyzed play routines in Study III. ............................. 77 
Table 5. The definitions and scoring of Emotional Availability 
Scales. ............................................................................... 80 
Table 6. Frequency and length of imitative bouts initiated by 
Emma or her mother. ......................................................... 85 
Table 7. Communication modalities used in the imitations by 
Emma and her mother. ...................................................... 86 
Table 8. Emotional availability between Emma and her mother. ...... 86 
Table 9. Frequencies of Robin’s gestural expressions and his 
mother’s signs. .................................................................. 88 
Table 10. The sign vocabulary of Robin and his mother. ................... 88 
Table 11. The means and ranges of emotional availability for 
Robin and his mother before, during, and after the 
bodily-tactile early intervention. .......................................... 95 
Table 12. Frequencies of the mothers’ use of tactile noticing, 
tactile anticipatory cues, and tactile signs. ....................... 108 
Table 13. The means and ranges of emotional availability for the 
children and their mothers before, during, and after the 
bodily-tactile early intervention. ........................................ 110 
Figures 
Figure 1.  Study designs and the progress of data collection. ............ 56 
Figure 2.  The content of the intervention sessions. ........................... 62 
Figure 3.  Illustration of tactile contact. ............................................... 63 
Figure 4.  Illustration of tactile noticing. .............................................. 65 
Figure 5.  Illustration of tactile anticipatory cues. ................................ 66 
Figure 6.  Illustrations of tactile signs: Coactive signing (A) and 
body signing (B). ................................................................ 67 
Figure 7.  Illustrations of hand-under-hand guidance (A) and 
hand-over-hand guidance (B). ........................................... 68 
Figure 8.  Illustration of tactile pointing. .............................................. 68 
Figure 9.  Illustrations of the mother’s holding of Emma and 
Emma’s action of placing her hands on her mother’s 
face. ................................................................................... 84 
Figure 10. The mother’s use of the bodily-tactile modality in 
interactions and touches and movements connected to 
play routines as a percentage of time per session. ............ 87 
Figure 11. The mother plays the rhyme coactively with Robin................ 90 
Figure 12. Robin’s mimetic gesture. .................................................... 91 
Figure 13. Robin’s mother coactively touches his fingers one by 
one. ................................................................................... 91 
Figure 14. The mother lifts her hand up coactively with Robin. ........... 92 
14 
Figure 15. Robin’s anticipatory gesture before his mother’s touch 
on his wrist. ........................................................................93 
Figure 16. The mother releases her hold on Thea’s left leg. ................97 
Figure 17. Thea bends her left knee during the pedaling 
movement. ..........................................................................98 
Figure 18. Sara is still during her mother’s question and touches. ..... 100 
Figure 19. Sara turns and moves her legs. ........................................ 101 
Figure 20. The swinging movement begins. ...................................... 103 
Figure 21. Alex leans backward and moves his left leg. ..................... 104 
Figure 22. The mother notices Alex’s leg movement tactilely. ............ 104 
Figure 23. The mothers’ use of nonconventional games as a 
percentage of time per session. ........................................ 106 
Figure 24. The mothers’ use of conventional games as a 
percentage of time per session. ........................................ 107 
  
 15 
List of Original Publications 
This dissertation is based on the following original publications, which are referred 
to in the text by their Roman numerals:  
I Peltokorpi, S., Daelman, M., Salo, S., & Laakso, M. (2020). Effect of tactile 
imitation guidance on imitation and emotional availability. A case report of a 
mother and her child with congenital deafblindness. Frontiers in Psychology, 
11, Article 540355. doi: 10.3389/fpsyg.2020.540355 
 
II Peltokorpi, S., Salo, S., Nafstad, A., Hart, P., Tuomikoski, E., & Laakso, M. 
(2023). Bodily-tactile early intervention for a mother and her child with visual 
impairment and additional disabilities: A case study. Disability and 
Rehabilitation, 45(12), 2057–2072. doi: 10.1080/09638288.2022.2082563    
 
III Peltokorpi, S., Salo, S., Hart, P., Nafstad, A., Kajamies, A., & Laakso, M. 
(2024). Developing reciprocity between one-year-old children with visual 
impairment and additional disabilities and their mothers: The effects of 
bodily-tactile early intervention. Learning, Culture and Social Interaction, 48, 
Article 100849. doi: 10.1016/j.lcsi.2024.100849  
 
IV Peltokorpi, S., Salo, S., Nafstad, A., Hart, P., Biringen, Z., & Laakso, M. 
(2024). Bodily-tactile early intervention: A pilot study of the role of maternal 
touch and emotional availability in interactions between three children with 
visual impairment and additional disabilities and their mothers. Frontiers in 
Psychology, 15, Article 1439605. doi: 10.3389/fpsyg.2024.1439605 
The original publications have been reproduced with the permission of the copyright 
holders. 
 
 16 
1 Introduction 
Children with visual impairment (VI) are a heterogeneous population. The majority 
of them have additional disabilities such as an intellectual disability (ID) or a motor 
impairment. The type and degree of VI and the combination of additional disabilities 
vary between children. Children with congenital deafblindness (CDB) form a 
specific subgroup of children with visual impairment and additional disabilities 
(VIAD) due to their dual sensory loss and dependence on the sense of touch. 
Typically, all children with VIAD have difficulties in accessing the visual 
information connected to their parents’ facial expressions, gestures, and actions. 
Similarly, it may be hard for their parents to read their children’s subtle and atypical 
expressions. These challenges can easily compromise interactional reciprocity 
(Rowland, 1984), which consists of turn-taking and mutual emotional 
responsiveness (see Stevanovic & Peräkylä, 2015). Further, compromised 
reciprocity in early interactions may prevent children with VIAD from developing 
their full potential.    
Reciprocity in interactions between children with VIAD and their parents may 
increase if the bodily-tactile modality is used to compensate for the children’s lack 
of vision. Although modality is not a clearly defined term, it typically refers to the 
communicative modalities of the body such as gestures, gaze, or speech and the 
senses associated with these communicative modalities (Deppermann & Streeck, 
2018). In this regard, the term bodily-tactile modality refers to interaction and 
communication through touch and movements (Nafstad & Rødbroe, 2015). 
Interaction can be understood as reciprocal action or influence between persons in 
which the participants exchange behaviors and emotions with each other 
(Trevarthen, 1980). Communication specifies a dynamic and interactive process of 
shared meaning through verbal and nonverbal signals (Bullowa, 1979).  
In this study, children’s language development is understood as a process which 
has its basis in early social interactions (e.g., Bruner, 1975; Trevarthen, 1980). 
Although the focus of the analysis is on the mothers’ bodily-tactile actions and their 
children’s embodied participation, interaction is regarded as a multimodal and 
integrated system. Multimodality is understood as meaning-making (making sense 
of life events) through different modalities, which often appear together (Jewitt et 
Introduction 
 17 
al., 2025). However, due to children’s VI, their ability to perceive multimodal 
information in interactions is easily compromised without compensatory strategies. 
Moreover, for some children with VIAD, the bodily-tactile modality may be a 
primary resource for meaning-making. This is a challenge because typically there is 
not a shared cultural sense within the hearing-sighted community of how bodily-
tactile resources can realize meaning. A mismatch in parent-child interactions can 
be avoided if parents are familiarized with the bodily-tactile modality as a resource 
for meaning-making from the outset (see Bezemer & Jewitt, 2010).   
Early intervention provides a great opportunity to support parent-child 
interactions in families with children with VIAD (see Guralnick, 2011). As parents 
play a key role in their child’s development, it is essential that professionals work in 
close collaboration with them and involve them in activities that strengthen their 
existing competencies (e.g., Breemer, 2025; Dunst & Dempsey, 2007). Early 
intervention is most effective when it is started within the first two years of children’s 
lives (e.g., Bailey et al., 2005; Launonen, 1998). However, currently, systematic 
support for parent-child interactions in families with children with VIAD may not 
be available at this age, and it is not self-evident that parents will be closely involved 
in the interventions. There has also been very limited scientific interest in 
investigating the effects of early interventions for children with VIAD and their 
families. Therefore, there is a fundamental need to gain more knowledge about the 
principles that foster reciprocal interactions between children with VIAD and their 
parents.  
This doctoral study explores the effects of two interventions that utilize the 
bodily-tactile modality as a resource in interactions between mothers and their 
children with VIAD. The first intervention, “Tactile imitation guidance,” focuses on 
fostering mother-child interactions through guiding a mother of a child with CDB to 
add tactility in her (vocal) imitations. The second intervention, “Bodily-tactile early 
intervention,” guides mothers of children with VIAD to utilize the bodily-tactile 
modality for several purposes, including in the context of interaction and 
communication. Both interventions aimed to increase accessibility to interactions 
between children with VIAD and their mothers. By increasing accessibility and 
guiding the mothers to respond to their children’s bodily expressions, the 
interventions aimed to promote reciprocity in mother-child interactions.  
 
 18 
2 Review of the literature 
2.1 Children with visual impairment and additional 
disabilities 
More than half (60–70%) of children with VI in Western societies have additional 
disabilities (Hatton et al., 2013; Sonksen & Dale, 2002). Because these additional 
disabilities have a major impact on their development, children with isolated VI and 
children with VIAD should be considered as two separate populations (Rahi & 
Gilbert, 2013; Sonksen & Dale, 2002). However, even when regarded as a separate 
population, children with VIAD form a remarkably heterogeneous group considering 
their abilities and disabilities. For instance, it is common for a child with VIAD to 
have more than one additional disability and other medical problems such as epilepsy 
(Rudanko, 2007). In this chapter, VI and the typically associated disabilities are 
described so as to obtain an understanding of each impairment and their impact on 
children’s development. Lastly, special attention is given to a subgroup of children 
with CDB to recognize their specific and vulnerable conditions for communication 
and language development.  
2.1.1 Visual impairment 
The term “visual impairment” refers to a moderate or severe VI or blindness (World 
Health Organization [WHO], 2013a). Children who have normal sight in one eye or 
normal corrected vision are not classified as having VI (Näkövammaisten liitto, n.d.). 
Currently, the definitions of VI are based on assessments of visual acuity and visual 
field. A far acuity refers to a person’s ability to recognize small details from a long 
distance. The WHO defines blindness as a presenting visual acuity of worse than 
3/60 or a corresponding visual field loss to less than 10° in the better eye. Severe VI 
is defined as a presenting visual acuity of worse than 6/60 and equal to or better than 
3/60. Moderate VI is defined as a presenting visual acuity in the range from worse 
than 6/18 to 6/60 (WHO, 2013a, p. 7). Alternatively, visual acuity can be expressed 
as a decimal number. The prevalence of VI in children varies between countries 
(Rahi & Gilbert, 2013). In a Finnish study, Rudanko (2007) found VI in 556 
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individuals from a population of 1 138 326 children aged 0–17 years, which gives a 
prevalence of 49/100 000. 
Kran et al. (2019) calls for a re-evaluation of the current criteria used to define 
VI, as they do not account for cerebral/cortical visual impairment (CVI). CVI can be 
defined as “a verifiable visual dysfunction, which cannot be attributed to disorders of 
the anterior visual pathways or any potentially co-occurring ocular impairment” (Sakki 
et al., 2018). CVI has become the leading cause of pediatric VI in developed countries 
due to improved neonatal intensive care (Chang & Borchert, 2020; Kran et al., 2019). 
The most common cause of CVI is perinatal hypoxia-ischemia (İdil et al., 2021). 
Typically, CVI is associated with other disabilities (Hatton et al., 2013; Huo et al., 
1999; Rudanko, 2007) and it also affects most of the children in this study. CVI 
negatively impacts children’s functional vision. Huo et al. (1999) found that 43% of 
the children with CVI had only light perception, 28% of them could occasionally 
fixate on large objects, faces, or movement, while only 14% of the children could 
occasionally fixate on small objects or reliably fixate on faces. However, in most 
children with CVI, visual acuity improves over time while their functional vision 
may stay invariable (Chang & Borchert, 2020). Despite the growing knowledge 
concerning CVI, its diagnostic criteria and assessments are not well-defined (Boster 
et al., 2021). Moreover, early visual habilitation and communication interventions 
for children with CVI have received very limited attention (Boster et al., 2021).      
VI affects children’s development. Children with VI can experience difficulties 
in pragmatic language skills (use of language in a socially appropriate way; Tadić et 
al., 2010) and emotion recognition according to vocal qualities (Dyck et al., 2004; 
Minter et al., 1991). Negative consequences accumulate when children with VI also 
have additional disabilities. Boulton et al. (2006) found that children with VIAD had 
a remarkably lower health-rated quality of life and poorer general health than 
children with VI.   
2.1.2 Motor, intellectual, and hearing impairments 
Motor impairment. “Motor impairment is the partial or total loss of function of a 
body part, usually a limb or limbs. This may result in muscle weakness, poor 
stamina, lack of muscle control, or total paralysis” (International Neuromodulation 
Society, n.d.). In the study by Rudanko (2007), motor impairments were found in a 
third (33%) of Finnish children with VI.  
Cerebral palsy (CP) is a typical cause of a motor impairment in children with VI 
(Flanagan et al., 2003; Hatton et al., 2013). “CP describes a group of permanent 
disorders of the development of movement and posture, causing activity limitation, 
that are attributed to non-progressive disturbances that occurred in the developing 
fetal or infant brain. The motor disorders of CP are often accompanied by 
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20 
disturbances of sensation, perception, cognition, communication, and behavior, by 
epilepsy, and by secondary musculoskeletal problems” (Rosenbaum et al., 2007, p. 
9). CP categorization includes information on the affected body parts (Rosenbaum 
& Rosenbloom, 2012). Hemiplegia describes a condition in which one side of the 
body is affected and diplegia refers to a functional limitation affecting either the arms 
or the legs. Quadriplegia (or tetraplegia) refers to a condition in which the legs, 
hands, pelvis and trunk are affected (Rosenbaum & Rosenbloom, 2012). The CP 
categorization also includes information concerning motor impairment, which 
comprises four sub-types: spastic CP, ataxic CP, dyskinetic CP (including dystonic 
CP and choreo-athetotic CP) and non-classifiable CP (Cans, 2000). 
Coleman et al. (2013) found that nearly two thirds of two-year-old children with 
CP had difficulties in their communication development. Children who had more 
severe gross motor functional impairment also had lower communication skills. CP 
often hampers expressions with face and body movements and gestures (Pennington, 
2008). CP can also cause deterioration in speech intelligibility, which can vary from 
mild disorders to an inability to utter recognizable words (Pennington, 2008). These 
challenges can compromise reciprocity in parent-child interactions and lead to 
conversations in which children with CP become passive communicators. The 
passive role may persist later when the children have access to augmentative and 
alternative communication (AAC; Pennington & McConachie, 2001).  
Intellectual disability. ID, also called learning disability, is diagnosed when a 
person has impairment in cognitive functioning and adaptive skills during his or her 
developmental period (Harris, 2006). ID has multiple prenatal (e.g., chromosomal 
and syndrome disorders), perinatal (e.g., neonatal disorders), and postnatal (e.g., 
infections; Harris, 2006) causes. In a Finnish study, cognitive impairment was found 
in more than a third (39%) of children with VI (Rudanko, 2007). In persons with 
CDB, the prevalence of ID has been found to be even higher. Dalby et al. (2019) 
found cognitive impairment in most people with CDB (87.5%). However, sometimes 
a developmental delay in a person can be a consequence of CDB instead of ID 
(Deuce & Rose, 2019). Moreover, challenges in the diagnostic processes of persons 
with sensory and multiple disabilities may lower the reliability of assessment. First, 
their cognitive assessment requires special attention from the assessor to apply 
competent partner strategies, individuality, and time for the person being assessed to 
show their potential (Tuomi et al., 2021). Without these adjustments, their cognitive 
assessment may not be valid. Second, the typical assessment protocols may not 
address tactile cognition, which could demonstrate most of the abilities in persons 
with CDB (Damen & Ask Larsen, 2014). Tactile cognition refers to “the higher order 
processing and integration of tactile information through active touch that includes 
the mental processes of attention and memory” (Nicholas, 2013). Third, family 
knowledge needs attention in the diagnostic process. Only parents have contextual 
Review of the literature 
 21 
everyday knowledge of the cognitive capacities of their children with CDB 
(Breemer, 2025). 
The Tenth Revision of the International Classification of Diseases (ICD-10) 
divides ID into six different types: mild, moderate, severe, profound, other, and 
unspecified ID (Terveyden ja hyvinvoinnin laitos, 2011, pp. 272–273). 
Approximately 85% of people with ID have mild ID. In early childhood, mild ID 
may not be identifiable and it can be found later, at preschool or school age (Harris, 
2006). Typically, children with mild ID can participate in conversations and learn to 
read, but they have difficulties in more demanding academic performance (Harris, 
2006). Moderate ID affects approximately 10% of individuals with ID. Some of 
these individuals may be able to join simple spoken conversations, while others may 
express themselves through AAC (Harris, 2006). Around 3%–4% of individuals with 
ID have severe ID, and 1%–2% are affected by profound ID (Harris, 2006). Almost 
all individuals with severe or profound ID have other neurodevelopmental, motor, 
or sensory comorbidities (Rensfeldt Flink et al., 2021). Danker et al. (2023) found 
that some adults with severe or profound ID did not have any functional 
communication and some of them communicated through aided AAC (e.g., a 
communication book), signing, gestures, facial expressions, vocalization, or speech. 
Limited communication increases dependence on others. Williams et al. (2020) 
found that 5–18-year-old children with ID who had higher dependency on others had 
a poorer quality of life. Moreover, higher-level functioning was connected to more 
frequent participation, which was associated with an increased quality of life. The 
researchers concluded that a poorer quality of life in children with ID can be partly 
explained by their less-frequent participation in community activities. These findings 
indicate that participation is key to enhancing the quality of life in children with ID 
from the start. The first contexts to support their participation can be early 
interactions with their parents (see Sameroff & MacKenzie, 2003a; Våpenstad & 
Bakkenget, 2021).  
Hearing impairment. Hearing impairment is caused by damage in any parts of 
the auditory system, which is responsible for hearing (Zeng & Djalilian, 2010). The 
damage can be in the outer and/or middle ears (conductive loss), in the inner ear 
(cochlear loss), in the auditory nerve (neural loss), in the backward-feed pathway 
(feedback loss) or in the brainstem and cortex (central loss; Zeng & Djalilian, 2010). 
The prevalence of hearing impairment in children with VI differs in studies. In a 
Finnish study (Rudanko, 2007), hearing impairment was found in 6% of children 
with VI, whereas in a British study the prevalence was 13% (Teoh et al., 2021). The 
etiology of childhood hearing impairment can be congenital or acquired (Liddle, 
2022). Congenital etiologies are most common, and they include genetic (e.g., 
Trisomy 21), structural (e.g., hypoplastic or absent VIII nerve), and prenatal (e.g., 
cytomegalovirus; Liddle, 2022) factors. Acquired etiologies include perinatal (e.g., 
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22 
asphyxia) and postnatal (e.g., meningitis; Liddle, 2022) causes. Approximately a 
third of children have an unknown etiology of their hearing impairment and almost 
40% of them have one or more additional disabilities (Häkli et al., 2014).  
The degree of hearing impairment is defined by the better ear hearing level. The 
severity of the hearing impairment is indicated in decibels (dB), which describe the 
loudness of sounds for a person to hear them (American Speech-Language-Hearing 
Association, n.d.). In the revised grading system of the WHO (2021), hearing 
impairment can be mild (20 to < 35 dB), moderate (35 to < 50 dB), moderately severe 
(50 to < 65 dB), severe (65 to < 80 dB), profound (80 to < 95 dB), or complete 
hearing impairment/deafness (95 dB or greater). Most children with hearing 
impairment and additional disabilities who have mild, moderate, or severe hearing 
impairment use hearing aids whereas the majority of children with a profound 
hearing impairment use cochlear implants (Cupples et al., 2018). As hearing is 
pivotal for language learning in the auditory modality, the degree of hearing 
impairment influences speech and language development. Cupples et al. (2018) 
found that milder hearing impairment, higher level of nonverbal cognitive ability and 
use of oral communication were associated with better language outcomes in 
children with hearing impairment and additional disabilities.  
2.1.3 Congenital deafblindness 
Children with CDB form a specific subgroup of children with VIAD due to the 
combined effect of dual sensory impairment. The dual sensory impairment can affect 
the social participation of children with CDB to a greater extent than for children 
with VIAD in general, therefore children with CDB need special attention. The 
severe hearing and vision impairment of children with CDB is present at birth or 
before language has been developed (Dammeyer, 2012a). However, many of them 
have some residual hearing and/or vision. It is also typical that children with CDB 
have additional motor or cognitive impairments or complex medical conditions. In 
acquired deafblindness, the dual sensory impairment occurs later in life when the 
person has developed language (Dammeyer, 2012a). CDB is an uncommon 
condition. In the study by Dammeyer (2010), the prevalence of CDB in children was 
1:19 000. Moreover, CDB has various etiologies, which makes it challenging to link 
it to a specific cause. Even the most common etiologies, CHARGE syndrome and 
perinatal asphyxia, do not cause CDB in every child (Dammeyer, 2010). Moreover, 
several rare syndromes such as Trisomy 13 can cause CDB (Andersen & Rødbroe, 
2005).     
CDB can be defined in different ways. The Nordic definition of deafblindness is 
as follows: “Deafblindness is a combined vision and hearing impairment of such 
severity that it is hard for the impaired senses to compensate for each other. Thus, 
Review of the literature 
 23 
deafblindness is a distinct disability. To varying degrees, deafblindness limits 
activities and restricts full participation in society. It affects social life, 
communication, access to information, orientation and the ability to move around 
freely and safely. To help compensate for the combined vision and hearing 
impairment, especially the tactile sense becomes important” (Nordic Welfare Centre, 
n.d.). Ask Larsen and Damen (2014) argue that the heterogeneity of CDB definitions 
makes it difficult to define the population and compare the results of different 
studies. A diagnosis could facilitate this process, but currently there is no diagnosis 
code for deafblindness in ICD-10. However, identifying CDB in a child is essential, 
because identification can give access to appropriate services and interventions for 
the families. Without the right kind of support and systematic interactions through 
the bodily-tactile modality, the learning potentials of children with CDB may be 
missed, and the CDB may result in secondary consequences such as emotional and 
social disorders and social isolation (Andersen & Rødbroe, 2005). The International 
Classification of Functioning, Disability, and Health (ICF) framework can help to 
evaluate the functioning of individuals with CDB (WHO, 2013b). For clinical 
practice, a smaller set of ICF codes (Core Set) is currently being developed for 
deafblindness (Jaiswal et al., 2024). 
Nordic countries such as Denmark, Norway, and Sweden have established 
national state-funded resource centers for deafblindness that apply the Nordic 
definition to identify cases of CDB in need of specialized service (Anderzén-
Carlsson, 2017; Dammeyer, 2010). The assessment procedures include medical 
examinations, functional assessment of vision, hearing and tactile modality, and 
assessment of the functional use of senses in social interaction and communication 
(Dammeyer, 2012a). However, there appears to be no similar process for identifying 
CDB in Finland. Thus, in many cases Finnish families with children with CDB may 
lack appropriate services and support.   
2.2 Early interactions between children with VIAD 
and their parents 
Reciprocal parent-infant interactions are the basis for children’s social-emotional 
and language development. The first signs of reciprocity can be observed in the 
responsiveness of infants and their parents to each other’s visual attention (Brazelton 
et al., 1974). Later, infants use multimodal resources including gaze, facial 
expressions, vocalizations, movements, and gestures to engage in reciprocal 
exchanges with their parents (Paz & Frenkel, 2024). When infants produce their first 
words at around one year old, verbal communication simply becomes part of their 
existing interpersonal exchanges (Trevarthen, 1979).  
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24 
Long periods of hospitalization after birth easily challenge reciprocity between 
parents and their infants with VIAD. Being separated allows limited time for parent-
infant togetherness. It may also complicate the parent-infant emotional relationship. 
However, only a small amount of scientific information is available on the quality of 
these interactions. The findings of the few studies conducted indicate compromised 
reciprocity in interactions (Rogers & Puchalski, 1984; Rowland, 1984). Further, 
compromised reciprocity in early interactions creates a risk of compromising broader 
emotional availability (EA; Biringen, 2008) later in childhood. To prevent problems 
arising, attention must be directed to the quality of early interactions. High-quality 
interactions will provide infants with VIAD access to the same reciprocal processes 
that advance the development of typically developing infants. For this, parents may 
need to learn strategies to compensate for their infants’ lack of vision and challenges 
in reciprocity.   
2.2.1 Primary and secondary intersubjectivity 
Intersubjectivity can be defined as “awareness of self and other’s intentions and 
feelings in the dynamic sharing of minds acting in companionship, exchanging self-
conscious intentions and emotional evaluations” (Kokkinaki et al., 2023). Infants are 
already equipped with readiness, interest, and capacity for social interactions with 
other persons at birth (Trevarthen, 1979, 1980). During their first months, they 
engage in face-to-face interactions with their parents through gaze, facial 
expressions, movements, and vocalizations. Trevarthen (1979, 1980) called this 
interpersonal activity primary intersubjectivity. Dyadic interactions have a structure 
resembling a conversation (Bateson, 1979; Trevarthen, 1974). That is, parents 
address their infants as conversational partners and treat their expressions as 
meaningful actions in conversations (e.g., Filipi, 2009). By acting in this way, the 
parents create the cultural norms of conversation, which are characterized by turn-
taking and sequence organization (Filipi, 2009, p. 23). However, Damen et al. 
(2015b) found that the intersubjective development of children with sensory 
disabilities is easily delayed.   
Turn-taking is the basic structure for conversation (Sacks et al., 1974). Thus, 
acquiring turn-taking skills through nonverbal and vocal actions is a major 
accomplishment of children in learning to communicate (Papoušek, 1995). Turn-
taking involves temporally organized turns, responsiveness to a partner’s prior 
expression, and avoidance of long periods of silence and overlap (Filipi, 2009, p. 
24). However, simultaneous actions are typical in parent-infant interactions, and 
infants gradually learn to time their turn-taking appropriately (Harder et al., 2015).  
A child’s VI easily compromises turn-taking in early interactions. That is, due to 
lack of gaze, parents and their children with VIAD may not know when their 
Review of the literature 
 25 
expressions are being directed at each other (cf. D’Odorico & Cassibba, 1995). 
Moreover, children with VIAD often need a notably longer time to respond to their 
parents than typically developing infants. This can alter turn-taking patterns and 
complicate the interpretation of their expressions (Johnson & Parker, 2013). In 
addition, the findings of Rowland (1984) indicate challenges in turn-taking. She 
discovered that although infants with VIAD vocalized within normal limits, their 
vocalizations were not responsive to their mothers. Moreover, some of the mothers 
provided almost continuous vocal stimulation to their infants, which did not leave 
time for infants to take their turns. 
Some parental actions can facilitate turn-taking. One of these actions is 
questioning. Interestingly, parents address their infants as conversational partners 
from the start and pose infants questions in a phase in which the child cannot yet 
answer them (e.g., Snow, 1977; Trevarthen & Hubley, 1978). A question is a 
powerful way to create turn-taking, because it nominates an infant as the next 
speaker and creates an expectation of his or her answer (Filipi, 2009, p. 26). When 
the infant responds through a nonverbal expression, the parent treats it as an answer 
to their question (Sierra, 2017). Thus, through parents’ actions, their infants’ 
expressions become part of the turn-taking sequences.    
Imitation is another powerful mechanism to establish turn-taking. Parents 
spontaneously imitate their infants’ movements, facial expressions, and sounds with 
playful exaggeration. Infants recognize their parents’ imitations, and respond to them 
with increased attention, smiling, and approach behaviors (Sauciuc et al., 2020). 
Infants’ imitative ability is innate (Trevarthen, 1979). Newborns can already imitate 
adult facial and manual gestures (Meltzoff & Moore, 1977). At 1–3 months, infants 
begin to produce sporadic imitations of parents’ sounds that belong to their 
repertoire, and they use these imitations more systematically at 4–8 months 
(Papoušek & Papoušek, 1989). At 9 months, infants can exhibit immediate and 
deferred imitation (imitation after a delay) of novel objects (Heimann & Meltzoff, 
1996; Meltzoff, 1988). The low vision of children with VIAD easily prevents them 
from making nonverbal imitations and receiving visual feedback from their parents’ 
imitations. However, they can engage in imitative exchanges in the vocal (Rowland, 
1984; see also Preisler, 1991, 1995) or bodily-tactile (see Hart, 2006) modality.   
Affectionate parental touch is important for parent-infant bonding, temporal 
coordination of parent-infant behaviors, and infants’ social cognition (Carozza & 
Leong, 2021). Parents use touch to communicate emotions and information about 
their actions to their infants (Hertenstein, 2002). They also regulate their infants’ 
arousal levels and behavior through touch (Hertenstein, 2002). The use of touch by 
mothers is most frequent during the first months of their infants’ lives and decreases 
in the second half of the first year (Goldstein Ferber et al., 2008; see also Chiesa et 
al., 2015; Rattray & Zeedyk, 2005). However, mothers with VI continue using 
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26 
frequent touch throughout the first year of their infants’ life and beyond (Chiesa et 
al., 2015; Rattray & Zeedyk, 2005), which indicates touch as a strategy to 
compensate for their VI. Similarly, Loots et al. (2005) found that deaf parents used 
more visual-tactile strategies in interactions with their deaf or hard-of-hearing 
toddlers than hearing parents.  
Gaze is a powerful way for infants and parents to connect with each other in early 
interactions. Mutual gaze provides attentional signals and a context in which 
expressions become meaningful for the recipient (Wildt & Rohlfing, 2024). Parents 
monitor their infants’ gaze and interpret it as an intentional turn in interactions 
(Rączaszek-Leonardi et al., 2013). Similarly, infants obtain important emotional 
feedback from their parents’ faces through gaze (Winnicott, 2003). Mutual gaze 
between infants with VIAD and their parents is possible only if the infant has 
residual vision (see Gui et al., 2023). Infants with more severe VI use vocalization 
or body gestures to initiate contact (Preisler, 1991). However, the only secure way 
to establish contact with infants with CDB is through touch (Nafstad & Rødbroe, 
2015, p. 26).  
Lack of gaze can explain why young children with VIAD have been described 
as unresponsive and showing few initiations in interactions with their parents (Grumi 
et al., 2021; Rogers & Puchalski, 1984; Rowland, 1984; see also Van keer et al., 
2017). Low vision may prevent children with VIAD from anticipating actions and 
recognizing moments of turn-taking, which may reduce their initiations and 
responsiveness (cf. Nomikou et al., 2017; Sacks et al., 1974). Moreover, their limited 
facial expressions may not provide their parents with a sense of discourse (Fraiberg, 
1979). As a result, parents can experience a kind of stimulus deprivation and try to 
overcome it by understimulating or overstimulating their infants (see Stern, 1974).  
Delafield-Butt and Trevarthen (2015) argue that movements are an essential part 
of infants’ meaning-making. That is, infants’ movements are closely related to the 
temporal structure of adults’ actions from early on (Condon & Sander, 1974; Jover 
et al., 2019; Reddy et al., 2013). Neonates have been found to synchronize their 
motor behavior in the same rhythm as adults’ speech (Condor & Sander, 1974). At 
2–4 months, infants show postural changes indicating anticipatory responses when 
approached by their mothers (Reddy et al., 2013). Movements also express infants’ 
engagement. At 3 months, infants show individual patterns of limb movements 
during singing games (Fantasia et al., 2014). Older 6-month-old infants increase their 
motor activity during the time slots of the songs (Jover et al., 2019). Later, infants 
can use specific activity-related movements in their responses. Sierra (2017) 
observed that a 7–8-month-old infant used a bouncing movement involved in a 
singing game when responding to his mother.  
Preisler (1991, 1995) found a developmental process of the interactional use of 
movements in blind infants without AD. She discovered that 3–6-month-old blind 
Review of the literature 
 27 
infants increased motor activity in their hands and legs when they were approached 
by their mothers. At 6 months, they anticipated actions in rhythmic body-touching 
games and used eyebrow and body movements as turns in conversations. At 7–9 
months, they used repeated body movements to express their wish to replay a game. 
Moreover, some 9-month-old infants used play movements in their initiations. 
Rogow (1982) had similar findings of play movement-based initiations in older 
children with VIAD.  
During the second half of the first year, parent-infant interactions change from 
dyadic engagements to triadic person-person-object engagements. Trevarthen and 
Hubley (1978) call this stage secondary intersubjectivity. During secondary 
intersubjectivity and sometime later at 6–18 months, infants develop a growing 
interest in and capacity to share their attention between objects and other persons, 
which they express through gaze and gesture (Bakeman & Adamson, 1984). This 
ability is called joint attention. Joint attentional skills result from a process which 
has a foundation in dyadic face-to-face interactions (Reddy, 2003). That is, infants 
first experience themselves as the objects of their parents’ attention. Next, they 
become aware of their parents’ attention related to their actions, before they learn to 
share attention to external objects (Reddy, 2003). Infants’ abilities to direct their own 
attention and guide adults’ attention emerge gradually at 12–30 months. Multimodal 
information in interactions facilitates this process. That is, infants learn to respond 
to adults’ attempts to direct their attention earlier when they can perceive their 
expressions through speech, gazing, and pointing, compared to unimodal auditory 
information (Adamson et al., 2021). Likewise, it is easier for infants to invite adults 
to share a multimodal object than a sound (Adamson et al., 2021).   
VI often prevents infants from expressing their attention through gaze. However, 
very young infants with VI can express their attention toward their parents’ voices 
through stillness and immobility (Als et al., 1980). At an older age, infants with VI 
have challenges in developing joint attention skills (Ayyıldız et al., 2016; Bigelow, 
2003; Dale et al., 2014). Preisler (1995) found that although infants with VI began 
to increase activities with toys at 7–8 months, dyadic interactions were still their 
main activity at one year. This may be due to their difficulties in gaining visual 
information about their parents’ attention (Urwin, 1978). When infants with VI begin 
to express joint attention, they can do it through body orientation and vocalizations 
toward their parents (Urqueta Alfaro et al., 2021). However, these behaviors may be 
difficult for their parents to detect and interpret as joint attention.   
Overall, Trevarthen’s theory explains how typically developing infants are 
actively involved in early interactions from the start and how their abilities develop 
in reciprocal exchanges with their parents. The research indicates challenges in 
primary intersubjectivity for young children with VIAD and their parents. However, 
only little is known about how their dyadic interactions could be fostered in 
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28 
intervention contexts. Their interactional resources, especially those related to the 
bodily-tactile modality, have not yet been uncovered. 
2.2.2 Emotional availability 
Positive emotional interactions with others are important for the well-being of every 
person. For infants and older nonverbal children with VIAD, they can be even more 
fundamental. This is because emotional exchanges may provide a main medium for 
them to connect with others. Hence, it is essential to evaluate their interactions with 
others from an emotional perspective. This chapter discusses research-based findings 
on EA, which is one of the most central theories on parent-child interaction. 
EA refers to the emotional relationship between children and adults. It is closely 
connected to attachment theory and underlies children’s secure attachment (an 
affectional tie with parents; Ainsworth et al., 1974) and favorable social-emotional 
development (Biringen et al., 2014). However, EA is a more broadly-based construct 
of parent-child relationship than attachment is. It is connected to several other 
theories such as the transactional model of development (Sameroff & Chandler, 
1975) and mentalizing theory (Fonagy et al., 2002), which underline the reciprocal 
influence of parents and children on each other. That is, EA acknowledges not only 
the adult’s but also the child’s contribution to their emotional relationship (Biringen 
et al., 2014). EA has been found to predict children’s developing competences such 
as emotion regulation and social and language development (Biringen et al., 2014).  
EA is composed of six dimensions, which are all dyadic. This means that each 
dimension is viewed in relation to the partner’s response. Adult sensitivity refers to 
the parent’s ability to have a positive emotional connection with the child, read the 
child’s communications, and respond to them. Adult structuring is the ability to 
structure the child’s play through guiding or scaffolding and follow the child’s lead. 
Adult nonintrusiveness is connected to the adult’s ability to interact with the child 
without being overdirective, overstimulative, or overprotective. Adult hostility is the 
absence of nonverbal or verbal negativity toward the child. Child responsiveness 
refers to the child’s emotional and social responsiveness toward the parent. Child 
involvement is connected to the child’s initiative and ability to draw the parent into 
his or her play or activity. 
Different disorders such as sensory, intellectual, and physical disabilities can 
compromise EA (Biringen et al., 2005). Children’s deafness or blindness may 
especially complicate parents’ EA (Campbell & Johnston, 2009; Paradis & Koester, 
2015). Campbell and Johnston (2009) found that the mothers of one-year-old blind 
children without additional disabilities had challenges in sensitivity and structuring. 
Likewise, Paradis and Koester (2015) discovered that hearing mothers of deaf infants 
had lower sensitivity than hearing mothers of hearing infants. However, generally 
Review of the literature 
 29 
parents of children with disabilities have similar EA profiles to parents of typically 
developing children (Kubicek et al., 2013; Pipp-Siegel et al., 1998).  
Children with disabilities have comparable EA results to typically developing 
children (Kubicek et al., 2013; Pipp-Siegel et al., 1998). Nevertheless, some 
children’s characteristics may influence their EA. Gul et al. (2016) found that the 
EA scores of infants with autism spectrum disorder, other psychiatric disorders, and 
developmental delay were related to their age, diagnosis, and developmental level 
(language-cognitive, fine motor, gross motor, social, and self-help). Children who 
had a higher developmental level showed more responsiveness and involvement with 
adults. In contrast, Barfoot et al. (2017) found that the functional capabilities (self-
care, mobility, and social function) of children with CP were not related to parent-
child EA. Deafness may also influence the child’s EA. Paradis and Koester (2015) 
found that deaf infants of hearing mothers scored lowest in child responsiveness 
compared to deaf infants of deaf mothers, hearing infants of deaf mothers, and 
hearing infants of hearing mothers. These findings could be connected to the 
challenges hearing mothers experience with creating reciprocal communication with 
their deaf infants through the visual and tactile modalities and a lack of a shared 
language.  
The parents of blind children may have challenges in EA because they 
experience higher stress than parents of sighted children (Reda & Hartshorne, 2008; 
Sakkalou et al., 2018; Tröster, 2001). The severity of the child’s VI, difficulties in 
parent-child interactions, and the presence of additional disabilities can further 
increase parents’ stress (Gui et al., 2023; Sakkalou et al., 2018; Tröster, 2001; see 
also Hastings et al., 2006). In children with VIAD, low EA may lead to problems in 
attachment and emotional well-being. Lang et al. (2017) found that children with 
VIAD or VI already had lower social-emotional competences in empathy and peer 
relationships compared to their sighted peers at 1–3 years. Moreover, they 
discovered that children with VIAD had fewer competences in compliance than 
children with isolated VI. At the age of 4–11 years, children with VIAD already have 
four times more emotional and behavioral problems, including internalizing 
problems (withdrawal, anxiety/depression, somatic complaints) and externalizing 
problems (aggressive behavior and delinquent behavior), compared to typically 
developing children (Alimovic, 2013). Similar challenges have been described in 
children with CDB (Hartshorne & Schmittel, 2016; Nelson et al., 2013).     
Compensatory strategies may help children with disabilities to cope with their 
difficulties and establish EA with their parents (Biringen et al., 2005; Campbell & 
Johnston, 2009; Shahar-Lahav et al., 2022). For instance, research suggests that 
increased use of parental touch is related to higher EA in interactions between 
children with hearing impairment and their mothers (Paradis & Koester, 2015; Pipp-
Siegel et al., 1998). Thus, parents and their children with VIAD may benefit from 
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30 
compensatory strategies which can help them to be more emotionally available to 
each other. Their EA could be enhanced by increasing interactional reciprocity 
through the bodily-tactile modality. That is, the bodily-tactile modality increases 
reciprocal accessibility in the same modality and thereby may increase reciprocity. 
However, previous early intervention studies have not addressed this potential.  
2.2.3 Early social play routines as an intervention context 
Early social play routines may provide an especially useful context for enhancing 
turn-taking and EA in parent-child interactions. Their key mechanism is founded on 
predictability. By repeating early play routines, infants learn to recognize the actions 
in the routines and perform them. This facilitative mechanism of play routines is 
different from contingency to child’s behaviors, which is characterized by adults’ 
responsiveness toward infants’ actions (Snow et al., 1987).  
Camaioni and Laicardi (1985) divide early social play routines into 
nonconventional games and conventional games. Nonconventional games consist of 
multimodal stimulations and imitations, which are typically played with 3–6-month-
old infants (e.g., Stern, 1974). Parents use nonconventional games to provide infants 
positive emotional experiences and maintain them in a state of attention and arousal, 
which elicits positive social behaviors from the infants (Stern, 1974). As 
nonconventional games serve important functions in interactions, parents should 
have an adequate repertoire of them (Stern, 1974). Conventional games are rhythmic 
multimodal games which include repetition of a sequence of behaviors and pausing 
(e.g., “patacake,” “peekaboo,” and “give and take”). Even young infants can 
memorize multimodal structures of the games and notice if they are violated 
(Fantasia et al., 2014). The variety and time used for conventional games increase 
when infants are 6–12 months old (Camaioni & Laicardi, 1985; see also Crawley et 
al., 1978). This may be due to infants’ developing sensorimotor skills, which allow 
them to perform the motor components of the games (Crawley et al., 1978).  
Conventional games have several qualities which promote infants’ 
communication (Ratner & Bruner, 1978). First, they have a restricted semantic 
content and a limited number of successive actions, which make them easy to repeat 
(Nomikou et al., 2017; Ratner & Bruner, 1978). Infants do not need to understand 
the content of the game to be able to join it. Second, the multimodal game structures 
provide different resources for infants’ participation through joint actions (Fantasia 
et al., 2014). Third, the games have a clear temporal structure. The repetition of the 
game permits anticipation of the order of the events, which facilitates infants’ 
participation (Nomikou et al., 2017). Fourth, the multimodal games create positive 
emotional experiences for the participants (e.g., Fantasia et al., 2014). Tactile and 
kinesthetic games in particular have been found to evoke positive emotions in infants 
Review of the literature 
 31 
with VI (see Fraiberg, 1979; Preisler, 1991). Lastly, the roles of conventional games 
are reversible, which facilitates acquiring the conventions of social interaction. 
These roles can be roles as players (e.g., the mother or infant can hide in peekaboo) 
or motoric components of the games (e.g., rhythmic clapping; Crawley et al., 1978).  
Infants’ participation in the games gradually increases (Camaioni & Laicardi, 
1985; Gustafson et al., 1979). Initially, their engagement is expressed through 
emotional expressions (Ratner & Bruner, 1978). Next, infants begin to anticipate the 
actions of the game through smiling, laughing or vocalizations. Preisler (1991) found 
that 3–6-month-old blind infants without additional disabilities anticipated specific 
actions of the games by opening their mouth or raising their arm. At a later stage, 
infants can perform the actions of the games and reverse roles with adults (e.g., 
Ratner & Bruner, 1978). Infants first make the actions nonverbally, which is 
followed by attempts to match vocal utterances to the routinized expressions used in 
the game (e.g., “boo” in peekaboo). Gradually, infants learn to coordinate their 
nonverbal and verbal actions at appropriate moments in the game (Ratner & Bruner, 
1978). Finally, they also use the actions of the games in other contexts (Hodapp et 
al., 1984; Ratner & Bruner, 1978; Urwin, 1978).     
Parents can structure conventional games to be optimal for their infants’ 
participation by creating slots for turn-taking and anticipating actions (e.g., Hodapp 
et al., 1984; Nomikou et al., 2017). Anticipation can consist of game-related verbal 
or nonverbal cues, which help infants to prepare for the following action and 
establish joint attention to it (e.g., in peekaboo the mother lifts the cloth a bit, stops 
and says “attention” before covering her face; Nomikou et al., 2017). Anticipatory 
cues may also help infants to perform the actions of the games. For instance, 
Nomikou et al. (2017) found that mothers’ use of a preparation phase in peekaboo 
with their four-month-old infants was positively related to their infants’ participation 
two months later. In summary, early social play routines offer an optimal context to 
foster the participation of infants with or without VIAD. Therefore, early social play 
routines were selected as the primary avenue for change in the intervention described 
in this thesis. 
2.3 Communication and language development of 
children with VIAD 
Infants’ gestural expressions and word-like vocalizations during the second half of 
the first year do not appear out of nowhere. They are based on earlier skills that 
infants have gained in reciprocal interactions with their parents (e.g., Wildt & 
Rohlfing, 2024). Further, children’s preverbal communication skills predict their 
later language skills (e.g., Bates et al., 1979; Rowe & Goldin-Meadow, 2009; Wildt 
& Rohlfing, 2024) and social-emotional competencies (Rautakoski et al., 2021). In 
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32 
addition to early communication development, this chapter summarizes literature on 
the communication and language profiles of children with VIAD. As there is very 
little information available about this topic apart from AAC; the focus is on the 
communication profiles and gestural expressions of children with CDB.  
2.3.1 Communication development during the first year 
Gestures serve as an important means to communicate for typically developing 
children before they begin to talk. Their development is connected to intentional 
communication, which is characterized by intention to direct an expression toward 
adults through eye gaze, bodily orientation or touch and waiting for their response 
(Crais et al., 2004). Gestures are typically made with the hands and accompanied by 
gaze and vocalizations (Laakso et al., 2010). Some gestures can be made with facial 
features (e.g., lip-smacking for cookies) or bodily actions (e.g., bouncing up and 
down for a horse; Iverson & Thal, 1998). Fraiberg (1971, 1979) found that blind 
infants without additional disabilities expressed intentions through subtle gestures 
with their hands (e.g., an infant could touch the adult after a game as a means of 
expressing “more”). These gestures were not clear for most of their mothers, and it 
also took a long time for the professionals to learn to read them. When the mothers 
learned to read their infants’ gestures, their turn-taking dialogues increased.  
Deictic gestures such as showing, giving, reaching, and pointing refer to objects 
or events and are interpretable only in their contexts (Caselli, 1990). Infants begin to 
produce them at 8–14 months (Crais et al., 2004; Iverson & Thal, 1998). However, 
early forms of deictic gestures can already be seen earlier (Bates et al., 1979, p. 86). 
For instance, infants may use early pointing as part of their own directedness and 
interest toward the world and begin to use it in social situations when they learn its 
communicative function from the adults’ responses (Carpendale & Carpendale, 
2010; see also Bates et al., 1979).  
Representational gestures can be object-related (e.g., DRINKING) or culturally 
defined (e.g., nodding the head for “yes”) gestures, which have specified semantic 
content (Iverson & Thal, 1998). Typically, they emerge at 11–12 months (Caselli, 
1990). Caselli (1990) found that the first representational gestures of his son were 
bodily gestures derived from specific routines with his parents (e.g., DANCING 
expressing a request for music derived from a routine in which he was asked to dance 
to the sound of music at 11 months). Object-related gestures (e.g., PACIFIER) 
emerged later, at 12–13 months. The repertoire of representational gestures expands 
at the time when children utter their first words. Initially, the lexical items are 
acquired through gestures and words, but gradually speech becomes superior to 
gestures (Iverson & Thal, 1998).   
Review of the literature 
 33 
Residual vision can enable infants with VI to use gestures such as pointing 
similarly to sighted children (Preisler, 1991). However, when vision is severely 
impaired, gesture development follows atypical patterns. Rowland (1984) observed 
that 11–32-month-old infants with VIAD used nonconventional gestures (e.g., 
batting their arms), which were often connected to emotions such as excitement or 
aversion. Only one of the five children made conventional gestures (e.g., waving 
bye-bye). Giving and showing, as well as pointing and reaching, were absent. 
Similarly, Preisler (1991, 1995) found an absence of deictic gestures in blind infants 
without additional disabilities. At 10–11 months, blind infants expressed their 
attention to sounds of the environment by movements of the head and/or body toward 
the sound or a stiff body posture/face (Preisler, 1991, 1995). These movements, 
which functioned like body-pointing gestures, were easily misinterpreted as lack of 
interest by their parents. Other researchers (Fraiberg, 1979; Urwin, 1978), however, 
observed blind infants to make typical reaching gestures connected to familiar voices 
or sounds at the end of the first year.   
Blind infants can create representational body or hand gestures based on their 
experiences. These gestures can be elicited by sounds or speech connected to the 
experiences. For instance, Fraiberg (1979) described a 9-month-old blind infant 
making a pantomime of bell ringing with his hand when he heard the bell’s sound. 
Similarly, Preisler (1991) found a 10–11-month-old blind infant using hand 
movements as if she was splashing water when her mother talked about the activity. 
Moreover, Iverson et al. (2000) described a one-year-old blind boy, Teddy, who 
experienced a vocal-tactile routine with his mother. During the routine, the mother 
was running her hands over his hair from the front to the back of his head and said 
“Oh, Teddy is so pretty. He’s such a pretty boy.” Later, Teddy used the same gesture 
for commenting on various referents in different contexts.    
Vocalizations are an efficient means for infants to participate in proto-
conversations with their parents. At 2 months, infants produce cooing sounds and 
soundless movements with their lips and tongue, which Trevarthen (1974) called 
“prespeech.” Later, at 7 months, infants begin to produce canonical babbling 
consisting of consonant-vocal (CV) syllables (Kent & Miolo, 1995). Over time, 
infants elaborate syllables into proto-word utterances (e.g., CVCV), which their 
parents interpret as having different referents and functions based on the contextual 
and accompanying nonverbal information (Laakso et al., 2010). Proto-words are 
followed by infants’ first words, which appear at approximately one year old 
(Kunnari, 2000).  
Some studies have explored vocal development in infants with VI but there 
appear to be no descriptions of vocal development of children with VIAD. Preisler 
(1991, 1995) found that 3–6-month-old blind infants without additional disabilities 
made prespeech movements when their mothers began to talk to them and used 
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34 
cooing sounds in proto-conversations with their mothers. Canonical babbling also 
occurs in a typical timetable in blind infants (Fraiberg, 1979). At a later stage, blind 
children have roughly a half-year delay in word acquisition related to sighted 
children (Campbell et al., 2024). However, 20% of blind children have an advanced 
vocabulary over the average of sighted toddlers (Campbell et al., 2024).  
2.3.2 Communication and language profiles 
Only a limited number of scientific studies have explored the communication and 
language profiles of children with VIAD. Their findings indicate that the majority of 
these children use nonverbal means for expressing themselves for years or 
throughout their lives (Argyropoulos et al., 2020; Ayyıldız et al., 2016; Blackstone 
et al., 2021; Boster et al., 2021; Daelman, 2003; Mallineni et al., 2006; Miliou, 2024). 
For example, Argyropoulos et al. (2020) report that most of the children with VIAD 
in their Erasmus+ project communicated through nonverbal expressions such as 
smiling or body movements. Similarly, the parents in Blackstone et al. (2021) study 
(N = 63) reported that their 2–34-year-old children with VIAD depended primarily 
on bodily expressions in communication. However, some children with VIAD have 
been reported to use a few signs, words, or phrases (Aasen & Nærland, 2014). 
Children with VIAD who learn to produce speech often have numerous speech sound 
production errors (Gordon-Pershey et al., 2019), which limit their speech 
intelligibility.  
The communication of children with CDB has been studied more than that of 
children with VIAD who have normal hearing (e.g., Bruce et al., 2016; Damen et al., 
2017; Janssen et al., 2010; Wolthuis et al., 2019). However, the findings are mostly 
based on case studies, which cannot be generalized to the population. Findings 
suggest that early communication development appears to follow the same patterns 
as in typically developing children (Preisler, 2005). Nevertheless, the atypical 
contact initiatives of children with CDB through bodily expressions and signs can 
be easily unnoticed by their parents (Nafstad & Rødbroe, 2015, p. 21; Preisler, 2005). 
These challenges persist in toddlerhood. Vervloed et al. (2006) found that a 3-year-
old child with CDB and his teacher missed over half of each other’s initiatives. 
Moreover, less than 2% of the recording time in daily activities contained prolonged 
interactions between the child and his teacher. These findings exemplify a problem 
that may have resulted from mutual challenges to access communicative expressions. 
Older children with CDB communicate through different means and modalities. 
Dammeyer and Ask Larsen (2016) found that 3–18-year-old children with CDB 
(N = 71) used tactile language (23%), oral language (32%), or visual sign language 
(39%) in communication. The level of their language acquisition varied. Less than 
half of the children (41%) used preverbal communication, and for about the same 
Review of the literature 
 35 
number of children (42%), the language development was at symbolic level but 
delayed. Only a minority of the children (18%) had language skills corresponding to 
their age-related expectations. However, it is unclear whether children with Usher 
syndrome were included in the study. If they were, it is probable that the results 
indicate better than expected level of communication skills in children with CDB. 
This is because children with Usher syndrome generally have higher-level linguistic 
skills and fewer additional disabilities than other children with CDB, and their 
functional deafblindness is of a progressive type (see Dammeyer, 2012b). It is 
common that children with CDB who have other types of etiologies, such as Trisomy 
13, express themselves through nonverbal actions such as movements while some of 
them may develop a limited number of symbolic gestural expressions (e.g., 
conventional gestures or manual signs; Braddock et al., 2012; Liang et al., 2015) or 
single words (Liang et al., 2015).  
2.3.3 Bodily-tactile expressions of children with congenital 
deafblindness 
Descriptions of children’s spontaneous expressions through touch and movements, 
which arise from their bodily-tactile experiences come mainly from the deafblind 
field (e.g., Ask Larsen, 2003; Bruce et al., 2007; Daelman et al., 2004; Nafstad, 2018; 
Nafstad & Rødbroe, 2015; Souriau, 2015). This does not mean that only children 
with CDB can make such expressions. Rogow (1982) described bodily expressions 
based on familiar play routines in normally hearing children with VIAD. However, 
she did not report the modalities used in the routines, so it remains unclear whether 
the children’s expressions were related to their visual or bodily-tactile experiences. 
Overall, the connectedness between bodily-tactile experiences and gestural 
expressions has not yet received much scientific attention in normally hearing 
children with VIAD. However, as children with VIAD have the same bodily 
resources for expressing themselves as children with CDB, it is necessary to discuss 
the characteristics of the spontaneous bodily-tactile expressions of children with 
CDB and the conditions from which they may arise. This knowledge is also essential 
in supporting communication development through gestures and signs in normally 
hearing children with VIAD.   
 When contact through vision or hearing is not possible, children with CDB can 
make contact using their hands or feet when their parents are within reach (Nafstad 
& Rødbroe, 2015, p. 26). Tactile contact is necessary for their interactions with 
others, and its absence easily prevents communication (Vervloed et al., 2006). When 
interactions are of good quality, children with CDB often communicate their bodily-
tactile experiences through spontaneous gestures (e.g., Ask Larsen, 2003; Nafstad & 
Rødbroe, 2015; Souriau, 2015; see also Fraiberg, 1979). Ask Larsen (2003) calls 
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36 
these gestures “proto-signs.” Proto-signs can derive from bodily experiences related 
to inner states (e.g., emotions), perceived movements, tactile sensations, or location 
of touch (Ask Larsen, 2003). Due to their specific origins, proto-signs can be 
challenging to read (e.g., Ask Larsen, 2003; Nafstad & Rødbroe, 2015). This is 
because they convey messages that are not typical in the non-CDB community and 
may not match their experiential perspectives (Bezemer & Kress, 2014; Nafstad, 
2018). However, interpretation of proto-signs becomes easier if adults and children 
with CDB share the same experiences from which the proto-signs emerge (see 
Souriau, 2015).   
 There can be at least three different types of proto-signs arising from a child’s 
bodily-tactile experiences. BETs (Bodily-Emotional Traces) are spontaneous 
gestures that arise from emotionally-charged impressions of bodily-interactional 
experience (Daelman et al., 2004). Typically, a BET emerges as a touch that children 
with CDB make on a particular place on their bodies where a specific experience has 
left a trace (e.g., a child touches a spot on her cheek where she felt her mother’s kiss 
before; Nafstad & Rødbroe, 2015, p. 43). Mimetic gestures are imitations of 
movements, bodily positions, and emotions involved in an action that children with 
CDB experience in the bodily-tactile modality (Nafstad & Rødbroe, 2015, p. 149). 
Thus, mimetic gestures represent an action and its corresponding mental state. Iconic 
gestures are gestures that represent their references iconically. Typically, the 
resemblance between iconic gestures and mental images is observable from a visual 
perspective (e.g., the sign DRIVE referring to holding a wheel when driving a car; 
Nafstad & Rødbroe, 2015, p. 151). In children with CDB, iconic gestures can be 
connected to their bodily-tactile impressions of an experience (e.g., after exploring 
a panel wall tactilely, a child with CDB might refer to his experience through a 
gesture in which his fingers iconically represent the panel boards with cracks, and 
the bent-in thumb demonstrates the position of the thumb during the exploration; 
Forsgren et al., 2018). Iconic gestures only partially express an experience, which 
differentiates them from mimetic gestures and makes them more difficult to detect 
(Forsgren et al., 2018; Nafstad & Rødbroe, 2015, p. 151; Souriau, 2015).       
Proto-signs can also be called “authentic communication” or “thinking gestures,” 
which may not be initially directed at others (Nafstad, 2018). However, they express 
children’s sense-making cognition and have high meaning potential (Daelman et al., 
2004; Gregersen, 2018; Nafstad, 2018). That is, when the gestures are noticed and 
responded to, they can be shared and developed into a shared sign (Nafstad & 
Rødbroe, 2015, p. 44). The first part of the process is spontaneous engagement in 
making sense of an impression; the second part is the negotiation of the gesture into 
a sign function that takes place through reciprocal imitation in the bodily-tactile 
modality. The third phase in the process is the pragmatic use of the proto-sign in 
particular contexts, which enables the co-construction of shared meaning (Nafstad, 
Review of the literature 
 37 
2018). If the thinking gestures are not responded to, they may disappear (Daelman 
et al., 2004).  
Brede and Souriau (2016) described a process in which a BET from five-year-
old Fredrik with CDB was developed into a shared sign. During the first stage, 
Fredrik made an emotion-based gesture (moving his fisted hands down on his 
cheeks) in anticipation of tooth brushing—a bodily-tactile experience that he 
strongly disliked. This gesture also appeared in other situations in which Fredrik 
experienced something he felt sorry about. His caretakers started responding to this 
BET through immediate imitation, which resulted in a more conscious use of the 
gesture. At the next stage, Fredrik’s teacher began to use the cultural sign CRY by 
performing it on his cheeks when he was crying. CRY was also embedded in a hurt-
and-cry story. Next, Fredrik was observed gesturing to himself, and a new modified 
gesture CRY-SORRY emerged. Fredrik’s teacher responded to this gesture, sharing it 
with Fredrik. Later, when Fredrik was crying, he grabbed his caretaker’s hand, 
placed it on his cheek, and helped the adult perform the modified sign. In the last 
phase, when Fredrik’s teacher saw him making the sign, she first imitated it on his 
cheek and then took his hand and led him to feel the sign on her own face. In this 
way, the newly constructed sign became communicative because both Fredrik and 
his caretakers knew what it meant.      
The storytelling of children with CDB can consist of mimicry and deictic 
expressions. Souriau (2015) analyzed shared storytelling between a mother and her 
four-year-old son, Emil, who had CDB and a cochlear implant. When they discussed 
their earlier visit to the playground, Emil did not use standard signs, but his use of 
physical space and mimicry in retelling about his bodily-tactile experiences of 
climbing up a ladder, sliding down, and meeting a girl with a cochlear implant. In 
his narrative, Emil used real space (physical space) to refer to actions that occurred 
in the narrative space (mental imaginary space) and combined his expressions into 
haptic-temporal sequences of action.   
Although categorizing the proto-signs of children with CDB may not always be 
clear-cut, recognizing the different gesture types can increase an understanding of 
the bodily-tactile experiences from which they may arise. This recognition of proto-
signs is essential for them to become co-created signs. Furthermore, as proto-signs 
often relate to what children with CDB think about, their communicative function 
reaches beyond instrumental communicative acts, to which AAC is often restricted. 
Overall, the proto-signs suggest that children with CDB have an innate meaning-
making ability. However, language acquisition in the bodily-tactile modality is a 
special case because tactile language acquisition has not been reported to exist 
naturally, like language acquisition in other modalities (cf. deaf children acquiring 
sign language from their deaf parents, Vonen & Nafstad, 1999). That is, children 
with CDB typically do not have the possibility of many direct tactile interactions 
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38 
with other deafblind individuals, which would allow for a new language community 
to arise (Vonen & Nafstad, 1999). This makes it difficult to measure or describe 
“typical” language acquisition in the bodily-tactile modality (Ask Larsen, 2013). 
2.3.4 Augmentative and alternative communication 
Children with VIAD can learn to use AAC (Brittlebank et al., 2024). However, 
finding the best solutions for them is challenging, as AAC systems are mostly visual 
(Boster et al., 2021; McCarty & Light, 2023). Moreover, studies provide limited 
information on the rationales for how these solutions are selected for children with 
VIAD (Boster et al., 2021). The selection process would necessitate detailed 
knowledge of children’s functional vision (e.g., CVI range assessment; Blackstone 
et al., 2022; Wilkinson et al., 2023). If this kind of essential information is lacking, 
it may complicate AAC decision making and confuse parents (McCarty & Light, 
2023). In general, parents of children with VIAD have experienced AAC 
interventions as ineffective in promoting their children’s language skills (Blackstone 
et al., 2021), which may be due to inadequate assessments and several limitations in 
implementing interventions. First, the interventions have focused mainly on 
requesting or choice making, while social interaction and the training of 
communication partners have often been disregarded (Brittlebank et al., 2024). 
Second, most interventions have been implemented in isolated contexts and were not 
connected to daily activities (Brittlebank et al., 2024). Third, the majority of the 
children included in AAC intervention studies were over six years of age, which is 
too old to achieve the best possible outcomes (Brittlebank et al., 2024). Lastly, 
speech-language pathologists (SLPs), teachers of the visually impaired, and other 
school-based professionals working with children with VIAD have identified a lack 
of expertise and training with CVI and AAC (Blackstone et al., 2021).    
When these critical aspects are considered, AAC interventions can be successful. 
For instance, Blackstone et al. (2022) investigated 3–11-year-old children with CVI 
(N = 13) who studied in a school specialized for children with multiple disabilities. 
Each class was co-taught by a full-time special education teacher and an SLP. The 
school also used systematic CVI assessments and interventions, which were 
integrated into the education curricula and AAC interventions. All 13 children with 
CVI used multiple means of communication. Twelve used gestures; nine used 
pictographic symbols, photos, or PAAS (Partner-Assisted Auditory Scanning); and 
seven used speech. Five children used letters and numbers, four utilized written 
words or phrases, and two used tangible symbols. Only one child used manual signs. 
Children who had better functional vision and fewer medical diagnoses had higher 
communication skills than the others. The findings indicate that children with VIAD 
have more capacity to develop communication with AAC than expected and can 
Review of the literature 
 39 
utilize their potential when provided with appropriate assessments and interventions 
(see also Wilkinson et al., 2023). However, the possibilities related to tactile 
communication are rarely addressed in the literature. Aasen and Nærland (2014) 
found that 5–17-year-old blind children with additional disabilities were more likely 
to follow requests, which were expressed by tactile symbols, compared to verbal 
instructions. Thus, the tactile symbols appeared to help the children become more 
active in participating in school activities. If normally hearing children with VIAD 
were provided access to services for children with CDB from infancy, they could 
have more systematic support for developing their interactional and communicative 
skills in the bodily-tactile modality (Andersen & Rødbroe, 2005). 
2.4 Early intervention 
Early intervention has the potential to minimize the negative effects of children’s 
disabilities, enhance children’s development, and provide support to families (Bailey 
et al., 2005; Guralnick & Bruder, 2020; Heckman, 2006). This potential is connected 
to heightened brain plasticity in infancy, which allows for possibilities of affecting 
brain functioning through positive experiences (Chen, 2014, p. 5). Early 
interventions achieve the best results when children are younger than 3 years and 
their parents are involved in the process (Bailey et al., 2005; Launonen, 1998; see 
also Heckman, 2006). Children with VIAD are no exception. It is essential to address 
their parents when increasing reciprocal accessibility in interactions. This is because 
parents have knowledge of their children’s lived experiences and are typically the 
most important people in their children’s lives. However, it is not self-evident that 
parents are included in interventions for children with VIAD.  
Family-centered practices recognize that children are interconnected within their 
family contexts, and the best results of interventions can be achieved by involving 
parents in natural environments, including homes (Ely & Ostrosky, 2018; see also 
Bronfenbrenner & Ceci, 1994). Family-centered practices can empower parents with 
new attitudes, knowledge, and skills that give them the perception of control, 
confidence, and competence (Dunst & Dempsey, 2007). Guralnick (2011) argues 
that parent-child interactions that consist of sensitive responsiveness, affective 
warmth, and engagement are especially fundamental to parents’ empowerment. That 
is, early intervention can help parents create positive transactions with their children 
(Sameroff & MacKenzie, 2003a).     
Parents’ empowerment necessitates relational and participatory practices in 
early intervention (Dunst & Dempsey, 2007). Strong relational practices involve 
close professional-parent collaboration, mutual trust, and active listening (Dunst & 
Dempsey, 2007; Ely & Ostrosky, 2018; Konstantina et al., 2014). Hopkins and 
Puhlman (2025) discovered that a strong relationship with an early interventionist 
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40 
contributed to parents’ feelings of empowerment during early interventions. 
Participatory practices involve parents in decision making and engage them in 
activities that strengthen their existing competencies (Dunst & Dempsey, 2007). 
These practices also involve professionals learning from the expertise of parents 
concerning their children’s uniqueness (Rouse, 2012; see also Breemer, 2025).    
This chapter discusses participation as a right of children and explains why 
accessibility is a necessity for the participation of children with VIAD. It also 
introduces tactile strategies that can be used to increase accessibility and 
multimodality in interactions. The studies described have explored the effects of 
early interventions for parents and their 0–2-year-old children with VIAD. This 
demarcation excludes early interventions for children with isolated VI (e.g., 
Beelmann & Brambring, 1998; Dale et al., 2018; Fraiberg, 1979), for children aged 
3 and older with VIAD (see Sundqvist et al., 2023), and those that did not involve 
parents (Lake, 1985).   
2.4.1 Participation as a right of the child 
Early intervention can fulfill children’s rights to development and participation 
(Brown & Guralnick, 2012; United Nations [UN], 1989). Participation can be 
defined as follows: “Participation describes meaningful involvement in life 
situations in the home, at school, and in the community and provides opportunities 
for the development of functional skills, connecting with others, developing 
independence, and engaging in enjoyable and meaningful activities” (Williams et al., 
2020). Generally, participation is discussed in relation to older speaking children, 
but it is also relevant to preverbal infants, who are often ignored in policies, 
discussions, and decision making (Bakkenget & Våpenstad, 2023). Infant 
participation is embodied in parent-infant intersubjectivity, which makes the 
relationship with their parents the most important context for infants’ participation 
(Våpenstad & Bakkenget, 2021). As infants do not express themselves verbally, their 
voices originate through their playful, interactive and affectionate initiatives in 
particular cultures of interaction (Bonsdorff, 2021). A detailed analysis of parent-
child interactions can reveal these expressions and their impact on parents and vice 
versa (e.g., Trevarthen, 1974, 1979). When infants’ contributions are recognized and 
valued, we can learn more about their cultural agency (creative activity that 
contributes to society) and capacity to co-create communicative events (Bonsdorff, 
2021).   
Nonverbal children with VIAD are often in a position similar to typically 
developing infants regarding participation because they cannot express themselves 
verbally. Nevertheless, their voices can be heard through their initiatives in 
interactional activities with others. Early social play routines in the bodily-tactile 
Review of the literature 
 41 
modality are optimal contexts for this because they provide repetitive interactional 
experiences that children with VIAD can utilize in creating their communicative 
gestures. Thus, early interventionists can guide parents of infants with VIAD to use 
accessible imitation-based and game-based routines as initial contexts to foster their 
children’s participation (Chen, 2014, pp. 430–431; Rogow, 1982). Through 
participation, children with VIAD can develop agency, learn new communication 
skills, and have their voices heard (Bruner, 1975; Nomikou et al., 2017; Smith & 
Fluck, 2000).   
Parents of infants with VIAD may experience challenges accessing services that 
provide systematic support for their children’s participation and development. That 
is, children’s complex medical conditions, low expectations of medical and 
educational professionals (Breemer, 2025; McCarty & Light, 2023), professionals’ 
lack of knowledge, or diagnostic practices (Blackstone et al. 2021; McCarty & Light, 
2023) can delay the start of early intervention. When early intervention programs are 
available, the families of children with VIAD are generally satisfied with them 
(Battistin et al., 2024; Konstantina et al., 2014). However, parents continue to 
experience anxiety about their children’s lack of speech and difficulty interpreting 
their idiosyncratic expressions (Miliou, 2024). This suggests that general early 
intervention programs may not always provide families with enough knowledge 
about how to support their children’s participation and communication. This may be 
due to professionals’ lack of knowledge. Ely et al. (2020) found that vision 
professionals felt inadequately trained to work with young children with VI/VIAD. 
Similarly, House and Davidson (2000) discovered that a great number of SLPs did 
not feel knowledgeable about VIs (59%) or deafblindness (76%). The recent findings 
of Luo et al. (2022) showed no improvement in the self-evaluations of SLPs, which 
indicates a need to develop the content of the study programs for vision professionals 
and SLPs.     
2.4.2 Accessibility 
Early intervention can help to increase accessibility in interactions between children 
with VIAD and their parents. Due to VI, children with VIAD have limited access or 
no access to their parents’ nonverbal expressions. Specifically, although sighted 
infants can use visual information to gain knowledge of others’ emotions, actions, 
and intentions, infants with VIAD often miss these. However, when other senses are 
used to compensate for the lack of vision, VI does not necessarily compromise the 
quality of early interactions (Rattray & Zeedyk, 2005). This makes the conditions 
for perception and cognition fundamental in designing interactions and interventions 
for children with VIAD (Gregersen, 2018; see also Loots et al., 2005). Accessibility 
through the bodily-tactile modality is important for children with VIAD and critical 
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42 
for children with CDB. To be precise, the communication development of children 
with CDB depends fully on sharing tactile and motor experiences with others 
(Souriau, 2015). However, Bruce (2003) discovered that although the teachers of 
three children with CDB were responsive, they often used only verbal expressions, 
which were inaccessible to two children and intermittently inaccessible to the third 
child.    
When bodily-tactile information is aligned with speech, it aims to increase 
children’s possibilities for cross-sensory perception (matching of stimuli from 
different senses; Guellaï et al., 2019). Adults use cross-sensory perception in actions 
such as speech perception, which consists of integrating auditory information from 
speech and visual information from mouth movements (Rosenblum, 2008). Even 
infants are able to make cross-sensory correspondences based on the temporal 
synchrony of sensory information (Guellaï et al., 2019). Moreover, they can transfer 
information from one modality to another. The pioneering study of Meltzoff and 
Borton (1979) found that 1-month-old infants showed a clear visual preference for 
the shape of the pacifiers they had previously explored orally. The mechanism of 
cross-sensory perception, however, is not well understood. Stern (1985, pp. 47–53) 
suggests that infants might process sensory information in a supramodal form, which 
involves encoding sensory information from one or more modalities into a modality-
neutral amodal representation of the experience (see also Kaup et al., 2024; Spence 
& Di Stefano, 2024). Amodal representations are understood as abstract descriptions 
of the objects they represent (e.g., Kaup et al., 2024). Their formulation may be 
enhanced by multimodal stimulation (Bahrick et al., 2004).  
When adults use the bodily-tactile modality to increase accessibility in 
interactions with their children with VIAD, the children receive information through 
passive touch (Gibson, 1962). Gibson (1962) distinguished passive touch from active 
touch, which means touching and exploring something. Generally, active perception 
is considered superior to passive perception. That is, exploring an object tactilely 
gives more information about its form than just passively feeling it in the palm 
(Gibson, 1962). However, Magee and Kennedy (1980) discovered that persons 
whose index fingers were passively traced around pictures identified them more 
accurately than persons who used independent exploration. They suggested that this 
difference could be explained by the execution of movements. Active explorers need 
to plan their movements, which may limit their resources to distinguish relevant 
kinesthetic information (knowledge of how movements occur in space). Thus, the 
term “passive” conveys incorrect information when considering the complexity of 
tactile information processing in the brain.  
Review of the literature 
 43 
2.4.3 Tactile strategies 
Children with VIAD can benefit from tactile strategies, which are “planned, systematic 
methods of using the sense of touch to support a child’s understanding of information 
and to promote interaction and communication (Chen & Downing, 2006, p. 73).” As 
the sense of touch is most often intact in children with VIAD, tactile strategies work 
to their strengths and help to complement auditory and visual information (e.g., Aasen 
& Nærland, 2014; Atkinson, 2022; Bruce, 2005; Chen & Downing, 2006; Daelman et 
al., 2004; Deuce & Rose, 2019; Lindström, 2019; McLinden & McCall, 2016; Miles, 
2003; Vege & Nafstad, 2022). However, processing tactile information is slow and 
requires more time than processing information from other sensory modalities (e.g., 
Goold & Hummel, 1993, p. 70). In addition to their therapeutic use, tactile strategies 
are observed in natural interactions between deaf parents and their infants (Loots et al., 
2005; Maestas y Moores, 1980). 
Tactile strategies need to be utilized respectfully (Chen & Downing, 2006, p. 
73). Respectful touch requires the consent to touch, considers the location of touch, 
and responds to children’s feedback (Atkinson, 2022; Goold & Hummel, 1993). 
Moreover, it is important to observe whether a child with VIAD has tactile 
defensiveness, which refers to the avoidance of touch, aversion to non-noxious (non-
painful) touch, atypical affective responses to non-noxious tactile stimuli, and 
objection, withdrawal, or negative responses to touch contact (Bundy & Lane, 2020, 
pp. 167–171). Tactile defensiveness should be treated first to help children with 
VIAD habituate themselves to tactile interactions. 
Tactile strategies can increase accessibility to nonverbal information in several 
ways. First, they can transmit information related to the context of the interaction. 
For instance, the movements and gestures of early social play routines become 
accessible for children with VIAD when their parents coactively create them with 
their children. Alternatively, children with VIAD can be placed in a position that 
enables an embodied perception of their parents’ movements and postures (see 
Gregersen, 2018).   
Second, tactile strategies can be used to increase access to nonverbal 
information. Touch-speech cues are “a simultaneous touch-speech production in 
which a target word for comprehension is paired with a specific signal on a specific 
location on the learner’s body or limbs” (Goold & Hummel, 1993, p. 18). They were 
developed to enhance the receptive communication of children with multiple and/or 
sensory disabilities (Goold & Hummel, 1993). Some touch signals may also involve 
moving a body part. Touch-speech cues are individualized and context-based, not 
symbols like body signs (Chen & Downing, 2006, p. 103). Goold and Hummel 
(1993) discovered that touch-speech cues were helpful for three 10–18-year-old 
youngsters with VIAD to anticipate actions, recognize and comprehend target words, 
and develop the use of object symbols in communication.   
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44 
When adults want to signal that they have perceived a bodily expression of a 
child with VIAD, they can do so by providing confirmation of the child’s expression 
in the bodily-tactile modality. This may be especially important if the child cannot 
access or understand the adults’ speech (Nafstad & Rødbroe, 2015, p. 59). However, 
bodily-tactile confirmation has been studied mainly in the deafblind field. For 
instance, Damen et al. (2014, 2015a) guided communication partners to attune their 
behaviors and emotions to those of persons with CDB in an accessible (tactile) way 
(e.g., by lightly tapping on the cheek of a person with CDB to respond to his smiling). 
The communication partners’ use of these strategies, along with other strategies, 
increased reciprocity in interactions.   
Imitating the nonverbal actions of children with VIAD in the bodily-tactile 
modality can foster reciprocity in adult-child interactions in the same way that 
parents’ imitations foster dialogue in early interactions with their typically 
developing infants (Miles, 2003). When children with VIAD perceive that their 
movements are imitated, they learn that they can influence another person. Thus, 
imitating the hand and body movements of children with VIAD can develop their 
agency (the ability to initiate and control their actions) and create tactile turn-taking 
exchanges with them (Chen & Downing, 2006, pp. 34–36; Hart, 2006; Lee & 
MacWilliam, 2008, p. 25; Miles, 2003).     
Third, tactile strategies can provide access to cultural language and AAC. 
Manual signs of the visual sign languages can be adapted for children with VIAD in 
such a way that they can be received through the sense of touch (Chen & Downing, 
2006, pp. 120–121). Body signs are made on children’s bodies. Maestas y Moores 
(1980) found that deaf parents spontaneously used body signs in interactions with 
their infants. They made signs on their infants’ torsos, foreheads, and hands and used 
their infants’ bodies as referents for the pronoun “you.” When signs are made on 
children’s bodies, they receive information about the place of the sign and potentially 
also about its movement. However, body signs do not provide information about the 
signer’s hand shapes. Thus, only when the other types of tactile signs are used with 
children with VIAD will they receive the information that is needed to recognize the 
signs and learn to produce them (Chen & Downing, 2006, p. 122). In coactive 
signing, the adult physically helps the child to produce the sign from the child’s 
perspective (Chen & Downing, 2006, p. 126). The findings from natural interactions 
between deaf parents and their infants suggest that coactive signing can be a helpful 
strategy for children to learn to produce signs during the early stages of signing. 
Maestas y Moores (1980) observed that deaf parents guided their infants to produce 
different signs when the infants were 2–5 months old. However, coactive signing has 
the potential to be intrusive, which is why it needs to be used with caution (Rose, 
2018). In tactile signing (also referred to as ”hands on,” “hand-over-hand,” or “hand-
under-hand” signing), the signer produces a sign, and the receiver holds on to the 
Review of the literature 
 45 
hands of the signer, which allows him or her to follow the signer’s hand movements 
(Mesch, 2001). Following the hand movements of others through tactile signing can 
enhance the expressive use of signs and tactile sign language acquisition in children 
with VIAD (Chen & Downing, 2006, p. 128; see also Dammeyer et al., 2015).  
Some children with VIAD may have the capacity to learn more complex 
linguistic skills beyond single signs if they are provided with access to tactile sign 
language. However, it is unlikely that hearing parents of children with VIAD have 
knowledge of the visual sign language of the community when their children are 
born (see Kanto, 2022), which may delay children’s access to tactile sign language. 
Deafblind people with Usher syndrome are typical users of tactile sign language. 
They learn visual sign language as their first language and begin to use tactile sign 
language after their vision deteriorates or disappears (Mesch, 2001, p. 9). 
Furthermore, some individuals with CDB may develop tactile sign language skills 
(Tuomi & Lahtinen, 2019). The processing of tactile linguistic information shapes 
the brain’s functioning. Obretenova et al. (2010) found activation within the occipital 
cortical regions and in the classical language areas when an early blind and 
congenitally deaf man was presented with words in tactile sign language, braille, and 
print on palm (sequential writing of the alphabet on the palm when spelling words). 
These findings indicate that the brain processes tactile language like any other 
language.  
Fourth, some tactile strategies can be used to increase access to information 
about the environment. In hand-over-hand guidance, adults place their hand/s over 
the child’s to help him or her grasp or manipulate an object (Chen & Downing, 2006; 
McLinden & McCall, 2016, pp. 65–67). This strategy can be used in activities such 
as feeding children. However, hand-over-hand guidance can be intrusive and may 
cause resistance in some children with VIAD (Chen & Downing, 2006, p. 88). This 
type of guidance may also develop passivity in children, as adults lead the 
exploration (Miles, 2003). Hand-under-hand guidance is a less intrusive and 
preferable strategy. In hand-under-hand guidance, adults guide a child with VIAD 
by placing their hand/s underneath his or her hands (Chen & Downing, 2006, p. 84). 
This allows the child to have more control of the situation, as he or she can freely 
move his or her hands. Moreover, adults’ movements and touches under the child’s 
hand can function like a tactile variation of the pointing gesture when they are 
exploring an object (Miles, 2003).    
Lastly, tactile strategies can increase access to emotional expressions. For 
example, parents can express their emotions by touching the shoulders of their 
children with VIAD, who can learn to recognize emotions from the type of their 
parents’ touch and movements (Lahtinen, 2008, p. 121; see also Metell, 2015). 
Moreover, some parents’ emotions, such as laughter, are manifested in the whole 
body and become more accessible to their children with VIAD when the parents’ 
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46 
and children’s bodies are aligned with each other (Gregersen, 2018). Furthermore, 
parents can attune to the emotions of children with VIAD by imitating them tactilely 
(Damen et al., 2014). 
Overall, there is limited scientific information available regarding the benefits of 
tactile strategies and how parents and other caretakers learn to use them in practice. 
Lindström (2019) discovered that care workers of Martin, a youngster with CDB, 
used several strategies over the years to transform customs from visual sign language 
to tactile sign language. The tactile signing position (hand-over-hand position) 
developed gradually as Martin developed the ability to participate in tactile 
conversations. When Martin was in the tactile signing position, the care workers 
expressed deictic gestures to him through tactile pointing (see also Souriau, 2015). 
Moreover, the care workers used their hand and body movements to refer to people 
in the signing space and a “wiggling motion” of their hands and body to share 
positive emotions with Martin (see also Martens et al., 2017).    
Some interventions have utilized tactile strategies with positive outcomes 
(Shakele et al., 2022; see also Brady & Bashinski, 2008; Janssen et al., 2010). 
Shakele et al. (2022) found that after a bodily-tactile intervention, the mother and 
brother of a 3-year-old girl with CDB increased their use of tactile sign language, 
tactile imitations, and hand-over-hand positions. They also became aware of the 
girl’s signals and responded to them appropriately. The girl began to use more 
communicative expressions, including imitation, signs, and hand-over-hand 
positions, after the intervention. 
Chen et al. (2000) discovered that a focus group consisting of family members 
and service providers of children with VIAD found an individualized approach 
essential in selecting appropriate tactile strategies. They also identified a need to 
develop guidelines for the process of determining tactile strategies. Moreover, the 
focus group emphasized that the instruction of tactile strategies needs to be positive, 
non-intrusive, and implemented in familiar routines. Furthermore, they underlined 
the importance of systematicity in instruction (routines and repetition) and 
considered tactile learning to involve not only the hands but the whole body.   
Lastly, Loots et al. (2005) found that visual-tactile communication strategies 
(e.g., tapping the child to attract the child’s attention, placing hands on the upper 
body of the child to stimulate and check the child’s vocalizing, placing the child’s 
hands in the form of sign configurations, and making body signs) facilitated primary 
and secondary intersubjectivity between hearing parents and their deaf or hard-of-
hearing toddlers. However, the results indicated that the use of sign language was 
necessary to foster the development of symbolic intersubjectivity (“mental 
involvement in a mutual exchange of linguistic or symbolic meaning”; Loots et al., 
2005) in the parent-child dyads. 
Review of the literature 
 47 
2.4.4 Early interventions focused on parent-child interaction 
and communication 
Four studies explored the effects of interventions that fostered interaction or 
communication between young children with VIAD and their parents. Two utilized 
music and early social play routines as the content of the intervention (Metell, 2015; 
Rogow, 1982). The first, Rogow’s (1982) study, used early social play routines to 
develop intentional communication, imitation, and the use of social signals (cues 
used to elicit a response from others) in children with VIAD. The participants were 
10 children aged 15 months to 7 years. Three children were visited in their homes, 
and their mothers participated in the intervention. Seven children had school visits. 
Rogow (1982) did not report the total length of her intervention. However, as the 
video data was gathered every 2 months, the intervention continued over several 
months. The results indicated that all the children became more aware of their roles 
in the interactions. Moreover, they developed communication skills, including 
imitation and intentional communication, in their early social play routines. The 
children used gestures and body positions to refer to the games they wished to play 
(e.g., one child stretched her arms in front to indicate her desire to play London 
Bridge). Each child expressed himself or herself through the modalities that were 
most accessible. 
The other study, that of Metell (2015), explored the effects of music therapy on 
bonding and social interaction between 10 children with VIAD aged from 1 to 4 
years old and their parents. The intervention was implemented weekly in a 
pedagogical institution and continued for over 10 weeks. The results indicated that 
music therapy fostered positive bonding and enhanced the elements of early 
interaction. The parents and their children with VIAD obtained experiences of joy, 
joint attention, and togetherness. In this way, music therapy empowered both the 
children and their parents.      
Chen et al. (2007) investigated the primary outcomes of a curriculum called 
Promoting Learning Through Active Interaction (PLAI). The PLAI curriculum aimed 
to support interactions between 27 infants with VIAD aged 8–33 months and their 
parents within daily routines in their homes. It was implemented during 6–21 months 
and consisted of five modules: 1) understanding child cues, 2) identifying child 
preferences, 3) establishing predictable routines, 4) establishing turn-taking, and 5) 
encouraging communicative initiations. Each module included several objectives, 
such as identifying different kinds of sensory cues to help children with VIAD 
anticipate well-known routines. The results suggested that the parents found the PLAI 
curriculum strategies helpful in fostering interactions with their children with VIAD 
and supporting their children’s communication development. For instance, the parents 
reported that their infants began to anticipate more activities and to participate in them.     
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48 
Lastly, Rensfeldt Flink et al. (2023) investigated the effects of a communication 
course AKKtiv ComAlong for two mothers and their children aged 2 and 7 years with 
severe/profound intellectual and multiple disabilities. The 2-year-old participant also 
had VI. The communication course consisted of eight sessions organized at local 
habitation centers for children. It aimed to guide parents in identifying their 
children’s behaviors and communication and in using naturalistic communication 
strategies and AAC in the home. The results indicated that there were no observable 
behavioral changes in responsive communication style, mothers’ use of AAC, or 
interactive engagement of their children after the course. However, the mothers 
expressed that their understanding of communication with their children changed 
during the course, which suggests that they became more aware of their children’s 
behaviors.     
2.4.5 Early interventions focused on parents’ sensitivity 
Two studies explored the effects of interventions that aimed to foster parents’ 
sensitivity and parent-child relationships in families with children with VIAD. The 
first one, video-feedback intervention to promote positive parenting-visual (VIPP-
V), was based on an attachment-focused and evidence-based intervention called 
VIPP (Platje et al., 2018). The participants were 77 children with VIAD or VI aged 
1–5 years and their parents, who were randomized into two groups (VIPP-V and 
care-as-usual). The intervention followed the four themes of the original VIPP: 1) 
exploration versus attachment behavior, 2) “speaking for the child,” 3) “sensitivity 
chain,” and 4) sharing emotions. However, the intervention was individualized and 
adapted for each family. In adapting the intervention, the specific focus was on 
increasing exploration, joint attention, and the parents’ capacity to read their 
children’s expressions and emotions. VIPP-V included 7 sessions and was conducted 
over approximately 5 months in the home. The results showed that the intervention 
did not increase parents’ sensitivity or the quality of parent-child interactions. 
However, the self-efficacy of the parents was boosted, and this predicted an increase 
in parent-child interaction.   
Another study by Dyzel et al. (2023) investigated the effects of an interactive 
technology-based playmat, the Barti-mat, on parents’ sensitivity and responsiveness, 
including mirroring, and the happiness of their children with VIAD or VI. Mirroring 
was defined as the mimicking of a child’s vocalizations (verbal mirroring), 
movements (behavioral mirroring), or voicing the child’s experiences and emotions 
(affective mirroring). Altogether, 11 parents and their children with VIAD (N = 9) 
or VI (N = 2) aged 9–55 months participated in the study. The home-based 
intervention had a within-series single-case design with randomized blocks, which 
consisted of playing with the Barti-mat and play-as-usual. The intervention took 
Review of the literature 
 49 
place within 1 hour. The results indicated that at least one subcategory of the parents’ 
mirroring behavior improved. Moreover, the results suggested that the Barti-mat 
increased happiness among the participating children.  
To summarize, the different interventions for 0–2-year-old children with VIAD 
and their families used different means, including early social games, music, daily 
routines, a communication course, video feedback, and technology-based material. 
The findings indicate that play routines and music-based activities were helpful 
contexts in which to develop the participation of children with VIAD and reciprocity 
in interactions with their parents. The results also suggest that parents benefit from 
different strategies, including sensory cues and interactive play material, to support 
interactions with their children with VIAD. Moreover, the findings indicate that 
theoretical guidance alone is not sufficient to support interactions and 
communication between children with VIAD and their parents. Although Metell 
(2015) observed touch as a means for contact and attention between parents and their 
children with VIAD, and Chen et al. (2007) utilized tactile cues, among other sensory 
cues, for anticipating actions, neither of these studies had the main focus of utilizing 
tactile strategies to increase accessibility in interactions. Moreover, previous studies 
did not explore EA, which is a more comprehensive construct than parents’ 
sensitivity.     
 50 
3 Aims of the study 
The main aim of this research was to gain research-based knowledge of early 
intervention to enhance early interactions between children with VIAD and their 
parents. Currently, only a few studies have explored the effects of early interventions 
for 0–2-year-old children with VIAD, and none have focused on investigating the 
systematic use of bodily-tactile modality as an interactional strategy to compensate 
for the child’s lack of vision. For this reason, this doctoral study developed and 
implemented a home-based early intervention in which mothers were guided to use 
the bodily-tactile modality in interactions with their children with VIAD. The 
mothers were also guided to respond to their children’s bodily and gestural actions 
in addition to their vocalizations. This study aimed to explore mothers’ use of the 
bodily-tactile modality in interactions with their children with VIAD and the 
reciprocity of their interactions before, during, and after the early intervention. A 
special interest in this research was to explore the relatedness of mothers’ actions to 
their children’s participation. Moreover, this study aimed to investigate whether 
possible changes in mother-child interactions during the intervention have an impact 
on the emotional availability of dyads. The intention is that the results of this study 
will inform practices for implementing early interventions for children with VIAD 
and their families.    
 
The specific research questions were as follows:  
1) Does tactile imitation guidance change the characteristics of imitations 
between a mother and her child with CDB (Study I)? 
2) Does the mothers’ use of the bodily-tactile modality in interactions with 
their children with VIAD change during the early intervention (Studies I, 
II, and IV)?  
3) Does the participation of children with VIAD change during the 
intervention, and if so, are the changes in the children’s expressions 
related to their bodily-tactile experiences of interactions with their 
mothers (Studies I, II, and III)? 
Aims of the study 
 51 
4) Does reciprocity between children with VIAD and their mothers change 
during the early intervention, and if so, how do the mothers and their 
children construct their interactions during the intervention (Studies I, II, 
and III)? 
5) Does the emotional relationship between children with VIAD and their 
mothers change during the early intervention (Studies I, II, and IV)? 
 52 
4 Methods 
4.1 Participants 
Information related to children’s development and functioning of the senses was 
gathered from medical records and a parental interview, which was designed for this 
study. The parents were asked about their children’s early development, vision, 
hearing, motor abilities, play, communication, emotional expressions, and family. 
All the children’s names are pseudonyms. 
4.1.1 Study I 
In Study I, the participants were a mother and her daughter Emma, who was 3 years 
and 10 months old. Emma had trisomy 13 (also called Patau syndrome), which is 
associated with multiple malformations (e.g., anomalies of the central nervous 
system) and typical facial features, including a sloping forehead, eye abnormalities, 
low-set ears with an unusual shape, a small jaw, a prominent occiput, and a cleft lip 
and/or palate (Pereira, 2023). Emma needed to stay five and a half weeks in the 
hospital after birth. She had congenital visual and hearing impairments. In a hearing 
test, she was found to react to speech with hearing aids at 60/65 dB and music at 55 
dB. Emma had microphthalmia (an abnormally small eye) and congenital corneal 
opacity in both eyes. She could only see a small amount of light and black and white 
stripes, which indicated that she was almost blind. Based on her dual sensory 
impairment and the severity of the impairments (see Dalby et al., 2019), Emma was 
defined as a child with CDB in this study. Emma also had a severe learning disability, 
a congenital heart defect, epilepsy, an operated cleft palate, severe problems in her 
motor development, and an extra finger on one hand. Her motor problems prevented 
her from standing or walking independently. She also needed support when she was 
seated. However, Emma could keep her head upright and use her hands and fingers 
to explore objects and the faces of people (e.g., checking if the person was wearing 
glasses or earrings). Based on information from Emma’s mother, she herself was 
employed and had good physical and mental health.   
Emma and her family had received support for communication from a local 
center for individuals with developmental disabilities. A communication adviser 
Methods 
 53 
from the center met Emma in kindergarten weekly. Moreover, the family had been 
in a multidisciplinary individual rehabilitation course organized by the Finnish 
Federation of the Hard of Hearing. They had received 10 teaching sessions for 
manual signing. Emma had only had appointments with an SLP in the hospital. The 
parents mainly utilized vocal modality for interacting with Emma. However, they 
also used some tactile strategies, including tactile contact and objects of reference, 
in anticipating daily routines. Emma used noncanonical vocalization, smiling, 
laughing, and bodily means to express herself. She utilized one spontaneous sign 
DRINK, which she made in the air. Emma could imitate her parents’ tone of voice 
and make initiatives through movements with her hands and legs (e.g., lifting her 
hand up when expressing a wish to continue bodily activity). Her parents were not 
sure how much Emma could comprehend speech or signs.  
4.1.2 Study II 
In Study II, the participants were a mother and her son Robin, who was one year and 
five months old. He was born preterm and had an L1CAM gene mutation causing 
L1 syndrome with agenesis of the corpus callosum, obstructive hydrocephalus (with 
a shunt), adducted thumbs, epilepsy, and a mixed specific developmental disorder. 
Robin had unqualified visual loss in both eyes (suspected CVI), which caused an 
estimated 50% degree of visual disability. Moreover, he had strabismus and 
nystagmus. Robin used eyeglasses for half of the day. It was difficult for him to see 
objects that were not close to him or pictures in books, but he could detect a toy when 
it was brought near him. He had normal hearing. Robin could not sit without support 
or grasp objects with both hands. He had some tactile defensiveness with his hands. 
Robin’s mother is a healthcare professional. 
Robin and his family did not have systematic support for communication. 
However, they had had five counseling sessions with an SLP due to Robin’s eating 
difficulties. According to Robin’s mother, Robin appeared to understand his own 
name and easy speech connected to routines. Robin used vocalizing and body 
movements to express himself. He made initiatives infrequently. At times, he could 
bring his hands together at the beginning of the Finnish nursery rhyme “Hämä-hämä-
häkki” (Itsy Bitsy Spider), trying to imitate the movements of the song. Moreover, 
he could imitate his mother vocally if she used a sound belonging to his sound 
repertoire to initiate the dialog. Robin liked to sit on his parents’ laps and explore 
their faces using his hands. It was easy for Robin’s mother to read his emotions. 
However, she wished Robin could express his thoughts and desires better.  
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4.1.3 Studies III and IV 
The participants of Studies III and IV were Thea, Sara, and Alex and their mothers. 
All the children had epilepsy and developmental delays. Sara received a diagnosis 
of ID during the data collection. The children’s hearing was reported to be normal. 
However, Thea’s parents pointed out that Thea only showed her first reactions to 
sounds (e.g., rattles) at the age of 9–10 months. It was difficult for the children to 
make voluntary movements and sit without support. The families of Thea and Alex 
had not received systematic support for communication. Sara received speech 
therapy approximately once a month in kindergarten. The mothers of Thea and Sara 
work in healthcare, and Alex’s mother is a homemaker.   
Thea was exactly 1 year old. She had CVI and athetoid CP. Her disabilities were 
caused by severe birth asphyxia and infection. Thea needed to stay for long periods 
in the hospital during her first six months. She was medically fragile and had nursing 
assistance at home. Her parents could only achieve eye contact with her for a 
moment. Thea expressed herself through vocalizations, crying, and facial 
expressions. She did not imitate her parents’ expressions. Thea’s mother utilized 
some haptices (touch messages; Lahtinen, 2008) with Thea in daily activities. Thea 
had some functional vision. She could detect objects with a strong contrast in color 
and moving objects. Thea liked to be in bodily contact and enjoyed early social play 
routines, which included strong tactile sensory stimulation. Thea’s mother wished 
she could obtain guidance for elaborating on haptices and developing reciprocal 
interactions with Thea.  
Sara was 1 year and 9 months old. She had CVI and athetoid CP. Her disabilities 
were caused by prenatal hypoxic-ischemic encephalopathy and severe anemia as a 
newborn. She needed to stay in the hospital for approximately six weeks after birth. 
Her parents could achieve eye contact with her for short periods. Sara used 
vocalizations, crying, facial gestures, and movements (e.g., kicking her feet) to 
express herself. If her parents imitated her vocalization, she could sometimes 
continue the imitative exchange. Sara had some functional vision. She could see 
objects with bright colors or clear figures and detected them best from a distance of 
20–30 cm. The play between Sara and her mother consisted of interacting with toys 
and physiotherapy exercises. Sara liked to be in bodily contact with her parents and 
to interact with them. She smiled at her parents’ voices and other interesting sounds. 
Sara’s mother wished that they could have more reciprocity in interactions and that 
Sara could develop her expressive communication skills. 
Alex was 1 year and 7 months old. He had CVI and spastic quadriplegic CP. 
His disabilities were caused by severe birth asphyxia. Alex was born preterm, and 
he needed to stay in the hospital for approximately one month after birth. He also 
needed periods of hospitalization at a later stage. Alex spent weekends in a 
temporary care unit and the rest of the time with his family. He used smiling, 
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laughing, crying, and bodily actions to express himself. His parents had not 
observed him imitating their expressions. It was not clear how much functional 
vision Alex had. However, his mother indicated that his vision had improved and 
that he could perceive some objects. The play between Alex and his mother 
consisted of stretching, chatting, and exploring toys. Alex enjoyed being close to 
his family members and touched. Alex’s mother wished Alex could engage more 
in play and develop his expressive communication skills.    
4.2 Study design 
This study uses case report (Study I), single-case study (Study II), and multiple-case 
study designs (Studies III and IV). Case reports are connected to findings in clinical 
practices and may provide early signals of the effectiveness of interventions with 
previously unreported features (Alpi & Evans, 2019). Single-case study designs 
cover more complexity than case reports and may involve one or multiple 
participants (Horner et al., 2005). Single-case designs “often involve repeated, 
systematic measurement of a dependent variable before, during, and after the active 
manipulation of an independent variable” (e.g., applying an intervention; 
Kratochwill et al., 2010, p. 2). Typically, the behaviors of each participant are 
compared to his or her prior behaviors (Kratochwill et al., 2010). Single-case studies 
are useful in learning more about low-incidence disabilities, such as VIAD 
(Campbell & Johnston, 2009). They are also ideal for studying dynamic 
interdependencies among the participants (Marková et al., 2020). 
Single-case studies can have different designs. After considering the specifics of 
the interventions, it was concluded that the ABAB reversal design would not be 
appropriate for the studies because the dependent variables were unlikely to be 
reversed after the intervention (see Kratochwill et al., 2010). Study I used a case 
report design (AB). Study II was a single-case study using a longitudinal design 
(ABA). Studies III and IV were multiple-case studies using a longitudinal design 
(ABA). Longitudinal case studies produce information about how conditions and 
their underlying processes change over time (Yin, 2014, p. 53). The study designs 
are presented in Figure 1. A refers to the time without intervention and B to the 
intervention. The studies were approved by the ethics committee of the Helsinki and 
Uusimaa Hospital District, and research permits were granted from university 
hospitals in Southern Finland.   
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Figure 1.  Study designs and the progress of data collection. 
In Study I, the family was contacted through the Finnish Federation of the Hard 
of Hearing. The inclusion criteria for the child were dual sensory impairment and an 
early phase of language development (expressive vocabulary limited to a maximum 
of 10 spontaneous words or signs). A contact person in the Finnish Federation of the 
Hard of Hearing sent an information letter regarding the study to the family. The 
information letter explained to the parents that the study would focus on exploring 
the characteristics of interactions between children with CDB and their parents and 
would include video recordings. The parents were also informed about the place of 
the videorecording (home or another environment, if preferred) and the number and 
duration of the sessions. Moreover, that the study would consist of two parts was 
also explained to them. In the first part, the researcher will interview the parents and 
record free play between them and their child. In the second part, the researcher will 
cooperate with the parents and continue videotaping parent-child play sessions. 
Furthermore, the parents were informed that their own and their child’s contributions 
to the interaction would be analyzed. After reading the letter, the mother contacted 
the researcher by telephone. During the call, she had the opportunity to ask additional 
questions related to the study. The parents gave their informed written consent for 
their child’s participation.     
The participant families in Studies II, III, and IV were reached through 
university hospitals in Southern Finland. Searches for the children were made 
using the following criteria: (a) maximum age of two years, (b) severe VI, (c) 
preverbal language skills (no more than 10 words or signs in use), and (d) Finnish 
as the language spoken at home. Candidate families received an information letter 
about the study from contact persons at the university hospitals. The information 
letter explained to the parents that interactions with their children with VIAD can 
be fostered by guiding the parents to use communication strategies that their 
children can understand. They were also informed about the place of the 
intervention (home or another environment, if preferred), the number and duration 
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of the sessions, the video recording of the sessions, and the use of video feedback 
as part of the guidance. The volunteer mothers contacted the researcher by 
telephone, and the parents provided their written consent for their children’s 
participation. After the data collection, each family received a toy gift card for a 
maximum of 25 euros. 
4.3 Data collection 
This study used video recording as a method for data collection. Video recording is 
a useful method for data collection when the focus of the study is to investigate the 
subtle behaviors of the child. Without videos, the emerging behaviors of the child 
could be missed or captured only partly. Moreover, the videos can be viewed several 
times, which improves the reliability of the observations (Bates et al., 1979, p. 83; 
Nafstad & Rødbroe, 2015). Altogether, over 24 hours of data were gathered for 
Studies I–IV. The progress of the data collection is presented in Figure 1.  
Originally, the data for Study I were collected for a master’s thesis at the 
University of Groningen, the Netherlands (Peltokorpi, 2011). In this doctoral 
study, the data were analyzed with new research questions and methods. In Study 
I, the researcher met the family 10 times, and the video data were gathered from 9 
sessions (I–II and IV–X). This made over 2 hours of video data, which included 
mother–child interactions with or without toys, father-child interactions, and 
sessions in which both the father and mother played with Emma. Altogether, 2–3 
recordings were made per week over a 6-week period. The recordings A1–B4 and 
B8–B10 were made in the home. Recordings B5–B7 were made at the Service and 
Activity Centre for the Visually Impaired (IIRIS) in Helsinki, where the family 
stayed for a week. The first two sessions (A1–A2) were baseline sessions. Before 
the video recordings, the parents were asked to play with Emma as they normally 
would. Sessions B3–B10 included guidance for the parents. Emma had an ear 
infection during the data collection and could use her hearing aids only in sessions 
A1, A2, and B10.   
In Study II, the researcher met the family 15 times at home. Based on the parents’ 
decisions, only the mother participated in the intervention. During the first session, 
the mother was interviewed. Video data on free play were gathered from 14 sessions 
(A2–A4, B5–B12, and A13–A15) using two video cameras. The mother chose the 
most convenient day and time for the recordings, which was early in the morning. 
Before the free play recordings, the mother was asked to play with Robin with and 
without toys, as she liked. These two types of play were recorded separately. The 
baseline recordings (A2–A4) were made weekly and lasted about 30 min each. The 
recordings during the intervention (B5–B12) were made weekly, and each session 
included two separate recordings. The first recording included triadic play among 
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the researcher, Robin, and his mother, and the second recording consisted of free 
play between Robin and his mother. During free play, Robin and his mother played 
without toys in all sessions, and in some sessions, they played with toys. The 
intervention sessions lasted a maximum of 90 min. The follow-up recordings were 
made one, five, and nine weeks after the last intervention session and lasted about 
30 min each. Robin wore his eyeglasses during all the recordings. In the A14 and 
A15 recordings, he had nasogastric intubation due to eating problems and vomiting. 
Altogether, there were over 7 hours of video data. The data consisted of video-
recorded mother-child interactions with or without toys, triadic play sessions, and 
extra video clips of mother-child interactions.   
The data collection for Studies III and IV followed the principles of Study II, 
with some exceptions. First, four baseline recordings (A1–A4) were used instead of 
three to obtain a longer baseline period. Second, the mothers chose the most 
convenient day and time for the video recordings, which could be morning or 
afternoon. Third, the mothers were asked not to play with toys during the free play 
sessions. Fourth, there were exceptions to the scheduling of the recordings. Due to 
Thea’s illness, there were three weeks between baseline recordings A2–A3. For 
Alex, there were two weeks between baseline recordings A1–A2 and A3–A4. There 
were also some exceptions to the scheduling of the intervention sessions. Due to 
Alex’s illness, a one-week adaptation training course, holidays, and other family 
reasons, there were two weeks between recordings B7–B8, three weeks between 
recordings B8–B9, and two weeks between recordings B9–B10, B10–B11, and B11–
B12. There were no exceptions in the scheduling of intervention sessions with Sara 
or Thea. The follow-up recordings were carried out mostly as planned. However, 
Alex’s A15 recordings were made 24 weeks after the last intervention session due to 
the coronavirus pandemic. He stayed for about three months in temporary care 
between recordings A14–A15. All the children had frequent health problems during 
the recordings. Thea had difficulty breathing and nausea, Sara had epileptic seizures, 
and Alex had frequent serious respiratory infections and breathing difficulties. 
Altogether, over 14 hours of video data were collected. The data consisted of video-
recorded mother-child interactions with or without toys, triadic play sessions 
(mother, child, and the researcher), and extra video clips of mother-child 
interactions. 
In Studies III and IV, the mothers were given two questionnaires (Brief EA Self-
Report and a questionnaire designed for this study) after the first baseline recording 
and after the last intervention session. After the intervention, the parents of Study I 
were asked to give written feedback about the guidance. Similarly, all the mothers 
in Studies II–IV were asked to provide feedback using a feedback form, including a 
numeric evaluation of the intervention and a video-recorded interview. 
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4.4 Tactile imitation guidance (Study I) 
4.4.1 The theoretical framework 
Tactile imitation guidance (Study I) was inspired by research on typically developing 
infants and Trevarthen’s theory of intersubjectivity (Trevarthen, 1979; Trevarthen & 
Hubley, 1978). Trevarthen’s (1979) findings indicate that imitation creates turn-
taking in the dyadic interactions between infants and their parents. That is to say, 
when parents imitate their infants’ expressions, they treat them as initiatives. This 
encourages conversational activity and creates sequences in parent-child interactions 
during primary intersubjectivity (Trevarthen, 1974). Moreover, adults’ imitations 
have been found to have a positive impact on infants’ responsiveness, which is 
embodied through their increased levels of attention, smiling, and approach 
behaviors (e.g., Sauciuc et al., 2020). Due to these positive effects in connection to 
being imitated, imitation has become a well-known strategy to support reciprocity in 
interactions with persons with CDB or VIAD (Chen, 2014; Dyzel et al., 2023; Hart, 
2006; Nafstad & Rødbroe, 1999) or autism spectrum disorders (e.g., Delafield-Butt 
et al., 2020). Additionally, communication approaches, such as intensive interaction, 
utilize imitation as a strategy to foster the quality of interactions with persons with 
severe learning disabilities (Nind & Hewett, 2001). 
Tactile imitation guidance was also inspired by tactile strategies (e.g., Chen & 
Downing, 2006; Miles, 2003). The theoretical knowledge of cross-sensory 
perception and the brain’s flexibility in the processing of sensory information 
(Guellaï et al., 2019; Obretenova et al., 2010) made it possible to hypothesize that 
Emma (Study I) could connect the tactile information of the parents’ imitations to 
her own expressions. Thus, it was assumed that an increase in the bodily-tactile 
modality in imitations would increase their accessibility. The intervention was 
designed and implemented by a researcher with an MA in speech-language 
pathology and an MSc in educational sciences, with a specialization in 
communication and CDB.  
4.4.2 Content of tactile imitation guidance 
Based on observations during the baseline sessions, it was noted that Emma’s mother 
often used vocal modality to imitate Emma’s vocal expressions. She also made 
spontaneous nonverbal imitations of Emma’s movements and gestures, but it 
appeared that Emma was unable to perceive these imitations due to her severe VI. 
During the guidance, the researcher shared information about imitation with 
Emma’s parents and gave them suggestions for imitation. She guided the parents 
before the recorded play sessions or after them and sometimes also during the 
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recordings. The researcher explained to the parents the characteristics of imitation in 
typical early interactions and the use of imitation as a strategy to enhance reciprocity 
in interactions with children with CDB (e.g., Dyzel et al., 2023; Shakele et al., 2022). 
Moreover, she showed some video examples of the previous sessions to demonstrate 
moments of imitation. She also shared video examples of other caretakers imitating 
persons with CDB to model different ways of tactile imitation (Janssen & Rødbroe, 
2007; Rødbroe & Janssen, 2006). All the video examples were discussed together. It 
was concluded that it is unlikely that the parents’ nonverbal spontaneous imitations 
were accessible to Emma. The parents agreed that they could begin to use more of 
the bodily-tactile modality in their imitations to compensate for Emma’s VI. They 
could transmit their nonverbal imitations tactilely and add tactile elements to their 
vocal imitative responses to increase multimodality in their imitations (e.g., making 
the imitative response on Emma’s body, guiding her hand in a hand-over-hand 
position to “listen” the parent’s imitation, or imitating her movements in a manner 
that enables perception through the sense of touch). 
When guiding the parents, the researcher advised that almost all Emma’s 
movements or vocalizations could be imitated. However, she emphasized that 
parents do not need to imitate Emma’s every action, and they can apply tactile 
imitation in interactions naturally the way they prefer. The researcher also provided 
concrete examples of tactile imitation when she interacted with Emma. Moreover, 
she informed the parents that when they succeeded in establishing turn-taking 
exchanges with Emma through imitation, they could make variations in their 
imitations to keep the content of the interaction interesting. The variations should 
belong to Emma’s vocalization and gestural repertoire, and new expressions could 
be used at a later stage. 
4.5 Bodily-tactile early intervention (Studies II–IV) 
4.5.1 The theoretical framework 
The theoretical base of bodily-tactile early intervention is connected to the findings 
of cross-sensory perception (Guellaï et al., 2019), the brain’s capacity to process 
information through alternative modalities (Obretenova et al., 2010), and the 
literature on tactile strategies (e.g., Chen & Downing, 2006; Miles, 2003). Based on 
this knowledge, sensory accessibility became a crucial concept for the intervention. 
Moreover, Study I inspired the broadening of the use of bodily-tactile modality 
beyond imitation. The researcher developed the bodily-tactile early intervention 
model based on theories that emphasize the role of the social environment and 
parent-child interactions in children’s development (e.g., Bronfenbrenner & Ceci, 
1994; Sameroff & Chandler, 1975; Vygotsky, 1978). One of the most influential 
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theories is the transactional model of development, which underlines the mutual 
influences of children and their social environments (Sameroff & Chandler, 1975). 
According to this theory, the development of a child is a result of dynamic 
interactions between the child and his or her social environment over time (Sameroff 
& MacKenzie, 2003a). 
Sameroff and Chandler (1975) demonstrated that poor clinical status or other risk 
factors in newborns do not solely explain children’s later outcomes. Instead, the 
findings indicated that the environment had a great impact on children’s 
development, which could be positive or negative. Furthermore, they discovered that 
not only did parents influence the child but also the child influenced his or her 
parents. The researchers concluded that it was the specific transactions of a child 
and his or her parents that predicted the child’s developmental outcomes. However, 
this was not to say that severe disabilities would not compromise children’s 
development in optimal social environments. Nevertheless, it is the view of the 
transactional model that supportive social environments can help children with 
severe disabilities reach their full developmental potential (Sameroff & MacKenzie, 
2003a). When implementing an intervention, it is essential to understand how parents 
and children think about each other, as this impacts their behavior in interactions. 
Moreover, understanding how their actions influence each other is relevant for 
guidance (Sameroff & MacKenzie, 2003a).  
Before implementing the intervention of this study, an extensive quantity of 
literature on the developmental milestones of children with VI/VIAD and the 
characteristics of their interactions with their parents was studied (e.g., Als et al., 
1980; Fraiberg, 1971; Preisler, 1991, 1995; Rogow, 1982; Urwin, 1978). The 
findings indicated the importance of reciprocity and emotional connection in parent-
child interactions and the parents’ ability to provide rich multimodal experiences for 
their children with VI/VIAD. The intervention was also inspired by an intervention 
model developed for children with CDB (Nafstad & Rødbroe, 2015) and the 
mentalization-based parent-child intervention model called “Nurture and Play” (Salo 
et al., 2019). 
4.5.2 Main principles 
The bodily-tactile early intervention utilized elements similar to previous early 
interventions designed for children with VIAD and their parents. These elements 
included early social play routines, music, the use of imitation, and video feedback 
(e.g., Dyzel et al., 2023; Metell, 2015; Rogow, 1982). However, unlike the previous 
interventions, the bodily-tactile early intervention focused primarily on increasing 
accessibility in early interactions between children with VIAD and their mothers 
through the sharable bodily-tactile modality. Thus, the intervention was based on 
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the children’s strengths. The aim was that increased accessibility would enhance 
reciprocity in mother-child interactions and children’s participation. 
The baseline recordings of each family were viewed several times to learn the 
characteristics of their interactions. The observations were discussed with other 
research group members, and the information was utilized in planning the content of 
the intervention. Thus, although the themes and principles were the same for all the 
mothers and their children with VIAD, the intervention was individualized based on 
their individual characteristics and preferences. Moreover, some baseline recordings 
revealed the children’s abilities, which were discussed with the mothers. For 
instance, the baseline recordings of Study II revealed that Robin had learned three 
gestures from “Itsy Bitsy Spider,” which he had played several times by coactive 
signing with his mother. However, Robin’s mother was not aware that Robin could 
make these gestures independently. After the last baseline recording, the researcher 
informed the mothers about the content of the intervention and gave them the first 
suggestions related to the use of tactile strategies. Each intervention session 
consisted of three parts: (a) discussion and video feedback, (b) triadic play session, 
and (c) free play session (Figure 2). 
 
Figure 2.  The content of the intervention sessions. 
4.5.3 Discussion and video feedback 
The first part of the intervention session included introducing the themes of the 
session and discussing them with the mothers. The themes (different tactile 
strategies) were designed before the intervention, and the most appropriate themes 
were selected for each child. Video examples of other children with VIAD and their 
caretakers and modeling were used to demonstrate different tactile strategies to the 
mothers (Janssen & Rødbroe, 2007; Rødbroe & Janssen, 2006). Moreover, during 
the intervention, the researcher analyzed the video data and showed some video clips 
to the mothers to demonstrate reciprocity in the mother-child interactions, the 
children’s participation, and the mothers’ use of the tactile strategies. All the videos 
were analyzed and discussed with the mothers. The mothers were given explanations 
of why specific strategies could be useful in interactions with their children with 
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VIAD. Moreover, the researcher utilized the video recordings and the mothers’ ideas 
to design the content of the following sessions. The researcher gave the mothers 
folders that included brief texts about the themes of the sessions and the lyrics of the 
songs, which aimed to help them learn and memorize the information. The mothers 
also received information sheets on useful books, articles, and webpages connected 
to tactile strategies and early intervention.  
4.5.4 Triadic play session 
During the triadic play sessions, the researcher played with the children and their 
mothers. Occasionally, the father or other family members were also present in some 
families, but they did not engage in the play activities. Typically, the researcher 
modeled how the bodily-tactile strategies can be applied in play with the children 
and asked their mothers to repeat the modeled actions with their children. Thus, 
modeling was a frequently used strategy in the guidance. The researcher also gave 
feedback to the mothers on their use of tactile strategies during the play activities. 
Overall, the guidance aimed not to cause an over-reliance on professional input. 
Instead, it was aimed at supporting mother-child interactions and equipping the 
mothers with new ideas and resources. Initially, the researcher informed the mothers 
that their children may use tactile contact instead of eye contact (Figure 3). This was 
important because otherwise, the contact initiatives of the children with VIAD could 
have been unnoticed (Nafstad & Rødbroe, 2015). During the sessions, several tactile 
strategies were practiced, which are described below.  
 
Figure 3.  Illustration of tactile contact. Illustration: Saara Waked. 
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The mothers were introduced to new bodily-tactile play routines. Creating new 
early social play routines was important because they create discourse frames in 
early parent-infant interactions (Snow et al., 1987). Moreover, ensuring that play 
routines have a bodily-tactile structure makes them accessible to children with 
VIAD. Some mothers already had several bodily-tactile play routines in their 
repertoire at baseline, and some of them did not have any. In the case where a mother 
already had a large repertoire of bodily-tactile play routines at baseline, emphasis 
was placed on the optimal structuring of the play routines for her child’s 
participation. The new intervention-based play routines in the bodily-tactile modality 
consisted of existing cultural play routines with bodily-tactile structure (e.g., a 
Finnish rhyme “Magpie Makes Porridge”), self-created choreographies for songs, 
and self-created games. When trying out new games, the mothers provided important 
insights into their children’s preferences, and the games that appeared most 
enjoyable for the children were utilized in the triadic play sessions. In Study II, 
Robin’s mother was guided to use play routines with and without toys when playing 
with Robin. However, in Studies III and IV, only play routines without toys 
(nonconventional and conventional games) were utilized because they were 
considered developmentally easier activities for Thea, Sara, and Alex than games 
with toys (Trevarthen, 1980). 
The mothers were guided to create slots for their children’s turn-taking and to 
observe their children’s bodily expressions during the slots. This was essential 
because children with VIAD may need a longer wait time to process information to 
respond to their communication partners (Johnson & Parker, 2013; see also Damen 
et al., 2014). Moreover, focusing on children’s participation was a necessary part of 
the intervention because most of the tactile strategies were connected only to the 
input for children with VIAD. When observing the children, special attention was 
paid to their bodily and gestural expressions, which are often difficult for their 
communication partners to detect and interpret (e.g., Fraiberg, 1979; Nafstad & 
Rødbroe, 2015). Moreover, this study aimed to support turn-taking in mother-child 
interactions by guiding the mothers to respond to diverse movements of the children. 
Responding to children’s movements was also used in a previous approach 
“Learning together” developed for children with VIAD (Lee & MacWilliam, 2008, 
pp. 21–40).   
When the mothers observed their children’s bodily responses during the slots, 
they were encouraged to notice them through touch (Figure 4). Thus, if a child moved 
his hand, the mother was encouraged to touch the hand after the movement while 
acknowledging the child’s action verbally. Tactile noticing can be considered a 
variation in the parent’s responsiveness (Bigelow, 2003; Damen et al., 2015a; 
Nafstad & Rødbroe, 2015). Providing a means to strengthen the multimodality of 
parents’ responsiveness is important because parents’ responsivity is critical for 
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developing socioemotional competences in children with VIAD (Lang et al., 2017; 
Van keer et al., 2017). Moreover, parents’ tactual and vocal responsiveness expresses 
to children with VIAD that their actions have an impact on others, which can help 
them associate meaning with their behaviors (Bigelow, 2003; Yoder & Warren, 
1998). Furthermore, tactile noticing can also be a helpful strategy for marking 
segments of action in parent-infant interactions (see Bruner, 1975). Specifically, 
when a mother touches her child’s hand or leg after movement, her touch can 
facilitate forming units (turns) in sequences. Finally, tactile noticing may provide 
tactile information for children with VIAD about their parents’ attentional focus (see 
Bigelow, 2003). 
 
Figure 4.  Illustration of tactile noticing. Illustrations: Saara Waked.  
The mothers were guided to use tactile anticipatory cues to anticipate actions 
(e.g., touching the child’s hand before moving it in a game; Figure 5). Tactile 
anticipatory cues are touches or movements that are used in connection with speech 
to inform the recipient about the following action. Thus, they aim to increase 
perceptual accessibility to adults’ intentions (cf. Reddy, 2015). Tactile anticipatory 
cues resemble touch-speech cues described by Goold and Hummel (1993) and 
haptices (Lahtinen, 2008). However, as tactile anticipatory cues are used only for 
anticipation, their function is narrower. Tactile anticipatory cues were considered 
important in helping the children predict the subsequent actions and prepare them 
(see Nomikou et al., 2017; Reddy et al., 2013). When children can anticipate the next 
action and its timing, they can coordinate their own actions with those of others (see 
Axelsson et al., 2014; Deppermann & Streeck, 2018; Reddy et al., 2013).  
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Figure 5.  Illustration of tactile anticipatory cues. Illustrations: Saara Waked. 
Tactile imitation was introduced to the mothers as a strategy to enhance turn-
taking with their children (Hart, 2006; Miles, 2003; see also Chen, 2014). The 
mothers were encouraged to imitate their children’s movements and gestures in an 
accessible way through a sense of touch. For instance, if the children were tapping 
with their hands, the mothers were encouraged to respond by tapping the children’s 
hands or legs. Moreover, the mothers were encouraged to continue their personal 
ways of imitating their children’s expressions vocally. 
Tactile signs. The mothers were informed of the different ways of making tactile 
signs. This was to provide the children with the opportunity to learn the cultural signs 
of Finnish Sign Language from early on. Coactive signing (Figure 6A) and body 
signs (Figure 6B) were practiced in the play routines. These strategies were easy to 
implement with young children with VIAD, as they were often sitting on their 
mothers’ laps or lying on a mattress during play activities.   
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Figure 6.  Illustrations of tactile signs: Coactive signing (A) and body signing (B).  
Illustrations: Saara Waked. 
In Study II, Robin’s mother was instructed to use hand-under-hand guidance 
(Figure 7A) as a less intrusive and alternative way to hand-over-hand guidance 
(Figure 7B) when she was guiding Robin to explore toys. She was also shown how 
a tactile pointing gesture could be made (Figure 8). Because Robin had some 
functional vision, tactile pointing was aimed at helping him follow his mother’s 
pointing gestures. Hand-under-hand guidance and tactile pointing were also 
addressed in discussions with other families in Studies III and IV, but they were not 
actively practiced in the sessions.  
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Figure 7.  Illustrations of hand-under-hand guidance (A) and hand-over-hand guidance (B). 
Illustrations: Saara Waked. 
 
Figure 8.  Illustration of tactile pointing. Illustration: Saara Waked. 
Overall, the different themes were rehearsed several times during the sessions, 
and some themes were practiced more with some mothers than with others. 
Moreover, the mothers were encouraged to continue speaking to their children with 
VIAD as they typically did. Thus, tactile strategies were not aimed at replacing any 
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verbal behaviors but at complementing them and giving the children access to 
multimodal information about interactions.  
4.5.5 Free play session 
After each triadic session, free play between the mothers and their children was 
recorded (Figure 2). These data were utilized to evaluate the effects of the 
intervention in the video analysis. In Study II, free play with and without toys was 
recorded separately. In Studies III and IV, only free play without toys was recorded. 
This was due to the different developmental stages of the children and the 
individualized aims for their interventions. Before the recordings, the mothers were 
asked to play with their children as they wished. After the free play recordings, the 
mothers were given some suggestions for the strategies they could apply in 
interactions with their children during the following week.  
4.6 Data analysis 
In Study I, four recordings (A1, B4, B8, and B10) of Emma and her mother were 
analyzed. The length of the recordings varied between 8 and 10 minutes, resulting in 
a total of 36 minutes of data. The recordings from other sessions were omitted from 
the analysis due to the change in participants (father and Emma in recordings A2 and 
B5), Emma’s sleepiness due to a different location for the recordings (recordings B6 
and B7), and technical reasons (recording B9). In Study II, free play without toys 
was analyzed from three baseline, three intervention, and three follow-up sessions. 
The length of the recordings varied between 10–13 minutes, making a total of 1 hour 
and 43 minutes of data. ELAN (2020, version 6.0) software was used to code the 
videos. In Study III, altogether, 1 hour 21 minutes of video data were analyzed from 
baseline, intervention, and follow-up sessions. In Study IV, free play from four 
baseline, three intervention, and three follow-up sessions was analyzed for each 
mother-child pair. The researcher selected one recording from the beginning, middle, 
and end of the intervention for the analysis. The selection was made based on the 
children’s activity in the interactions. The length of the recordings varied from 9 to 
17 minutes for Thea, from 10 to 14 minutes for Sara, and from 10 to 11 minutes for 
Alex. This resulted in 5 hours and 39 minutes of analyzed data. ELAN (2021; version 
6.2) software was used in the coding. The different methods that were utilized in 
analyzing the video data are presented in Table 1.  
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Table 1.  The participants, interventions, and analyses used in the studies. 
STUDY PARTICIPANTS INTERVENTION DATA ANALYSIS 
STUDY I Emma and her 
mother 
Tactile imitation guidance Imitation coding procedure 
EA Scales 
STUDY II Robin and his 
mother 
Bodily-tactile early 
intervention 
Bodily-tactile coding procedure 
Multimodal conversation analysis 
EA Scales 
STUDY III Thea, Sara and 
Alex and their 
mothers 
Bodily-tactile early 
intervention 
Multimodal conversation analysis 
STUDY IV Thea, Sara and 
Alex and their 
mothers 
Bodily-tactile early 
intervention 
Bodily-tactile coding procedure 
EA Scales 
4.6.1 Imitation coding procedure 
In Study I, the characteristics of imitations between Emma and her mother were 
analyzed using a coding system devised by O’Neill and Zeedyk (2006), which was 
modified in this study. The imitation coding procedure was used to discover whether 
the characteristics of imitations between Emma and her mother changed during 
tactile imitation guidance (Research Question 1). These characteristics were related 
to the modalities used in the imitations, Emma’s participation, and the length of the 
reciprocal imitative dialogs (Research Questions 2–4). First, an imitative bout was 
coded when Emma or her mother imitated the other’s vocal or nonverbal 
expressions. A minimum imitative bout included an expression and its imitation. An 
imitation of Emma or her mother needed to appear within three seconds of the end 
of the initial expression to be registered. A longer time than in the original study 
(O’Neill & Zeedyk, 2006) was used because Emma’s imitations occurred at a slower 
pace. The initiator and length of the imitative bout were marked. The length was 
calculated by calculating the number of rounds in each imitative bout. If an 
expression was imitated only once, the imitative bout had a length of one round. 
Next, the communicative mode of each imitative bout was registered. As the 
original coding procedure (O’Neill & Zeedyk, 2006) included only two categories 
(vocal and physical imitation), more categories were created for the present study. 
The categories were 1) vocal imitations (e.g., vocalizations, imitative sighs, and 
whispers), 2) gestural imitations (e.g., head-shaking), 3) tactile imitations (e.g., the 
mother touched Emma in a similar way as she had touched her), 4) gestural-vocal 
imitations (e.g., simultaneous vocalization and shaking head gesture), and 5) vocal-
tactile imitations (e.g., the mother imitated Emma vocally and traced the movement 
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of her mouth onto Emma’s hand). For instance, vocal imitation was marked if the 
mother imitated Emma’s “ah” sound by saying “ah.” Accordingly, a gestural 
imitation was registered if Emma shook her head and the mother imitated it by 
shaking her head. 
4.6.2 Bodily-tactile coding procedure 
A bodily-tactile coding procedure was developed for Studies II and IV. It was used 
to gain information about the frequency and duration of the mothers’ use of the 
bodily-tactile modality in interactions with their children with VIAD (Research 
Question 2). Thus, a bodily-tactile coding procedure was developed to capture 
potential changes in accessibility. Moreover, in Study II, the bodily-tactile coding 
procedure was utilized to investigate potential changes in Robin’s participation 
(Research Question 3). A new coding procedure was developed because the existing 
coding procedures did not capture the characteristics of the data. The length of each 
recording was edited and rounded to the nearest full minute (e.g., 10:00 or 12:00) to 
compare the frequencies of the studied phenomenon per minute. The bodily-tactile 
expressions were coded in their contexts. This was necessary to be able to categorize 
the expressions correctly (e.g., using tactile noticing to respond to a child’s 
expression). Mutually exclusive categories were used in the coding. However, if 
there were two simultaneous bodily-tactile actions belonging to different categories 
(e.g., nonconventional play and tactile noticing), both actions were coded. 
The categories used in the coding were based on the data. However, only bodily-
tactile behaviors related to interaction and communication were noted. Study II used 
more categories in the coding than Study IV used. This was due to the low frequency 
of some behaviors in Study IV and the different emphasis on the content of the 
interventions based on the children’s abilities. The bodily-tactile behaviors related 
to the themes of the intervention were coded in both studies. In Study II, the 
spontaneous tactile behaviors of the mother were also coded. In Study IV, the 
category “touches related to anticipating and noticing” used in Study II was divided 
into two different categories (tactile anticipatory cues and tactile noticing). 
In Study II, two successive similar touches or movements were coded as one 
behavior if they occurred within 2 s in the following categories: signs, touches 
related to anticipating and noticing, touches or movements connected to play, hand-
over-hand guidance, and other tactile attention-directing gestures. The timeframe 
clarified the coding; otherwise, it would have been difficult to determine whether the 
behaviors should be coded as one or two separate actions. The categories used in the 
coding are presented in Table 2. 
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Table 2.  The categories of the mothers’ bodily-tactile behaviors in Studies II and IV. 
 STUDY II STUDY IV 
INTERVENTION-
BASED ACTIONS 
Touches and movements 
connected to play 
Nonconventional and conventional 
games 
 Touches related to anticipating and 
noticing 
Tactile anticipatory cues 
 Bodily-tactile imitation Tactile noticing 
 Tactile attention-directing gestures: 
Hand-under-hand guidance and 
tactile pointing 
Coactive signs and body signs 
 Tactile and nontactile signs  
SPONTANEOUS 
ACTIONS 
Conventional gestures  
 Tactile attention-directing gestures: 
Hand-over-hand guidance and 
other spontaneous gestures 
 
 Touches connected to naming  
 Bodily-tactile emotional 
expressions 
 
 
Early play routines. In Study II, touches and movements connected to early 
social play routines were coded. The registering of movements required that they 
were accessible to Robin (e.g., bouncing movements when Robin sat on his mother’s 
lap). Tickles, blowing on the skin, and playful touches with objects were also coded. 
However, coding of the sensations created with air flow necessitated tactile contact 
between Robin and his mother. This was due to the interactional aspect of the game. 
 In Study IV, games with toys were not registered because they were not used in 
the intervention. Moreover, the play routines were coded using a modified version 
of Camaioni and Laicardi’s (1985) procedure. An early play routine was defined as 
an “interaction episode characterized by the repetition of specific behaviors or the 
presence of invariant conventional roles” (Camaioni & Laicardi, 1985, p. 32). The 
play routines included two categories: nonconventional and conventional games.  
In a study by Camaioni and Laicardi (1985), a nonconventional game was 
registered when at least one action made in the previous turn (e.g., motor or vocal 
component of a tickling game) was repeated in the same person’s subsequent turn, 
while other elements of the previous turn could change. Nonconventional games 
consisted of tactile, motor, visual, and/or acoustic stimulation or vocal or gestural 
imitation. In Study IV, a nonconventional game was registered when mothers 
stimulated their children repetitively in the bodily-tactile modality with or without 
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speech (e.g., bouncing). Moving, wiggling, massaging, or stretching the child’s 
limbs were registered only if they were play-like activities, including sounds or 
melodies. This criterion facilitated coding because otherwise, it would have been 
challenging to decide which actions could be classified as social games. Tickling, 
bouncing, and swinging were registered only in cases where there were at least two 
subsequent actions successively. If there were five seconds or less between the 
actions, they were registered as one long stimulation. However, actions such as 
moving the child during the mother’s singing without conventional lyrics were coded 
from the beginning until the end because they resembled conventional games. 
Imitations were not included in the nonconventional games. This was done to prevent 
double coding.   
Camaioni and Laicardi (1985) defined a conventional game as one that includes 
invariant conventional roles (e.g., giving-taking or pat-a-cake). In Study IV, 
conventional games were registered when the mothers played nursery rhymes and 
games with a systematic bodily-tactile structure with their children with VIAD (e.g., 
peekaboo or “Head, Shoulders, Knees, and Toes”). The games were coded from 
beginning to end. The coding was paused only if the children were unwell and their 
mothers had to stop playing and lift the children up. If a conventional game was 
repeated and there were five seconds or less between the first and second games, 
they were coded as one game. Conventional games that included tactile signing were 
not coded as conventional games to avoid double coding. 
 Tactile noticing. In Study II, touches associated with noticing were coded in the 
same category as anticipation (see Table 2). Tactile noticing was coded when the 
mother touched some part of Robin’s body after detecting his movement or gesture. 
For instance, she might touch Robin’s hands and tell him that she noticed his gesture 
but did not understand it yet. In Study IV, three different tactile noticing behaviors 
were included in this category: (a) separate touches related to the mother’s 
responsiveness (e.g., the child moves her leg while playing, and the mother responds 
to it by touching the leg before continuing the play), (b) bodily-tactile imitation (e.g., 
the child rolls on his or her right side, and the mother imitates the movement with 
her body, while the child’s legs are on the mother’s shoulders), and (c) contingent 
responses to the child’s reaching gestures in the form of an action (e.g., the child 
reaches her hand toward the mother, and the mother responds to it by making a 
vibration sound on the child’s hand with her lips). The tactile noticing behaviors 
needed to have the same locus as the child’s expressions to be coded. However, the 
quality of the touch associated with the tactile noticing could vary (e.g., tapping or 
stroking). In cases in which two or more subsequent tactile noticing behaviors 
followed the child’s action, they were coded as one behavior if there were five 
seconds or less between them.   
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Tactile anticipatory cues. Tactile anticipatory cues correspond to preliminaries 
of spoken conversations (Schegloff, 1980). Speakers use preliminaries to project 
their subsequent actions, such as posing questions (e.g., “Can I ask you a question?”; 
Schegloff, 1980). By doing so, they aim to ensure the recognizability or 
understandability of the projected actions and set the stage for the next move in the 
conversation. Verbal and nonverbal anticipatory actions have also been observed in 
typical early interactions (e.g., Nomikou et al., 2017). In Study II, touches associated 
with anticipation were coded in the same category as tactile noticing (see Table 2). 
They were defined as touches that preceded an action involving Robin’s body (e.g., 
the mother touches Robin’s armpits before lifting him up).  
In Study IV, tactile anticipatory cues were defined as touches or movements that 
informed the child with VIAD about the following action (e.g., touching the child’s 
hands before grasping them). Thus, the category of tactile anticipatory cues was 
broadened to include movements (Goold & Hummel, 1993). Tactile anticipatory 
cues during speech or without speech were both registered. However, tactile 
anticipatory cues had to make contact with the same place on the body as the 
following touch or movement to be coded.  Two subsequent tactile anticipatory cues 
were coded as one cue if there were five seconds or less between them. Tactile 
anticipatory cues associated with toys were not registered because only interactional 
games without toys were used in the intervention. Moreover, to prevent double 
coding, tactile signs used to anticipate actions were not registered.  
Tactile signs. In Studies II and IV, signs from Finnish Sign Language and self-
created signs were both coded as signs. In Study II, the modality (tactile or 
nontactile) and context of the signs (made during a song or speech) were registered. 
In Study IV, signs were coded only if they were made in an accessible way as 
coactive signs or as body signs. Two subsequent similar signs were coded as one 
sign if there were five seconds or less between them. Whether a sign was made 
during a song or speech was indicated by the coding. Tactile signs made during songs 
and during speech were coded as separate signs, even if there was less than five 
seconds between them. 
Tactile attention-directing gestures. Tactile attention-directing gestures were 
coded only in Study II. They were defined as tactile strategies that aimed to help 
direct Robin’s attention or facilitate his exploration of objects. The subcategories 
were hand-under-hand guidance (Figure 7A) and tactile pointing (Figure 8). 
Nontactile pointing was registered separately. 
Bodily-tactile imitation. Bodily-tactile imitation was registered as a separate 
category only in Study II. In Study IV, it was included in the category of tactile 
noticing. In Study II, bodily-tactile imitation was defined as the mother’s imitation 
of Robin’s hand or body movements in an accessible way through the sense of touch. 
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Based on the observational data, the imitation had to occur within 3 s of Robin’s 
action to be coded. 
In Study II, the mother’s nonintervention-based bodily-tactile forms of 
communication were also coded. First, conventional gestures that have a cultural 
meaning (e.g., clapping hands) were coded if they were not part of a game. Tactile 
and nontactile forms of conventional gestures were registered. Second, the mother’s 
spontaneous tactile attention-directing gestures were registered. These included 
hand-over-hand guidance (Figure 7B) and other gestures (e.g., the mother lifting 
Robin’s head up to get his attention). Third, touches connected to verbal naming 
were registered (e.g., the mother touching Robin’s leg and naming it). Fourth, the 
mother’s bodily-tactile emotional expressions were coded (e.g., kissing and 
hugging). The child’s expressions were coded only in Study II. The categories used 
for the coding and their descriptions are presented in Table 3.   
Table 3.  The categories of Robin’s expressions in Study II. 
CATEGORY DESCRIPTION 
SIGNS Signs from Finnish Sign Language and self-created referential 
expressions with negotiated meaning. Two similar signs were coded as 
one sign if there were less than 2 s between them. Sign imitations were 
coded separately. A sign imitation had to appear within 4 s of the 
mother’s sign. 
REACHING AND 
REQUESTING 
Reaching was coded if Robin reached with one or both hands toward his 
mother or an object. Intentional actions with objects were also registered 
(e.g., pulling a scarf from a mother’s face in peekaboo). The actions were 
coded as one behavior if there were less than 2 s between two similar 
subsequent actions. 
MOTOR IMITATION Tactile or nontactile imitation of the mother’s preceding hand or body 
movement. The imitation needed to occur within 4 s of the mother’s 
movement. 
VOCAL 
EXPRESSIONS 
The highest level of vocal expression was marked in each recording. 
Three different levels were defined: non-canonical vocalizations, 
canonical vocalizations, and single words. Canonical vocalization was 
defined as a vocalization which has at least two subsequent consonant-
vowel syllables (e.g., ma-ma).  
4.6.3 Multimodal conversation analysis 
The principles of multimodal conversation analysis (CA; Mondada, 2018) were used 
to explore potential changes in the children’s participation and interactional reciprocity 
in Studies II and III (Research Questions 3 and 4). Multimodal CA draws on detailed 
microanalysis to explore verbal and nonverbal conduct, including tactile interactions 
(e.g., Iwasaki et al., 2019). Multimodal CA was selected for this study because in-
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depth sequential and longitudinal analyses can be particularly useful for studies 
investigating potential changes in transactions between parents and their children with 
VIAD (Van keer et al., 2017). Micro-level analysis is useful for identifying potential 
changes in turn-taking structures and can reveal dialogical processes that could not 
otherwise be identified (Nafstad, 2015). Moreover, microanalysis is an optimal means 
of gaining information on gradual transitions in children’s development of 
communication skills (Bates et al., 1979, p. 101). Multimodal microanalysis can also 
be used to investigate how persons with disabilities participate in interactions with 
others and learn about the characteristics of their expressions (Antaki, 2011). Thus, 
multimodal CA can identify the competencies of individuals with disabilities. 
Observations of atypical interactions can be analyzed in light of concepts and 
knowledge related to typical conversations (Antaki, 2011). 
Multimodal CA analyzes sequences, that is, turns organized as serial units 
(Jefferson, 1972). This focus offers a more comprehensive understanding of the 
interactions between children with VIAD and their parents than investigations of 
single expressions. By analyzing several turns, a researcher can gain information 
about parents’ strategies for engaging their children and features of the children’s 
participation (Chen, 1996). For instance, sequence analysis can provide detailed 
information about how children’s bodily expressions are connected to their parents’ 
previous actions. Early social play routines provide an optimal context for analyzing 
sequences because they follow a predictable pattern of subsequent actions, which 
children can learn to utilize in their own participation (Chen, 1996).  
In Study II, the data indicated that Robin’s new gestural expressions appeared in 
the context of “Magpie Makes Porridge” during the intervention. “Magpie Makes 
Porridge” is an early play routine that includes a simultaneously verbal and bodily-
tactile narrative that climaxes at the end. It resembles the English nursey rhyme 
“Round and Round the Garden.” Six episodes of “Magpie Makes Porridge” were 
found in the data and analyzed in detail using multimodal CA. Robin’s gestures were 
recognized from the play routines and analyzed sequentially with respect to timing 
and the bodily-tactile experiences initiated by his mother. The verbal and tactile 
structure of “Magpie Makes Porridge” is described below, and an English translation 
is provided. 
 
1. Harakka huttua keittää, hännällänsä hämmentää. 
Magpie makes porridge, stirring it with her tail. 
THE MOTHER MAKES A CIRCULAR MOVEMENT ON THE CHILD’S PALM WITH HER 
INDEX FINGER. 
2. Antaa tuolle pojalle, antaa tuolle pojalle, tuolle pojalle, tuolle pojalle, mutta yksi poika jäi 
ilman.  
She gives (it) to that chick, gives (it) to that chick, that chick, that chick, but one chick 
is left without. 
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THE MOTHER TOUCHES THE CHILD’S FINGERS ONE BY ONE, STARTING FROM THE 
THUMB. 
3. Se hyppäsi kivelle, 
She jumps on a stone, 
THE MOTHER TOUCHES THE CHILD’S WRIST. 
4. kannolle 
on a tree stump  
THE MOTHER TOUCHES THE CHILD’S ELBOW. 
5. ja lähti vettä hakemaan, ja lähti vettä hakemaan.  
and goes to look for some water and goes to look for some water. 
THE MOTHER TICKLES THE CHILD’S ARMPIT.  
 
In Study III, the analysis of the data gathered in the time-series design took the 
form of longitudinal CA, which investigates how social interactions change over 
time (Deppermann & Pekarek Doehler, 2021). Ten play routines that indicated a 
potential increase in reciprocity were selected for the analysis of each mother and 
her child: four routines from the baseline, five from the intervention, and one from 
the follow-up recordings. Information on the analyzed play routines is presented in 
Table 4.  
Table 4.  The analyzed play routines in Study III. 
 BASELINE INTERVENTION FOLLOW-UP DURATION  
THEA The Elephant 
March 
Head, Shoulders, 
Knees, and Toes 
Five Little Ducks (2) 
The Elephant March 
Head, Shoulders, Knees, 
and Toes 
The Wheels on the Bus (3) 
The Wheels on the Bus 26 min 
SARA Soft pianoa 
Soft book 
Teddy bear 
Tambourine 
The Wheels on the Bus (2) 
The Little Dog Sings 
The bouncing play 
Magpie Makes Porridge 
The counting game 33 min 
ALEX Peek-a-boo 
Lifting up game 
Leg stretches 
Arm stretches 
The swinging game (2) 
Arm stretches 
The dog game 
The counting game 
Arm stretches 
 
22 min 
Note: The number indicated in the brackets indicates that the same play routine appeared in several 
recordings and was analyzed more than once. 
aThe data at baseline included only play routines with toys. 
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In the first phase of the analysis, annotations and rough transcriptions were made 
using ELAN (2021, version 6.2) computer software. The mothers’ verbal and bodily-
tactile expressions were annotated. This was followed by the annotation of the 
children’s vocalizations (phonation, grunting, and smacking sounds) and bodily 
actions. Children’s loud breathing sounds, silent mouth movements, and yawning 
were annotated only if the mothers responded to them. Similarly, if the mothers held 
their children’s legs while the children moved, the movements were annotated only 
if the mothers verbally confirmed the children’s initiative in making the movements. 
Otherwise, it would have been difficult to determine the initiator of the movements. 
Children’s movements stemming from epilepsy or difficulty keeping their heads 
upright were not annotated. In the second phase of the analysis, the children’s bodily 
expressions to which their mothers responded were marked and analyzed in 
collaboration with other researchers. The analysis of these expressions was based on 
prior research indicating that parents’ responses are pivotal in sensitizing children’s 
recognition of their expressions as social acts (e.g., Rączaszek-Leonardi et al., 2013; 
Yoder & Warren, 1998).  
In the third phase, the mothers’ questions were analyzed in detail. This focus was 
inspired by observational data and prior research indicating that mothers’ questions 
are crucial in establishing conversational patterns with their children, including turn 
taking (e.g., Snow, 1977). We explored whether the mothers expected answers from 
their children and, if they did, which kinds of behaviors from their children they 
treated as answers. Thus, we investigated the modalities according to which the 
mothers interpreted their children’s actions. 
Transcription. Multimodal CA was used in the transcription (Mondada, 2018, 
2022). In Study II, all selected play routines were transcribed. In Study III, the 
transcriptions included three play routines from each mother-child dyad. The 
transcriptions were simplified for readability, and some additional transcription 
conventions were used (see the Appendix). Since the objective of the study was to 
explore the effects of mothers’ bodily-tactile conduct on their children’s 
participation, the movements each participant made with their entire body were 
recorded in the transcriptions (Iwasaki et al., 2019; Mondada, 2018). The pauses 
were marked in different ways in the studies. In Study II, we marked pauses between 
the mother’s verbal utterances and Robin’s vocal and play-related gestural 
expressions. In Study III, pauses were marked only in moments in which there were 
no bodily-tactile or vocal actions. This analytical decision was based on the 
children’s bodily perspective. From this perspective, their mothers take a turn not 
only when speaking but also when they are actively touching or moving their 
children.  
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The mothers’ verbal utterances were transcribed in Finnish in bold letters, with 
the English translation in italics below (see Example 1, Line 01). The children’s 
vocalizations were transcribed using lowercase letters. However, only vocalizations 
involving phonation were considered turns. This choice was made based on the data-
based observation that the mothers responded almost exclusively to these types of 
vocalizations. The nonverbal actions of the mothers and children were transcribed in 
capital letters. However, we transcribed only the mothers’ nonverbal actions that 
were accessible to their children through the sense of touch (see Iwasaki et al., 2019). 
Moreover, a bodily-tactile action was transcribed on a line of its own if it occurred 
independently without speech. All the children’s movements were transcribed, but 
only those movements to which their mothers responded were transcribed as turns 
(Study III). The signs were written in italics and capital letters (Study II). The 
mothers’ gazes were transcribed in double parentheses (Study III). Instances of the 
children smiling were transcribed in italics below their bodily-tactile actions and 
indicated with slashes (Study III). Only the smiles to which the mothers verbally 
responded were marked as turns. An example of the transcription is provided below. 
 
Example 1.  
 
4.6.4 Emotional Availability Scales 
The EA Scales were used to investigate the emotional relationships between children 
with VIAD and their mothers in Studies I, II, and IV (Research Question 5). Full 
video recordings were used in the analysis. The EA Scales (4th edition) comprise an 
observational system for evaluating the quality and emotional reciprocity of parent-
child interactions (Biringen, 2008). It has four subscales for the parent (sensitivity, 
structuring, nonintrusiveness, and nonhostility) and two subscales for the child 
(responsiveness and involvement). Each subscale is evaluated based on global 
judgment rather than the assessment of discrete behaviors. These scales can be used 
to assess children from infancy to adolescence (Biringen et al., 2014). The EA Scales 
were chosen for the analysis because they are flexible enough to evaluate clinical 
populations and sensitive enough to capture changes related to interventions 
(Biringen et al., 2022). The EA guidelines for assessing children with disabilities 
were followed in the scoring process (Biringen et al., 2005; Biringen, 2008). 
Definitions of the EA subscales and their scoring are presented in Table 5.    
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Table 5. The definitions and scoring of Emotional Availability Scales. 
EA SUBSCALE DEFINITION SCORING 
SENSITIVITY Parent’s warmness 
and ability to create 
an emotional 
connection with the 
child. 
7 = highly sensitive 
5.5/6 = neutral sensitivity  
4 = inconsistently sensitive 
2.5/3 = somewhat insensitive  
1 = highly insensitive 
STRUCTURING Parent’s ability to 
guide the play with 
the child 
successfully. 
7 = optimal structuring  
5.5/6 = moderately structuring  
4 = inconsistent structuring 
2.5/3 = somewhat unstructuring 
1 = non-optimal structuring 
NONINTRUSIVENESS Parent’s capacity to 
interact with the 
child without 
intervening in his or 
her autonomy. 
7 = nonintrusive but emotionally 
present/available  
5.5/6 = generally nonintrusive but sometimes 
benign forms of intrusiveness  
4 = “benign” intrusiveness  
2.5/3 = somewhat intrusive 
1 = intrusive 
NONHOSTILITY Parent’s behavior 
which does not 
indicate overt or 
covert signs of 
negativity. 
7 = nonhostile 
5.5/6 = generally nonhostile  
4 = covertly hostile  
2.5/3 = slightly overtly hostile 
1 = markedly and overtly hostile 
CHILD  
RESPONSIVENESS 
Child’s positive 
affect and 
responsiveness 
toward the parent. 
7 = optimal in responsiveness  
5.5/6 = moderately optimal in responsiveness  
4 = complicated responsiveness  
2.5/3 = somewhat non-optimal in 
responsiveness  
1 = clearly non-optimal in responsiveness 
CHILD INVOLVEMENT Child’s initiative in 
interaction. 
7 = optimal in involving behaviors 
5.5/6 = moderately optimal in involving 
behaviors  
4 = complicated involvement  
2.5/3 = somewhat non-optimal in involving 
behaviors  
1 = clearly non-optimal in involving behaviors 
 
The EA assessments were made by different researchers in each study (Studies 
I, II, and IV). All assessors were trained and certified by the method developer. In 
Study I, the assessor was the first author, who was familiar with Emma’s sensory 
functioning and development. In Studies II and IV, the assessors were psychologists, 
who were given information about the children’s levels of sensory functioning and 
development prior to coding. They were also blinded to the occasions of the 
recordings.   
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In Study IV, the participating children had a lower level of developmental 
function than the children in Studies I and II, which necessitated flexibility in scoring 
(Biringen et al., 2005). In assessing sensitivity, there was a stronger focus on voice, 
touch, general emotional tone, and approach to the child than on eye contact. In 
evaluating structuring, developmental information related to the children’s motor 
and language development was considered. In particular, the use of both verbal and 
nonverbal guidance and their success (as opposed to the mere mechanical repetition 
of some play activity) were recognized. When evaluating nonintrusiveness, the 
children’s disabilities were considered, as many required additional stimulation and 
had special needs in terms of being held. In assessing nonhostility, there was no need 
for special flexibility. In assessing child responsiveness, it was necessary to consider 
the children’s level of communication. All their responses or efforts to respond were 
acknowledged (e.g., smiling, moving their hand or leg in response, or turning their 
head toward the sound). Similarly, in evaluating child involvement, all attempts by 
the children to make a connection or communicate were acknowledged. Overall, the 
participating children were assessed with reference to low responsiveness and 
involvement in their group and not in comparison to children without disabilities. 
Finally, the researcher who trained the others in the method (Z. Biringen) was 
consulted to clarify the scoring of the data. This resulted in a rescoring of 
nonintrusiveness for each mother. 
4.6.5 Reliability 
All second coders were informed of the observed children’s levels of development 
and sensory functioning. They were also blinded to the phase of the intervention 
prior to coding. The second coders of the EA Scales completed reliability training in 
the use of these scales and the coding framework, and they followed the EA 
guidelines for assessing children with disabilities (Biringen et al., 2005; Biringen, 
2008). The reliability of the coding was calculated as the percentage of agreement 
between the coders, that is, the number of agreements divided by the number of 
agreements plus disagreements multiplied by 100.  
The imitation coding procedure. In Study I, the reliability of the imitation coding 
procedure was measured using intrarater and interrater reliability tests. Intrarater 
tests were conducted for all data by the main researcher (first author). The level of 
agreement was 95%. The interrater reliability test was conducted by the first second 
coder (SC1), who has experience working with children with multiple disabilities 
and is fluent in Finnish Sign Language. She was trained to apply the imitation coding 
procedure to the data not used for analyzing reliability. Altogether, 25% of the data 
were reevaluated, and the interrater agreement was 88%.   
Sini Peltokorpi 
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The bodily-tactile coding procedure. SC1 also conducted the reliability test in 
Studies II and IV. Before coding, she was trained to use the bodily-tactile coding 
procedure with the unanalyzed data. In Study II, she was also given information on 
the sign repertoire of the data. In Study II, all data (100%) were recoded. In terms of 
the mother’s behavior, the interrater agreement varied between 88%–97% in 
different categories. For Robin’s expressions, the interrater agreement was 65% for 
signs, 69% for sign imitations, 70% for reaching and requesting, and 80% for motor 
imitation. As the levels of interrater agreement for signs, sign imitations, and 
reaching and requesting did not attain acceptable levels of reliability, only the 
expressions identified by both coders were included in the results. Among the signs 
identified by both coders, 3% were categorized under different labels (e.g., MAGPIE 
vs. SPIDER). The quality of Robin’s vocalizations was reanalyzed for 33% of the 
data. One video each from the baseline, intervention, and follow-up recordings was 
randomly chosen for the reliability test. The interrater agreement was 100%.  
In Study IV, 30% of the data were recoded by SC1. One video from the baseline, 
intervention, and follow-up recordings from each mother-child dyad was randomly 
chosen for the reliability test. The interrater agreement on bodily-tactile early play 
routines varied between 83%–100% among the mothers. The interrater agreement 
on tactile noticing was 89% for Thea’s mother, 42% for Sara’s mother, and 96% for 
Alex’s mother. Because the interrater agreement on tactile noticing for Sara’s mother 
was low, her results were not reported. The interrater agreement on tactile 
anticipatory cues varied between 81%–89% for the mothers. The interrater 
agreement was 100% on tactile signs for all mothers.   
EA Scales. In Study I, the reliability of the scores with the EA Scales was 
established by including another second coder (SC2). The researcher (the first 
author), together with SC2, negotiated the rating for one recording (25% of the data), 
and a reliability test was conducted with two recordings (50% of the data). The 
interrater agreement was 100%, with a 1-point difference between the coders. 
In Study II, the reliability of the scores assigned using the EA Scales was 
established by including SC2. One video each from the baseline, intervention, and 
follow-up recordings was randomly chosen for the reliability test. This comprised 
33% of the data. The reliability test resulted in 94% agreement when counting the 
maximum 0.5-point differences between the coders on each scale.  
In Study IV, the reliability of the scores on the EA Scales was established by 
adding a third second coder (SC3). She cooperated with the main scorer and 
practiced scoring with unanalyzed data. Altogether, 50% of the data from each 
family were reanalyzed. The videos for the reliability test were randomly chosen. 
However, we ensured that videos from each phase (baseline, intervention, and 
follow-up) were included in the reliability test, namely, two videos from the baseline 
recordings, and three videos from the intervention and follow-up recordings.  
Methods 
 83 
Due to the challenges in coding the data, some videos were watched by both SC3 
and the main scorer, including one video (all EA dimensions) for Sara and three (all 
EA dimensions) for Alex. For Thea, one dimension from each of two videos was 
watched by both researchers. The consensus scores were not included in the 
reliability test. The final number of videos included in the reliability test was 50% 
for Thea (including videos from all phases of the study), 40% for Sara (including 
videos from all phases of the study), and 20% for Alex (including videos from the 
intervention and follow-up). The rescored nonintrusiveness was not rescored in the 
reliability test because these scores were reached by consensus among the scorers. 
When calculating the maximum 1-point differences between the coders in each 
dimension, the agreement levels on the EA Scales were 91% for Thea and her 
mother, 90% for Sara and her mother, and 100% for Alex and his mother.   
 84 
5 Results 
5.1 Study I 
5.1.1 Postural and behavioral changes 
The typical interactional play between Emma and her mother was characterized by 
dyadic face-to-face interactions without toys in all the sessions. During the baseline 
session (A1), the mother held Emma either by her hands (Figure 9A) or under her 
armpits (Figure 9B). During the tactile imitation guidance (B4, B8, and B10), she 
mainly held Emma under her armpits, which allowed Emma to move her hands 
freely in interaction. Emma did not place her hands on her mother’s face during their 
interactions in A1. During the tactile imitation guidance, she once placed her hands 
on her mother’s face in B4, and this action occurred more frequently in B8. In B10, 
Emma continually placed her hands on her mother’s face, including beyond the 
imitative bouts (Figure 9C). Similar development was observed in Emma’s positive 
emotional expressions in relation to being imitated. During the tactile imitation 
guidance (B4, B8, and B10), Emma expressed her positive emotional expressions 
significantly more often when she was being imitated compared to A1. These 
findings indicate that the tactile imitation guidance had a positive impact on Emma’s 
participation (Research Questions 1 and 3).  
 
Figure 9.  Illustrations of the mother’s holding of Emma and Emma’s action of placing her hands on her 
mother’s face. Illustrations: Saara Waked. Original publication: Peltokorpi, S., Daelman, M., 
Salo, S., & Laakso, M. (2020). Effect of tactile imitation guidance on imitation and emotional 
availability. A case report of a mother and her child with congenital deafblindness. Frontiers 
in Psychology, 11, Article 540355. doi: 10.3389/fpsyg.2020.540355 
Results 
 85 
5.1.2 Frequency and length of imitative bouts 
The frequency and length of the imitative bouts are demonstrated in Table 6. Emma’s 
mother initiated most of the bouts in all sessions. Most of the bouts had a length of 
one round. Imitative reciprocity changed during the tactile imitation guidance 
(Research Questions 1 and 4). In A1, the imitative bouts were short, whereas at the 
end of the tactile imitation guidance (B10), they became notably longer.  
Table 6. Frequency and length of imitative bouts initiated by Emma or her mother. 
Participants A1 B4 B8 B10 
Mother 16 (1 round) 
3 (2 rounds) 
4 (1 round) 11 (1 round) 
2 (2 rounds) 
10 (1 round) 
3 (2 rounds) 
1 (3 rounds) 
1 (4 rounds) 
1 (9 rounds) 
1 (11 rounds) 
Emma 1 (1 ½ rounds) 1 (7 ½ rounds) 1 (1 ½ rounds) 1 (1 ½ rounds) 
1 (2 ½ rounds) 
Note: The length of an imitative bout is indicated in parentheses. 
5.1.3 Communication modes used in imitations 
Emma and her mother used various communication modes in their imitations, which are 
presented in Table 7. Emma’s mother made most of her imitations vocally in A1. She 
used a tactile modality only in connection to one vocal imitation in which she imitated 
Emma’s laughter by shaking Emma’s hands in the same rhythm as Emma’s laughter. 
During the tactile imitation guidance, the characteristics of the mother’s imitations 
changed, as she began to use more tactility in her imitations (Research Questions 1 and 
2). In B4, she made one tactile imitation by touching Emma’s arm in the same way as 
Emma had touched her. When Emma vocalized, her mother made vocal-tactile 
imitations by tracing the movement of her mouth onto Emma’s hand (Figure 9B). In B8, 
Emma’s mother made 10 vocal-tactile imitations altogether. She could imitate Emma’s 
vocalization by tracing the movement of her mouth onto Emma’s hand, kissing Emma’s 
cheek, or touching Emma’s head with her nose, forehead, or head while speaking or 
vocalizing. In B10, Emma’s mother used tactility less often in her imitations than in B8. 
This was due to a change in Emma’s interactive behavior. Emma was often touching her 
mother’s face before her mother began to imitate Emma’s vocalizations. Thus, as Emma 
was continually touching her mother’s face during and after her mother’s imitations, 
there was no need for her mother to add tactility in her imitations.   
Emma occasionally made imitations of her mother’s actions, which belonged to 
Emma’s vocal or gestural repertoire. For instance, Emma’s mother could initiate a 
Sini Peltokorpi 
86 
dialogue by repeating a vocal utterance belonging to Emma’s repertoire. After 
several repetitions, Emma could imitate her mother vocally. When Emma made a 
gestural or gestural-vocal imitation, her mother had used tactility in transmitting her 
gestures to Emma during her previous turn. Thus, the mother’s gestures were 
accessible to Emma through the sense of touch.  
Table 7. Communication modalities used in the imitations by Emma and her mother. 
Communication modalities A1 B4 B8 B10 
Vocal 10 (E1) 0 (E1) 2 12 (E1) 
Gestural 5 0 1 (E1) 0 
Tactile 0 1 0 0 
Gestural-vocal 3 1 0 2 (E1) 
Vocal-tactile 1 2 10 3 
All imitations including the tactile modalitya 1 3 12 10 
Note: Emma’s imitations are marked with E and written in parentheses. 
a The turns in which Emma’s mother used the tactile modality in her imitations and the turns when 
Emma was exploring her mother’s mouth during her mother’s imitation. 
5.1.4 Emotional availability 
The raw EA scores of Emma and her mother are reported in Table 8. The results 
indicate that the tactile imitation guidance had a positive impact on the emotional 
relationship between Emma and her mother (Research Question 5). In A1, Emma’s 
mother scored 5 for sensitivity, structuring, and nonintrusiveness. During the tactile 
imitation guidance, her scores in these dimensions ranged between 6 and 7. Similar 
development was observed for Emma. Her scores for child responsiveness and child 
involvement ranged between 3 and 4.5 in A1. During the tactile imitation guidance, 
her scores were higher, ranging between 3.5 and 6. The clearest positive change was 
observed in her involvement in B8 and B10.  
Table 8. Emotional availability between Emma and her mother. 
 A1 B4 B8 B10 
Sensitivity 5 6 7 7 
Structuring 5 6 7 7 
Nonintrusiveness 5 6 7 7 
Nonhostility 7 7 7 7 
Child responsiveness 4.5 5 6 6 
Child involvement 3 3.5 6 5.5 
Note: All the scales range from 1 (low) to 7 (high). 
Results 
 87 
5.2 Study II 
5.2.1 The mother’s use of intervention-based and non-
intervention-based tactile strategies 
Robin’s mother increased her use of the bodily-tactile modality during the early 
intervention (Research Question 2). Figure 10 illustrates the results of the mother’s 
total use of the bodily-tactile modality in interactions and her use of touch and 
movement connected to play routines. Her use of the bodily-tactile modality 
increased in both cases. During the intervention, Robin’s mother began to use new 
play routines, including coactive hand and body movements and bodily-tactile 
sensory experiences (e.g., air flow).  
 
Figure 10. The mother’s use of the bodily-tactile modality in interactions and touches and 
movements connected to play routines as a percentage of time per session. Original 
publication: Peltokorpi, S., Salo, S., Nafstad, A., Hart, P., Tuomikoski, E., & Laakso, M. 
(2023). Bodily-tactile early intervention for a mother and her child with visual impairment 
and additional disabilities: A case study. Disability and Rehabilitation, 45(12), 2057–
2072. doi: 10.1080/09638288.2022.2082563     
Tactile signs. Table 9 presents the frequency and context of the mother’s tactile 
signs. Robin’s mother had already used several tactile signs at baseline. However, 
she used them only in “Itsy Bitsy Spider,” which she frequently played with Robin. 
During the intervention, Robin’s mother also began to use tactile signs to support 
her spoken messages when talking to Robin. She also increased her repertoire of 
songs in which she used tactile signs. Thus, the contexts for using tactile signs were 
Sini Peltokorpi 
88 
expanded during the intervention. Moreover, her sign vocabulary doubled as she 
began to use tactile signs in new play routines and daily activities with Robin during 
the intervention and follow-up (see Table 10). Robin’s mother made signs mainly 
through coactive signing (Figure 6A).      
Table 9. Frequencies of Robin’s gestural expressions and his mother’s signs. 
Participants and categories A2 A3 A4 B5 B9 B12 A13 A14 A15 
Robin’s mother          
Tactile signs  16 
(1.6)  
6 
(0.5) 
12 
(1.2)    
20 
(1.8) 
20 
(1.7)    
17 
(1.7)   
21 
(1.9)   
15 
(1.4)   
18 
(1.6)   
Tactile signs during speech 0 0 0 6 8 14 5 7  11  
Tactile signs during songs 16 6 12 14 12 3 16 8 7  
Robin          
Signsa 7 
(0.7) 
5 
(0.4)  
7 
(0.7)   
12 
(1.1)   
20 
(1.7)   
15 
(1.5)  
4 
(0.4)   
12 
(1.1) 
5 
(0.5)       
Sign imitations 0 1 1 1 0 1 2 1 0 
Reaching and requesting 4 8 1 4 12 4 4 7 9 
Motor imitation 0 1 0 1 1 3 0 4 0 
Note: The numbers in brackets show the frequency of the phenomenon per minute. 
a Mimetic gestures are included in Robin’s spontaneous signs. 
Table 10. The sign vocabulary of Robin and his mother. 
Categories Baseline Intervention Follow-up 
The mother’s tactile 
signs 
SUN, JUMP, SPIDER, 
ANTHILL, ANT, 
SLEEP, RAIN, TAKE 
AWAY, VIOLIN, 
DILIGENT 
SUN, JUMP, SPIDER, 
VIOLIN, SLEEP, 
RAIN, TAKE AWAY  
CAT, DOG, COW, 
PIGGY, BLOWING ON 
THE SKIN GAME, 
MAGPIE, THE END, 
EAT, ROBIN’S NAME 
SIGN, LAMP, MOTHER 
DILIGENT, JUMP, 
SLEEP, ANTHILL, 
SPIDER, ANT, VIOLIN 
MAGPIE, CAT, DOG, 
COW, PIGGY, THE 
END, RUB EYES, GO 
ON 
Robin’s spontaneous 
signs 
ANT, VIOLIN, SPIDER ANT, VIOLIN, 
SPIDER, MAGPIE 
ANT, VIOLIN, SPIDER, 
MAGPIE, DOG 
Robin’s sign 
imitations 
SPIDER DOG ANT, VIOLIN, EATa 
Note: The bolded words are signs from “Itsy Bitsy Spider.” 
a The sign was observed in a separate video clip in A15. 
Tactile attention-directing gestures. Robin’s mother did not use hand-under-
hand guidance (Figure 7A) during the recordings. She utilized nontactile pointing 
gestures at baseline (N = 3). However, Robin did not direct his attention toward the 
Results 
 89 
indicated objects in any of those situations. During the intervention, Robin’s mother 
began to use tactile pointing (Figure 8) in B9 (N = 13) and B12 (N = 2). Tactile 
pointing appeared to facilitate Robin’s attention direction, as he could direct his 
attention to the objects pointed at (e.g., a lamp) in about half the cases.  
Touches related to anticipating and noticing. Robin’s mother did not use the 
bodily-tactile modality for anticipating actions or noticing Robin’s expressions at 
baseline. She began to utilize these strategies during the intervention in B5 (N = 18) 
and continued using them in the follow-up sessions A13 (N = 13), A14 (N = 15), and 
A15 (N = 5). Her anticipation cues (Figure 5) were observed in connection to a specific 
game and before lifting Robin up. Her actions connected to tactile noticing (Figure 4) 
occurred in situations in which she wanted to express to Robin that she had noticed his 
movement or non-readable gestural expression. Robin’s mother used tactile imitation 
in one of the baseline sessions (e.g., Robin touched his mother’s leg with his fingers, 
and the mother touched his leg in a similar way). She continued using imitation in all 
the intervention sessions (e.g., creating dialogues based on tapping on each other’s 
hands) but did not imitate Robin’s actions in the follow-up sessions.  
Non-intervention-based bodily-tactile forms of communication. Robin’s mother 
used hand-over-hand guidance (Figure 7B) in all the sessions except one (B5). She used 
other non-intervention-based bodily-tactile forms of communication sporadically. 
5.2.2 Robin’s expressions 
Typically, Robin could not make eye contact with his mother during their 
interactions. However, he could make tactile contact with his mother using his foot 
when he was seated in a supportive chair facing his mother (Figure 3) or lying on the 
floor with his mother within reach. When he sat in his mother’s lap, tactile contact 
was established through body-with-body alignment.   
The frequencies of Robin’s gestural expressions are presented in Table 9, and his 
sign vocabulary is shown in Table 10. At baseline, Robin used three signs from “Itsy 
Bitsy Spider,” and he continued using these signs during the intervention and follow-
up. During the intervention, his participation increased as he developed new gestural 
expressions (Research Question 3). Robin used the mimetic gesture MAGPIE in the 
context of “Magpie Makes Porridge” and other contexts in B9, B12, and in all the 
follow-up recordings. Gradually, this gesture became a negotiated sign for “Magpie 
Makes Porridge.” Moreover, Robin began to use the sign DOG imitatively and 
spontaneously. Furthermore, during the follow-up recordings, Robin began to imitate 
the sign EAT. His mother reported that sometimes he also signed EAT spontaneously.   
Robin’s vocalizations consisted of an /s/ sound, phonation, vowel sounds, lip 
vibration sounds, smacking sounds, sighs, and laughter. His vocalizations were non-
canonical throughout the sessions. 
Sini Peltokorpi 
90 
5.2.3 Contextual emergence of new gestural expressions  
“Magpie Makes Porridge” was introduced to Robin and his mother in the fourth 
intervention session (B8). The analysis revealed how Robin participated in this play 
routine and how his gestural expressions were related to his mother’s actions in form 
and timing, indicating changes in the reciprocity of actions (Research Question 4). 
The first extract from B9 demonstrates the mother’s use of the bodily-tactile 
modality in the rhyme (Figures 11 and 13). Robin then makes a mimetic gesture in 
anticipation of his mother’s touch on his fingers (Figure 12).  
 
Extract 1. Robin’s mimetic gesture. 
 
 
Figure 11. The mother plays the rhyme coactively with Robin. Original publication: Peltokorpi, S., Salo, 
S., Nafstad, A., Hart, P., Tuomikoski, E., & Laakso, M. (2023). Bodily-tactile early intervention 
for a mother and her child with visual impairment and additional disabilities: A case study. 
Disability and Rehabilitation, 45(2), 2057–2072. doi: 10.1080/09638288.2022.2082563      
Results 
 91 
 
Figure 12. Robin’s mimetic gesture. Original publication: Peltokorpi, S., Salo, S., Nafstad, A., Hart, 
P., Tuomikoski, E., & Laakso, M. (2023). Bodily-tactile early intervention for a mother 
and her child with visual impairment and additional disabilities: A case study. Disability 
and Rehabilitation, 45(2), 2057–2072. doi: 10.1080/09638288.2022.2082563 
 
Figure 13. Robin’s mother coactively touches his fingers one by one. Original publication: 
Peltokorpi, S., Salo, S., Nafstad, A., Hart, P., Tuomikoski, E., & Laakso, M. (2023). 
Bodily-tactile early intervention for a mother and her child with visual impairment and 
additional disabilities: A case study. Disability and Rehabilitation, 45(2), 2057–2072. doi: 
10.1080/09638288.2022.2082563 
Robin’s left hand is the scene of the bodily-tactile narrative “Magpie Makes 
Porridge.” His mother makes rotating movements of the rhyme coactively with 
Robin’s right hand on his left hand (Figure 11). Robin is attentive in perceiving the 
story through auditive and bodily-tactile modalities. His attentiveness is observed in 
his body language, which reflects expectant stillness. The timing and form of his 
mimetic gesture shows his detailed knowledge of the rhyme. Robin’s action begins 
to emerge when his mother is still narrating the first phrase of the rhyme (Lines 01–
02). His mimetic gesture (Line 03, Figure 12) anticipates his mother’s subsequent 
touches on his fingers (Figure 13). Robin’s mother detects his gesture and responds 
to it verbally (Line 04), which reinforces its shared meaning.  
Sini Peltokorpi 
92 
When the story continues, Robin makes another anticipatory gesture that reflects 
his embodied memory of the rhyme. This time, the anticipated action is his mother’s 
touch on his wrist, where the story continues. Robin’s anticipatory gesture and its 
sequential context are presented in Extract 2. 
 
Extract 2. Robin’s gesture anticipating his mother’s next point of touch. 
 
 
Figure 14. The mother lifts her hand up coactively with Robin. Original publication: Peltokorpi, S., 
Salo, S., Nafstad, A., Hart, P., Tuomikoski, E., & Laakso, M. (2023). Bodily-tactile early 
intervention for a mother and her child with visual impairment and additional disabilities: 
A case study. Disability and Rehabilitation, 45(2), 2057–2072. doi: 
10.1080/09638288.2022.2082563 
Results 
 93 
 
Figure 15. Robin’s anticipatory gesture before his mother’s touch on his wrist. Original publication: 
Peltokorpi, S., Salo, S., Nafstad, A., Hart, P., Tuomikoski, E., & Laakso, M. (2023). 
Bodily-tactile early intervention for a mother and her child with visual impairment and 
additional disabilities: A case study. Disability and Rehabilitation, 45(2), 2057–2072. doi: 
10.1080/09638288.2022.2082563     
The mother continues storytelling by lifting her right hand up coactively with 
Robin’s right hand (Line 01, Figure 14). Because the movement is accessible to 
Robin, he can perceive detailed bodily-tactile information on the direction and 
timing of his mother’s hand movement. He responds to his mother’s action by 
making an anticipatory gesture in which he moves his fingers upward when his 
mother is about to touch his wrist (Figure 15).  
Although the rhyme did not include adjacency pairs (e.g., a question and an 
answer), it included adjacent actions, which consisted of the mother’s multimodal 
expressions related to storytelling and Robin’s anticipatory gestures. The bodily-
tactile structure of the rhyme helped Robin participate in the activity, as he could use 
the knowledge of the rhyme’s subsequent actions as a resource for his anticipatory 
gestural expressions. His gestures, however, were very subtle and hard to detect. 
Robin’s mother detected his first gesture and interpreted it as a part of the storytelling 
(Extract 1, Lines 03–04). She may not have detected Robin’s second gesture, as she 
did not comment on it.   
Robin’s first gesture was a mimetic gesture (Figure 12) that represented an action 
he had experienced during the rhyme. He imitated his mother’s movement of 
touching his fingers (index and middle fingers) from his perspective (see Nafstad & 
Rødbroe, 2015, p. 149). As this gesture occurred before the mother’s touch on 
Robin’s fingers, it was an anticipatory gesture. However, it was observed that Robin 
also used the gesture in other contexts for requesting the rhyme and sometimes for 
answering his mother. In these contexts, the mimetic gesture could be understood as 
a referential gesture representing the rhyme (Iverson & Thal, 1998). 
Robin’s second gesture (Figure 15) was also an anticipatory gesture, as it 
occurred at a specific part of the rhyme and anticipated his mother’s subsequent 
Sini Peltokorpi 
94 
touch on his wrist. This gesture could also be an early pointing gesture, which Robin 
utilized for directing his own attention to the subsequent action (see Bates et al., 
1979; Iverson & Thal, 1998). The findings from the data indicate that Robin also 
used other gestural expressions, which revealed his embodied memory of the rhyme. 
For instance, when his mother suggested that they would play “Magpie Makes 
Porridge,” he moved his fingers upward. This could be a signal of Robin’s thinking 
of the rhyme (“The game in which my fingers are touched”).   
In summary, Robin’s emerging gestures appeared to be closely connected to his 
bodily-tactile experiences of the rhyme. Ask Larsen (2003) had similar findings 
regarding the gestural expressions of a child with CDB, who used his gestures to 
refer to a bodily-tactile rhyme, “Round and Round the Garden.” 
5.2.4 Emotional availability 
The raw EA scores for Robin and his mother are presented in Table 11. The findings 
indicate positive changes in the emotional relationship of Robin and his mother 
during the early intervention (Research Question 5). The mother’s mean EA scores 
in sensitivity were at the neutral level at baseline and stayed at the same level during 
the intervention and follow-up. Her mean EA scores in structuring were at the 
moderately structuring level at baseline and remained at the same level during the 
intervention and follow-up. Her mean EA scores in nonintrusiveness were at the 
level of “benign intrusiveness” at baseline. During the intervention, her mean EA 
scores were elevated to the level of general nonintrusiveness. At follow-up, her mean 
EA scores in nonintrusiveness decreased back to the level of “benign intrusiveness.” 
Her mean EA scores in hostility were at generally nonhostile level and stayed at the 
same level during the intervention and follow-up. 
Robin’s mean EA scores in responsiveness indicated a complicated 
responsiveness at baseline. During the intervention, his mean EA scores in 
responsiveness were elevated to the moderately optimal level and stayed at the same 
level during follow-up. Robin’s mean EA scores in involvement corresponded to a 
complicated involvement in all the phases of the study. 
Results 
 95 
Table 11. The means and ranges of emotional availability for Robin and his mother before, during, 
and after the bodily-tactile early intervention. 
 Baseline Intervention Follow-up 
Sensitivity 5.8 (5.5–6.5) 6.0 (6.0–6.0) 6.0 (5.5–6.5) 
Structuring 5.7 (5.5–6.0) 6.0 (5.5–6.5) 6.0 (5.5–6.5) 
Nonintrusiveness 5.2 (5.0–5.5) 5.7 (5.5–6.0) 5.3 (5.0–6.0) 
Nonhostility 6.2 (6.0–6.5) 6.5 (6.5–6.5) 6.5 (6.0–7.0) 
Child responsiveness 5.2 (5.0–5.5) 5.8 (5.5–6.0) 5.7 (5.0–6.5) 
Child involvement 5.3 (5.0–6.0) 5.2 (5.0–5.5) 4.3 (3.5–5.5) 
Note: All the scales range from 1 (low) to 7 (high). 
5.3 Study III 
The results of the interactions of each mother-child dyad are reported individually. 
The focus of the analysis is on the mothers’ actions, which are closely linked to their 
children’s participation through movements. The findings indicate positive changes 
in interactional reciprocity and child participation for all the mother-child dyads 
(Research Questions 3 and 4). Only one extract from each mother-child dyad was 
selected for this summary. The original article (Study III) includes more examples 
of transcriptions and more comprehensive analysis of their interactions.  
5.3.1 Thea and her mother 
The analysis showed that Thea’s mother changed her way of structuring the play 
routines during the intervention. The most significant change was found in her way 
of creating time and space for Thea’s turn-taking, which allowed more reciprocity in 
interactions. During the intervention, Thea’s participation increased through bodily 
actions. When her mother noticed Thea’s turn-taking through a movement during a 
slot, she often touched the part of Thea’s body that she had moved. Moreover, Thea 
developed her participation during a game in which she began to cocreate a 
movement pattern with the help of her mother.  
Baseline. Thea’s mother instigated several bodily-tactile play routines with Thea 
at baseline. During the play routines, Thea was positioned on her back, face to face 
with her mother. The play routines included strong sensory experiences and were 
often played at a fast tempo. Thea enjoyed these routines and expressed her 
excitement by straightening her arms and smiling. Typically, Thea’s mother did not 
create slots for Thea to act spontaneously during the play routines. When she 
observed Thea’s reactions, she focused more on her face than on her bodily actions. 
In the moments in which she posed questions to Thea, she either waited for a 
Sini Peltokorpi 
96 
predetermined response from her (turning her head toward her mother) or did not 
wait for any response.    
Intervention. The mother’s way of structuring the play routines changed during 
the intervention as she started paying more attention to Thea’s participation. She 
began to create time and space for Thea’s turn-taking by pausing the play activity 
and releasing her hold on Thea. She also began to observe more of Thea’s bodily 
expressions during the slots. When she noticed Thea’s movement, she responded 
to it verbally and acknowledged the movement through touch (e.g., touching the 
leg that Thea had moved). Thus, through her mother’s touch, Thea could become 
aware that her movement had been noticed. Moreover, when the mother posed 
questions to Thea, she began to treat Thea’s spontaneous bodily responses as 
answers to her questions.  
In B7, Thea and her mother began to play a new song, “The Wheels on the 
Bus.” During the first verse, her mother moved Thea’s legs as though Thea were 
pedaling while Thea was positioned on her back. In the beginning, Thea 
participated in the song by bending one or both of her knees during the slots 
created by her mother. In B10, her participation in the song developed. She not 
only bent her knees during the time slots but also during the activity. That is, she 
could use her leg movements for cocreating the movement pattern of pedaling 
with her mother. This was possible because her mother released her grasp on one 
of Thea’s legs alternately, which enabled Thea to make a half round of pedaling 
independently in both legs. Her pedaling movements were captured in the 
recordings in B10, B12, and A15. Extract 3 illustrates Thea’s participation in “The 
Wheels on the Bus” in B10.  
Results 
 97 
Extract 3. Thea’s (T) co-constructed leg movements in “The Wheels on the Bus” in 
intervention session B10.  
 
 
Figure 16. The mother releases her hold on Thea’s left leg. Original publication: Peltokorpi, S., 
Salo, S., Hart, P., Nafstad, A., Kajamies, A., & Laakso, M. (2024). Developing reciprocity 
between one-year-old children with visual impairment and additional disabilities and 
their mothers: The effects of bodily-tactile early intervention. Learning, Culture and 
Social Interaction, 48, Article 100849. doi: 10.1016/j.lcsi.2024.100849 
Sini Peltokorpi 
98 
 
Figure 17. Thea bends her left knee during the pedaling movement. Original publication: 
Peltokorpi, S., Salo, S., Hart, P., Nafstad, A., Kajamies, A., & Laakso, M. (2024). 
Developing reciprocity between one-year-old children with visual impairment and 
additional disabilities and their mothers: The effects of bodily-tactile early intervention. 
Learning, Culture and Social Interaction, 48, Article 100849. doi: 
10.1016/j.lcsi.2024.100849 
The co-performed movement pattern of pedaling goes on several times and 
smoothly during the first verse. Thea participates in the action by bending her legs 
alternately (Lines 02 and 04) when her mother releases her hold on her legs (Lines 
01 and 03). One movement pattern begins when Thea’s mother releases her grasp of 
Thea’s left leg (Line 03, Figure 16). Thea continues the movement by bending her 
left knee (Line 04, Figure 17) before her mother grasps the leg again. When the same 
movement pattern was repeated with both of Thea’s legs, it resulted in a cocreated 
bodily-tactile “choreography” of the first verse. Rączaszek-Leonardi et al. (2013) 
argue that these types of coactions are essential for intentionality to emerge.  
In summary, during the intervention, Thea acquired new resources for 
participation through her leg movements. First, she could engage in the games by 
bending one or both of her knees during time slots created by her mother. At a later 
stage, she could use her leg movements for co-constructing the pedaling movement 
of “The Wheels on the Bus” by doing a part of the pedaling independently. These 
changes in Thea’s participation were based on the changes in her mother’s 
interactive behavior.  
5.3.2 Sara and her mother 
The findings indicate that during the intervention, Sara’s mother began to play 
dyadic play routines with Sara. Moreover, her structuring of the play routines 
changed. She began to create slots during the play routines and observe more of 
Sara’s body movements during the slots. This enabled Sara to take her turn through 
Results 
 99 
movements. When Sara’s mother detected Sara’s movements, she responded to them 
by touching the part of the body Sara had moved and acknowledged her actions 
verbally as if they were intentional.    
Baseline. Typically, Sara’s mother used sound toys for playing with Sara at 
baseline. During their play routines, Sara sat in front of her mother on the floor, and 
her mother’s gaze was focused on the toys or Sara’s face. Sara’s mother responded 
to Sara’s vocalizations but less to her movements. This is a common finding for 
mothers of infants with typical verbal development (Rączaszek-Leonardi et al., 
2013; Sierra, 2017; Vierijärvi, 1999). Sara’s mother posed questions to Sara 
frequently. She used questions to obtain information from Sara, to inform her about 
the subsequent actions, and as a means to respond to Sara’s vocalizations or smiling. 
As Sara could only occasionally respond to her mother vocally, her mother often 
answered the questions herself (e.g., “Do you like the song?” [pause] “Do you?” 
[pause] “Yeah”). 
Intervention. Sara’s mother began to engage in more dyadic play routines 
without toys with Sara during the intervention. During the play routines, Sara was 
either on her back on the floor (Extract 4) or on her mother’s lap. These positions 
gave her more opportunities to participate in the play routines by moving her legs. 
Sara’s mother changed her way of asking Sara questions during the intervention, as 
she began to expect Sara’s bodily answers besides her vocalizations. Moreover, 
Sara’s mother began to create slots for Sara’s turn-taking during the games and 
observed Sara’s body during the slots. When she detected Sara’s movement, she 
interpreted it as an intentional action and often acknowledged it tactilely by touching 
the part of Sara’s body she had moved. By doing so, her noticing of Sara’s movement 
became accessible to Sara.   
Extract 4 illustrates a moment of interaction in the first intervention session (B5). 
Sara and her mother are singing and playing “The Wheels on the Bus” and have 
finished the first verse. The mother asks Sara three times whether she would like to 
sing the next verse with leg movements (Lines 01–04). Next, Sara moves her body 
(Line 05), which her mother interprets as an answer to her question (Line 04).  
 
Sini Peltokorpi 
100 
Extract 4. Sara’s mother interprets Sara’s (S) movements as a response to her 
question in intervention session B5. 
 
 
Figure 18. Sara is still during her mother’s question and touches. Original publication: Peltokorpi, 
S., Salo, S., Hart, P., Nafstad, A., Kajamies, A., & Laakso, M. (2024). Developing 
reciprocity between one-year-old children with visual impairment and additional 
disabilities and their mothers: The effects of bodily-tactile early intervention. Learning, 
Culture and Social Interaction, 48, Article 100849. doi: 10.1016/j.lcsi.2024.100849 
Results 
 101 
 
Figure 19. Sara turns and moves her legs. Original publication: Peltokorpi, S., Salo, S., Hart, P., 
Nafstad, A., Kajamies, A., & Laakso, M. (2024). Developing reciprocity between one-
year-old children with visual impairment and additional disabilities and their mothers: 
The effects of bodily-tactile early intervention. Learning, Culture and Social Interaction, 
48, Article 100849. doi: 10.1016/j.lcsi.2024.100849 
The sequence in Extract 4 consists of three parts. The first part is the mother’s 
question with repetitions (Lines 01–04), the second part consists of Sara’s bodily 
action (Line 05, Figure 19), and the third part is the mother’s confirmation joo (yes) 
and touch (Line 04). The question, which is the first part of an adjacency pair sets up 
the conditional relevance of the second part—the answer. The mother’s turns include 
repetitions of her question (Lines 01–04) until she receives a response from Sara, 
which reflects an inner model of conditional relevance (Snow, 1977; Vierijärvi, 
1999). While the mother poses questions to Sara, she also touches her legs several 
times (Lines 01–03, Figure 18). The mother’s touches direct her and Sara’s attention 
to the same locus. Next, Sara responds by taking a bodily action of turning and 
moving her legs (Line 05, Figure 19). The “nextness” of her turn helps her mother 
interpret the bodily actions as an answer to her question. Sara’s mother expresses her 
interpretation of Sara’s action as an affirmative answer by uttering “Yes” and 
touching Sara’s legs (Line 04). Her interpretation of Sara’s bodily action as an 
affirmative answer can be linked to Sara’s rhythmic leg movements, which indicate 
excitement (Reddy et al., 2013). Through the mother’s interpretation, Sara’s bodily 
action becomes a second pair part of the adjacency pair. Sierra (2017) observed a 
similar sequence in which a mother interpreted the movement of her typically 
developing child as an answer to her question.  
The findings of the sequence suggest that the mother’s knowledge of Sara’s 
resources to participate in interactions through bodily actions changed her ways of 
responding to Sara. She began to show expectancy toward Sara’s bodily responses, 
and when she observed Sara’s movements, she interpreted them as intentional 
Sini Peltokorpi 
102 
actions. Moreover, Sara’s mother also began to interpret Sara’s movements as 
intentional actions in contexts in which she did not ask her anything (e.g., as 
participation in a game). These findings suggest that parents’ knowledge of their 
children’s bodily resources can increase the reciprocity of their interactions, which 
is in line with the transactional model of development (Sameroff & MacKenzie, 
2003a). Similar observations have been made of typically developing children. Ninio 
and Bruner (1978) discovered that when mothers became aware of their children’s 
new vocal abilities, their way of responding to their children changed qualitatively. 
Further, the changes in the mothers’ responses advanced their children’s vocal 
development.  
In summary, during the intervention, Sara gained new resources for participating 
in the play routines through movements. These positive outcomes were based on 
changes in her mother’s interactive behavior.  
5.3.3 Alex and his mother 
The analysis indicated that during the intervention, Alex obtained more opportunities 
for turn-taking through movements. This change was based on the changes in his 
mother’s interactive behavior. She began to create sequential slots for Alex’s turn-
taking and observe his actions with great attention. When she noticed Alex’s subtle 
movements during the slot, she treated them as intentional actions and interpreted 
them as his wishes to continue the game.  
Baseline. Alex’s mother used physical activities when playing with Alex at 
baseline. During the activities, Alex was on his mother’s lap, held face to face by his 
mother, or positioned on his back on the floor. Alex’s mother observed Alex’s 
responses from his facial gestures and tried to make eye contact with him. She posed 
frequent questions to Alex. However, she did not typically expect answers from him 
and used questions to inform Alex about the subsequent actions or to interpret his 
expressions in the activities. At times, her questions indicated her attempts to obtain 
Alex’s visual attention. She responded to Alex’s vocal and emotional expressions 
but less to his bodily actions. 
Intervention. During the intervention, Alex’s mother developed new play 
activities in the bodily-tactile modality with Alex. She also began to create more time 
and space for Alex to take his turn. During the slots, she paid close attention to Alex’s 
bodily responses. When she noticed Alex’s movements, she responded to them 
verbally and tactilely and often interpreted his actions as requests. Her touches 
related to Alex’s movements made her responsiveness accessible to Alex.    
Alex and his mother played a swinging game for the first time in B8. That time, 
Alex did not engage in the game with observable movements. In B9 and B12, Alex’s 
mother began to respond to his emerging movements in the game as intentional 
Results 
 103 
actions. Extract 5 illustrates this kind of moment in B12. Alex is positioned on his 
mother’s lap during the play activity (Figure 20). He can perceive the movements of 
swinging through the bodily-tactile modality, and he responds to the initiation of 
swinging with a smile (Line 01). When the swinging is finished, Alex’s mother creates 
a slot and observes his responses (Line 01). She expresses a soft exclamation hui (oh) 
(Line 02), referring to their shared experience, while observing Alex attentively.  
 
Extract 5. Alex’s mother interprets his subtle movements as intentional actions in 
intervention session B12.   
 
 
Figure 20. The swinging movement begins. Original publication: Peltokorpi, S., Salo, S., Hart, P., 
Nafstad, A., Kajamies, A., & Laakso, M. (2024). Developing reciprocity between one-
year-old children with visual impairment and additional disabilities and their mothers: 
The effects of bodily-tactile early intervention. Learning, Culture and Social Interaction, 
48, Article 100849. doi: 10.1016/j.lcsi.2024.100849 
Sini Peltokorpi 
104 
 
Figure 21. Alex leans backward and moves his left leg. Original publication: Peltokorpi, S., Salo, 
S., Hart, P., Nafstad, A., Kajamies, A., & Laakso, M. (2024). Developing reciprocity 
between one-year-old children with visual impairment and additional disabilities and 
their mothers: The effects of bodily-tactile early intervention. Learning, Culture and 
Social Interaction, 48, Article 100849. doi: 10.1016/j.lcsi.2024.100849 
 
Figure 22. The mother notices Alex’s leg movement tactilely. Original publication: Peltokorpi, S., 
Salo, S., Hart, P., Nafstad, A., Kajamies, A., & Laakso, M. (2024). Developing reciprocity 
between one-year-old children with visual impairment and additional disabilities and 
their mothers: The effects of bodily-tactile early intervention. Learning, Culture and 
Social Interaction, 48, Article 100849. doi: 10.1016/j.lcsi.2024.100849 
Alex leans slightly backward during his mother’s expectant attention (Line 02). 
His movement may be perceptible to his mother, who, however, does not respond 
to it. Next, after a long pause (Line 02), Alex repeats his movement of leaning back 
with a subtle movement with his left leg (Line 03, Figure 21). These subtle actions 
could mirror his bodily experiences of the game. Similar findings of mirroring 
Results 
 105 
movements have been observed in other children with VIAD (Rogow, 1982). 
These discoveries suggest that children with VIAD can build their bodily actions 
by reusing resources of former actions that they have perceived (cf. Goodwin, 
2013). Moreover, as Alex’s first movement (Line 02) was not responded to, his 
repetition of the movement (Line 03) could be an attempt to repair communication 
(Dincer & Erbas, 2010). This time, Alex’s bodily actions are noted by his mother, 
who interprets them as a request to continue swinging (Line 04). The mother’s 
interpretation is fundamental for creating shared meaning with Alex (for similar 
findings, see Rączaszek-Leonardi et al., 2013). In other words, if she had ignored 
Alex’s movements, their potential in interactions would have been unfulfilled. 
Further, Alex’s mother expresses to Alex that she noticed his movements by 
touching the loci of his body where she perceived his movements (Line 04, Figure 
22). In this way, the mother’s attention and nonverbal responsiveness become 
accessible to him. 
The swinging game is an example of an early play routine that provides many 
resources for the participation of children with VIAD, such as Alex. First, it is 
multimodal and accessible through the bodily-tactile modality. Second, it has a 
simple structure of one activity, swinging, which can be repeated. Third, it has a 
distinguishable rhythm, which has been found to enhance togetherness between 
caregivers and their children with VIAD (Metell, 2015). Fourth, the long time slots 
during the game can sensitize children with VIAD to perceive their parents’ bodily 
actions and engage in the activity (cf. Johnson & Parker, 2013; Rączaszek-Leonardi 
et al., 2013).  
In summary, during the intervention, Alex’s participation in the play routines 
increased. This was based on the changes in his mother’s interactive behavior, which 
provided more space and time for Alex to take his turns. Moreover, the mother’s 
interpretations of Alex’s subtle movements as intentional actions created reciprocity 
in their interactions.  
5.4 Study IV 
5.4.1 The mothers’ use of tactile strategies 
All the mothers increased their use of the bodily-tactile modality in interactions with 
their children with VIAD during the early intervention (Research Question 2). The 
changes in their use of the bodily-tactile modality are specified below. 
Early play routines. The changes in the amount of time the mothers’ played 
bodily-tactile nonconventional and conventional games with their children are 
illustrated in Figures 23 and 24. Overall, the mothers increased their use of the 
bodily-tactile play routines with their children during the intervention. However, 
Sini Peltokorpi 
106 
they had differences in the type of games they played more often with their 
children. Thea’s mother especially increased her use of conventional games with 
Thea during the intervention and follow-up, whereas the time used for 
nonconventional games decreased. Sara’s mother mainly used toys for playing 
with Sara at baseline. During the intervention and follow-up, she developed new 
dyadic conventional games with Sara. Alex’s mother also mainly used toys for 
playing with Alex at baseline. During the intervention, she began to play more 
nonconventional games with Alex.  
 
Note: B5 refers to the session at the beginning of the intervention (B5 or B6), B8 to the session 
in the middle of the intervention (B8 or B9), and B12 to the session at the end of the 
intervention (B11 or B12). 
Figure 23. The mothers’ use of nonconventional games as a percentage of time per session. 
Original publication: Peltokorpi, S., Salo, S., Nafstad, A., Hart, P., Biringen, Z., & Laakso, 
M. (2024). Bodily-tactile early intervention: A pilot study of the role of maternal touch 
and emotional availability in interactions between three children with visual impairment 
and additional disabilities and their mothers. Frontiers in Psychology, 15, Article 
1439605. doi: 10.3389/fpsyg.2024.1439605 
Results 
 107 
 
Note: B5 refers to the session at the beginning of the intervention (B5 or B6), B8 to the session 
in the middle of the intervention (B8 or B9), and B12 to the session at the end of the 
intervention (B11 or B12). 
Figure 24. The mothers’ use of conventional games as a percentage of time per session. Original 
publication: Peltokorpi, S., Salo, S., Nafstad, A., Hart, P., Biringen, Z., & Laakso, M. 
(2024). Bodily-tactile early intervention: A pilot study of the role of maternal touch and 
emotional availability in interactions between three children with visual impairment and 
additional disabilities and their mothers. Frontiers in Psychology, 15, Article 1439605. 
doi: 10.3389/fpsyg.2024.1439605 
Tactile noticing. The mothers of Thea and Alex used only a little tactile noticing 
(Figure 4) at baseline. They both increased their use of tactile noticing during the 
intervention. Thea’s mother continued her contingent responses to Thea’s reaching 
gestures, which she had already used at baseline. Moreover, she began to touch the 
part of Thea’s body that Thea had moved before she continued the play routine. 
Alex’s mother mostly utilized this type of tactile noticing in interactions with Alex 
during the intervention. Specifically, when Alex made a subtle movement with his 
hands, legs, head, upper body, or blinking eyes, his mother touched the part or close 
to the part of the body that he had moved to accompany her verbal responses. Both 
mothers infrequently used imitation for noticing their children’s actions.   
Tactile anticipatory cues. All the mothers began to utilize tactile anticipatory cues 
(Figure 5) during the intervention. This was a change in their interactive behavior, 
because only Thea’s mother had used some tactile anticipatory cues at baseline. The 
mothers’ intervention-based tactile anticipatory cues occurred in connection with their 
verbal questions (e.g., Thea’s mother would move Thea’s legs or hands in the same 
way as in the subsequent game when she asked Thea if she would like to play it). 
Sini Peltokorpi 
108 
Moreover, the mothers used tactile anticipatory cues to inform their children about 
subsequent actions (e.g., Sara’s mother would touch or move the part of Sara’s body 
that she was about to touch or move next in the game). The mothers of Thea and Sara 
made tactile anticipatory cues through touches and movements, whereas Alex’s 
mother utilized mainly touches for anticipating actions to Alex. 
Tactile signs. The mothers did not use tactile signs at baseline. During the 
intervention, the mothers of Thea and Sara began to utilize tactile signs in songs 
(e.g., “Itsy Bitsy Spider”) and sometimes to support their speech. Thea’s mother 
mainly used coactive signing (Figure 6A) with Thea, whereas Sara’s mother utilized 
coactive signing and body signs (Figure 6B) with Sara. Alex’s mother coactively 
signed DOG for Alex in a self-created game during the intervention. Table 12 
presents the mothers’ results of using tactile noticing, tactile anticipatory cues, and 
tactile signs before, during, and after the intervention. 
Table 12. Frequencies of the mothers’ use of tactile noticing, tactile anticipatory cues, and tactile 
signs.  
Categories A1 A2 A3 A4 B5a B8a B12a A13 A14 A15 
Thea’s mother           
Tactile noticing 4  
(0.2) 
0 3  
(0.2) 
3  
(0.3) 
20 
(2.0) 
37 
(3.7) 
10 
(0.8) 
17 
(1.5) 
17 
(1.1) 
14 
(1.4) 
Tactile 
anticipatory 
cues 
2 
(0.1) 
1 
(0.1) 
0 1 
(0.1) 
1 
(0.1) 
0 5 
(0.4) 
4 
(0.4) 
6 
(0.4) 
6 
(0.6) 
Tactile signs 0 0 0 0 0 0 17 
(1.4) 
16 
(1.5) 
17 
(1.1) 
0 
Sara’s mother           
Tactile noticingb - - - - - - - - - - 
Tactile 
anticipatory 
cues 
0 0 0 0 4 
(0.4) 
5 
(0.5) 
4 
(0.4) 
8 
(0.7) 
13 
(1.3) 
6 
(0.5) 
Tactile signs 0 0 0 0 0 8 
(0.8) 
15 
(1.5) 
5 
(0.5) 
6 
(0.6) 
9 
(0.8) 
Alex’s mother           
Tactile noticing 0 0 0 3 
(0.3) 
2 
(0.2) 
11 
(1.0) 
14 
(1.4) 
33 
(3.3) 
11 
(1.1) 
9 
(0.9) 
Tactile 
anticipatory 
cues 
0 0 0 0 0 1 
(0.1) 
7 
(0.7) 
3 
(0.3) 
5 
(0.5) 
9 
(0.9) 
Tactile signs 0 0 0 0 0 9 
(0.8) 
0 0 0 0 
Note: The numbers in brackets show the frequency of the phenomenon per minute. 
a B5 refers to the session at the beginning of the intervention (B5 or B6), B8 to the session in the middle 
of the intervention (B8 or B9), and B12 to the session at the end of the intervention (B11 or B12).  
b These results are not reported due to low reliability in the coding.  
Results 
 109 
5.4.2 Emotional availability 
The raw EA scores and means for the mothers and their children are reported in 
Table 13. The raw EA scores indicate positive changes in the children’s and their 
mothers’ emotional relationship during the early intervention (Research Question 5). 
For Thea’s mother, her mean EA scores remained at the same levels from baseline 
to intervention. For Sara’s mother, her mean EA scores for sensitivity increased from 
the inconsistent level to the neutral sensitivity level during the intervention. 
Similarly, her mean EA scores for nonintrusiveness increased from the “benign” 
intrusiveness level to the generally nonintrusive level. However, during the follow-
up, her mean EA scores for sensitivity and nonintrusiveness regressed back to the 
baseline level. For Alex’s mother, her mean EA scores for sensitivity increased from 
the inconsistently sensitive level to the neutral sensitivity level during the 
intervention and remained at the neutral sensitivity level during the follow-up. Her 
mean EA scores for structuring increased from the inconsistent structuring level to 
the moderately structuring level during the intervention.  
The children’s mean EA scores changed from baseline to intervention. For Thea, 
her mean EA scores for responsiveness increased from the complicated 
responsiveness level to the moderately optimal level of responsiveness during the 
intervention and remained at the moderately optimal level during the follow-up. Her 
mean EA scores for involvement increased from the complicated involvement level 
to the moderately optimal level in involving behaviors during the intervention. Sara’s 
mean EA scores for involvement increased from somewhat non-optimal level in 
involving behaviors to complicated involvement during the intervention. Her mean 
EA scores also remained at the level of complicated involvement during the follow-
up. Alex’s mean EA scores for responsiveness increased from the complicated 
responsiveness level to the moderately optimal level during the intervention. His 
mean EA scores for involvement increased from the somewhat non-optimal level to 
the complicated involvement level during the intervention and remained at the 
complicated level during the follow-up. 
Sini Peltokorpi 
110 
Table 13. The means and ranges of emotional availability for the children and their mothers before, 
during, and after the bodily-tactile early intervention. 
 Baseline Intervention Follow-up 
THEA’S MOTHER    
Sensitivity 5.8 (5.0–6.5) 6.2 (5.5–6.5) 5.8 (5.5–6.0) 
Structuring 5.9 (5.5–6.5) 6.2 (6.0–6.5) 6.0 (6.0–6.0) 
Nonintrusiveness 4.6 (4.5–5.0) 5.0 (4.0–5.5) 5.0 (4.5–5.5) 
Nonhostility 6.3 (6.0–7.0) 6.7 (6.0–7.0) 7.0 (7.0–7.0) 
Child responsiveness 5.4 (5.0–6.5) 6.3 (6.0–6.5) 6.0 (6.0–6.0) 
Child involvement 4.3 (3.0–6.0) 5.7 (5.0–6.0) 5.3 (5.0–5.5) 
SARA’S MOTHER    
Sensitivity 4.8 (4.0–5.5) 5.7 (5.0–6.0) 5.3 (4.5–6.0) 
Structuring 5.1 (5.0–5.5) 5.2 (5.0–5.5) 5.5 (5.5–5.5) 
Nonintrusiveness 4.4 (3.5–5.0) 5.5 (5.5–5.5) 5.3 (4.0–6.0) 
Nonhostility 5.8 (5.5–6.0) 6.2 (6.0–6.5) 6.0 (6.0–6.0) 
Child responsiveness 4.1 (3.5–5.0) 4.7 (4.5–5.0) 5.2 (4.5–5.5) 
Child involvement 3.5 (3.0–4.5) 4.0 (3.0–5.0) 4.5 (3.5–5.0) 
ALEX’S MOTHER    
Sensitivity 5.1 (4.5–6.0) 5.5 (5.0–6.0) 5.7 (5.5–6.0) 
Structuring 4.8 (4.5–5.0) 5.5 (5.5–5.5) 5.2 (5.0–5.5) 
Nonintrusiveness 4.9 (4.5–5.5) 5.3 (5.0–6.0) 5.8 (5.5–6.0) 
Nonhostility 6.3 (6.0–7.0) 7.0 (7.0–7.0) 7.0 (7.0–7.0) 
Child responsiveness 4.8 (4.0–5.0) 5.8 (5.5–6.0) 5.3 (5.0–5.5) 
Child involvement 3.8 (3.5–4.5) 5.3 (5.0–5.5) 4.8 (4.5–5.0) 
Note: All the scales range from 1 (low) to 7 (high). 
5.5 The mothers’ evaluation of the intervention 
All four mothers in Studies II–IV rated the intervention as very useful (5), using a 
scale from not useful at all (1) to very useful (5).   
 111 
6 Discussion 
6.1 Summary and discussion of the results 
The Study I findings suggest that the mother of the child with CDB (Emma) 
increased tactility in her imitations during the tactile imitation guidance. Her 
imitative exchanges with Emma became longer at the end of the guidance, and 
Emma began to respond to her mother’s imitations more by smiling and placing her 
hands on her mother’s face. Moreover, Emma and her mother became emotionally 
more available to each other during the intervention compared to at baseline. In 
Studies II, III, and IV, the mothers of children with VIAD (Robin, Thea, Sara, and 
Alex) increased their use of the bodily-tactile modality in play routines during the 
intervention. They also began to utilize more tactile anticipatory cues, tactile noticing 
behaviors, and tactile signs in interactions with their children. Moreover, the mothers 
began to create more time and space for their children to take turns and to respond 
to their children’s movements as if they were voluntary actions. The changes in the 
mothers’ interactive behaviors increased their children’s embodied participation 
through movements, gestures, and signs, which resulted in more reciprocity in 
interactions. Moreover, the EA of the children and their mothers strengthened during 
the early intervention. The mothers evaluated the intervention as very useful. 
Overall, the findings of this study suggest that the reciprocity connected to turn-
taking and the emotional exchanges between mothers and their children with VIAD 
increased during the bodily-tactile early intervention.   
6.1.1 The characteristics of the mother-child imitations after 
the tactile imitation guidance 
The Study I findings suggest that Emma’s mother imitated her expressions 
frequently at baseline. However, most of her imitations were vocal, and she used 
tactility in her imitations only once. This might be because for a sighted and hearing 
parent, it is natural to create a dialogue with a child through the vocal modality. 
When Emma’s mother was introduced to tactile imitation, she began to use the tactile 
modality more in her imitations during the guidance. She created her personal ways 
of applying tactility in imitations, such as tracing her mouth movements on Emma’s 
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hands. These findings suggest that systematic application of the tactile modality in 
imitations may not occur spontaneously in the parents of children with CDB, and 
they may benefit from tactile imitation guidance to make their non-vocal and vocal 
imitations more accessible to their children.   
It appeared that the mother’s more frequent use of tactility in imitations 
strengthened the tactile reciprocity, as Emma began increasingly to place her hands 
on her mother’s face during the intervention. Escalona et al. (2002) had similar 
findings in studies of 3–7-year-old children with autism, who responded to adults’ 
imitations by touching the adults. Moreover, Emma began to smile more as a 
response to her mother’s imitations during the intervention. Smiling indicates 
sensitivity to being imitated in typically developing infants (Nadel et al., 2004), and 
it is a common response to being imitated in persons with developmental delay or 
VIAD (O’Neill & Zeedyk, 2006). Emma’s increased smiling and tactile contact 
behaviors suggest that the intervention strengthened positive transactions through 
increased accessibility (Sameroff & MacKenzie, 2003b). Similarly, other studies 
have discovered that tactile imitations created positive encounters with individuals 
with CDB (Caldwell, 2006; Hart, 2006; Shakele et al., 2022).     
Emma’s mother initiated most of the imitative bouts, which usually lasted one 
round. Likewise, O’Neill and Zeedyk (2006) found that adults initiated most of the 
imitative bouts in interactions with 7–18-year-old youngsters with developmental 
delays, and most of the bouts did not extend beyond a single round. Emma made 
occasional imitations of her mother’s vocal and gestural expressions as part of her 
expressive repertoire. Her gestural imitations occurred after she accessed her 
mother’s gestures through the sense of touch.  
The length of Emma’s and her mother’s imitative bouts increased in the last 
intervention session, which indicates that their interactions included longer episodes 
of turn-taking. This was an important qualitative change in their interactions because 
turn-taking involved Emma as an active participant in interactions and could attribute 
agency to her. Moreover, the early forms of turn-taking are necessary precursors for 
the development of more mature interactional sequences (Berducci, 2010). It is 
unlikely that the increase in turn-taking could have occurred due to Emma’s natural 
development, because the intervention was implemented in a rather short time 
interval, and the changes in the length of the turn-taking exchanges were detected in 
the last intervention session. Thus, the results suggest that the tactile imitation 
guidance launched a process that prolonged the turn-taking exchanges over time.     
This study is unique in its ability to provide scientific information about tactile 
imitation guidance for the mother of a child with CDB. That is, although tactile 
imitation has been described as a useful strategy in the CDB literature (e.g., Nafstad 
& Rødbroe, 2015), and it has been utilized among other strategies in an intervention 
for a child with CDB (e.g., Shakele et al., 2022), no other interventions have explored 
Discussion 
 113 
the effects of tactile imitation guidance for parents of children with CDB (for a 
review, see Sundqvist et al., 2023). Overall, the results of Study I suggest that the 
mother’s use of the tactile modality in her imitations made her multimodal 
expressions more accessible and/or interesting to Emma and resulted in her increased 
engagement.  
Imitation provides a powerful means to create interactional reciprocity in the 
early phases of language development, when many other strategies might not yet be 
appropriate. This is because adults’ imitations treat children’s expressions as 
initiatives irrespective of whether they were originally initiations or not. 
Furthermore, when children with VIAD experience that they can have an impact on 
others’ behavior and lead the dialogue, it can radically change their roles in 
communication and create a feeling of shared understanding with their parents. 
However, imitation alone is not sufficient to foster language development. Instead, 
it is a starting point in a dialogue that can lead to more complex co-constructed 
interactions (Linell, 2009). Thus, parents need to have the opportunity to learn other 
(tactile) strategies to foster interactions and communication with their children with 
VIAD.  
6.1.2 The mothers’ use of the bodily-tactile modality 
In Studies II–IV, some of the mothers had already developed bodily-tactile play 
routines with their children at baseline, but this was not the case for all. Thus, there 
was individual variety in how the mothers spontaneously used the bodily-tactile 
modality for creating dyadic games with their children with VIAD. Furthermore, our 
findings suggest that the mothers increased their use of the bodily-tactile modality 
in the context of play during the intervention. They were able to develop new games 
easily, which corresponds to Stern’s (1974) findings. The findings also suggest that 
dyadic games were developmentally easier activities for the children to join than 
games with toys, which supports Trevarthen’s (1980) developmental theory of 
intersubjectivity. However, it is important to note that the mothers’ increased use of 
the bodily-tactile modality in play routines differs from the typical developmental 
process in which the proportion of tactile games decreases as infants age (Crawley 
et al., 1978). This is due to the differences in the resources that children with and 
without VIAD can use for their participation over time. Overall, multimodality can 
manifest differently in typical and atypical interactions. However, interactions with 
children with VIAD may need more focus on the bodily-tactile modality to create 
more equal encounters.   
Our findings suggest that children with VIAD could utilize non-vocal structures 
of the play routines in their participation. Similarly, Rogow (1982) found that 
children with VIAD used nonverbal structures of play routines for their initiations. 
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Thus, bodily-tactile play routines can be optimal activities for early intervention, and 
their usability may reach far beyond the first two years of life, depending on the 
child’s abilities and needs. The games can be optimally modified for children’s 
participation at different ages, considering their motor skills and other resources. 
Moreover, all the mothers in this study benefited from guidance on structuring games 
optimally for their children’s participation. Without this part of the intervention, the 
focus would have been only on input for the children, which would not have been 
adequate to support their participation. Thus, enlarging the repertoire of bodily-
tactile play routines is only a first step, and it is crucial to ensure that games are 
structured optimally for children’s multimodal engagement.     
In Studies II and IV, the mothers increased their use of tactile noticing during 
the intervention, which suggests that they began to recognize more of their children’s 
embodied participation. This, in turn, indicates that the intervention created positive 
mother-child transactions (Sameroff & MacKenzie, 2003b). Tactile noticing may be 
an accessible form of parents’ nonverbal responsiveness. In that case, tactile noticing 
could function like parents’ gaze responsiveness, which has been found to predict 
the language development of typically developing infants (Wildt & Rohlfing, 2024). 
In Study IV, the mothers used three different types of tactile noticing behaviors in 
responding to their children. It is possible that these tactile responses have different 
effects on children’s participation in the same way that mothers’ diverse vocal 
responses have on their typically developing children (see Gros-Louis et al., 2014). 
Moreover, tactile noticing may express embodied mentalizing, which is the parents’ 
capacity to read their infants’ mental states (e.g., wishes) from their bodily actions 
and adjust their own bodily actions accordingly (Shai & Belsky, 2011). Overall, the 
findings of this study generate new information on tactile noticing, because previous 
studies have utilized tactile noticing only in interventions for people with CDB 
(Damen et al., 2015a).    
The findings of Studies II and IV suggest that the mothers’ use of tactile 
anticipatory cues increased during the intervention. Similarly, Chen et al. (2007) 
discovered that parents of children with VIAD increased their use of diverse 
anticipatory cues, including touch cues, during an early intervention and found them 
useful for communicating better and understanding the needs of their children with 
VIAD. Tactile anticipatory cues can help children with VIAD anticipate activities, 
recognize and comprehend target words, and develop communication through 
objects (Chen et al., 2007; Goold & Hummel, 1993). Moreover, they may lower 
behaviors indicating stress and increase children’s active participation (Nelson et al., 
2013). These positive findings indicate that tactile anticipatory cues can provide 
access to adults’ intentions and create better sequential structuring of interactions, 
which facilitate children’s participation (Axelsson et al., 2014; Fantasia et al., 2019).  
Discussion 
 115 
Our results from Studies II and IV suggest that the intervention helped the 
mothers adapt tactile signs into play routines and support key words during their 
speech. Moreover, the results of Study II suggest that Robin began to imitate two new 
signs and made one of them spontaneously, which indicates that the intervention 
created positive transactions. It is likely that these new skills in signing occurred 
because Robin was already making signs at baseline and was developmentally at a 
higher stage than the children in Study IV. Overall, the present study resulted in new 
information about the potential of an early intervention to help the parents of children 
with VIAD learn tactile signs. To our knowledge, only Shakele et al. (2022) have 
addressed this topic and reported the positive effects of an intervention on the tactile 
signing of a 3-year-old girl with CDB and her family members.   
The findings regarding Robin’s signs suggest that learning signs through 
coactive signing can be useful for children with VIAD at the beginning of their sign 
acquisition and can provide them with access to manual sign acquisition. However, 
although tactile signing is described in the AAC literature (e.g., von Tetzchner & 
Martinsen, 1999, p. 41), this system is rarely addressed in AAC research or clinical 
practice. This may be because the deafblind field and the AAC field are not well 
connected. This study aimed to bridge the gap between these fields by demonstrating 
that tactile signing and tactile strategies in general may be useful tools for SLPs to 
support the communication development of children with VIAD.   
This doctoral study is one of the first to explore mothers’ use of tactile strategies 
in early interactions with their 1–3-year-old children with VIAD. The results suggest 
that the mothers increased their use of tactile strategies with their children with 
VIAD during the interventions. It is unlikely that these changes would have occurred 
spontaneously or were due to any factor other than the interventions because tactile 
strategies are specific means of multimodal communication that are not usually 
observed in systematic use in parent-child interactions. To use tactile strategies, the 
mothers needed to take on a learner’s role and acquire new skills in the bodily-tactile 
modality. Moreover, they needed to reflect on what it was like to perceive the world 
from a tactile perspective and sensitize themselves in perceiving their children’s 
subtle movements and gestures. This learning process could accomplish more equal 
and co-constructed interactions with their children with VIAD, as they were learning 
from each other (see Hart, 2010, p. 66). Accessibility has not been the focus of 
previous early interventions designed for young children with VIAD. Thus, this 
study raises new perspectives and principles regarding early interventions for 
families with children with VIAD.    
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6.1.3 Children’s participation and reciprocity of the mother-
child interactions 
In Study I, Emma’s multimodal participation increased during the tactile imitation 
guidance. She engaged in longer imitative exchanges in the vocal modality and made 
more tactile contact gestures toward her mother compared to at baseline. Similarly, 
other researchers have found that adults’ imitative responses enhance the 
participation of children with limited communication skills (Morris et al., 2021).   
In Study II, we observed that Robin participated in interactions by making tactile 
contact with his mother using his foot. This finding offers new information as child-
initiated tactile contact has been described earlier only in children with CDB and in 
the non-empirical literature (e.g., Nafstad & Rødbroe, 2015). Our findings suggest 
that children with VIAD may use tactile contact as an alternative to eye contact when 
their caretakers are within reach. It is essential that caretakers become more aware 
of tactile contact to be able to recognize it in interactions. Tactile contact is also an 
important strategy for adults to use in interactions with children and adults with 
VIAD (Damen et al., 2014).    
Our findings suggest that the repetitive nature of bodily-tactile games could help 
children learn the nonverbal components of the games and use them for their 
participation. At baseline, Robin used signs connected to the song “Itsy Bitsy 
Spider,” which he had learned through coactive signing. Moreover, the sequential 
analysis revealed that the negotiated sign MAGPIE developed from Robin’s bodily-
tactile play experiences. Ask Larsen (2003) described similar findings in relation to 
a boy with CDB who played a bodily-tactile rhyme with his mother. Furthermore, 
the findings of Study III suggest that some of the children’s movements could mirror 
their bodily-tactile experiences. Similarly, Rogow (1982) found that the gestures and 
actions of children with VIAD mirrored their play experiences.    
In Study III, the children participated in the play activities through movements 
that expressed their activity or enthusiasm. In addition, other researchers have found 
that typically developing infants (Fantasia et al., 2014; Jover et al., 2019; Reddy et 
al., 2013) and children with VI/VIAD (Liang et al., 2015; Preisler, 1991, 1995; 
Rogow, 1982) participate in interactions through physical activity. However, 
movement-based participation has not gained much scientific attention. This may be 
because movements are a momentary resource for participation in typically 
developing infants, and in the case of VIAD, children often receive more attention 
for their motor difficulties than for their embodied participation. However, it is 
essential that adults consider the movements of children with VIAD as their 
resources for participation. Participation through movements can create positive 
transactions (Sameroff & MacKenzie, 2003b) and launch a developmental process 
that advances their movements to more specific game-based bodily intentional 
Discussion 
 117 
actions and gestural expressions (Lee & MacWilliam, 2008, p. 29; Preisler 1991, 
1995; Rogow, 1982).   
In Study II, the baseline observations suggest that Robin’s mother did not detect 
most of Robin’s subtle gestures. Similarly, Fraiberg (1979) found that mothers had 
challenges reading their blind infants’ hand gestures. However, Maestas y Moores 
(1980) discovered that deaf parents read semantic intent from their infants’ hand 
configurations and movements from early on, which can be related to their expertise 
in sign language and their understanding of hands as articulators. Thus, it is crucial 
to guide the parents of children with VIAD to detect and respond to their children’s 
spontaneous gestures because they can take on sophisticated communicative 
functions and become their voices when recognized as such.  
In Study III, we discovered that mother-child interactions had limited reciprocity 
at baseline. The mothers posed questions to their children with VIAD, but they did 
not typically expect responses from them. This might stem from the mothers’ 
interactional experiences of not perceiving responses from their children. Instead, 
the mothers often responded to the questions themselves. However, this type of 
interaction may hinder children’s communication development because it lacks their 
involvement. Our findings indicate that mother-child interactions became more 
reciprocal during the intervention. Moreover, we observed that the positive changes 
in reciprocity were based on changes in the mothers’ interactive behaviors. Similarly, 
Janssen et al. (2002) discovered that positive changes in the interactive behaviors of 
children with CDB were gained through changes in their educators’ interactive 
behaviors. These findings indicate that interventions focused on caretakers can make 
positive changes in adult-child transactions (Sameroff & MacKenzie, 2003b).  
Furthermore, our findings suggest that the changes in reciprocity were closely 
connected to the changes in the mothers’ expectations. That is, when the mothers 
began to expect bodily responses from their children, they responded to their 
children’s movements as if they were voluntary actions. Similarly, Berducci (2010) 
found that parents of typically developing infants attributed agency to their infants’ 
natural reactions that they expected (e.g., commenting “good job” after an infant’s 
burp). We also discovered that the mothers began to treat their children’s bodily 
actions as answers to their questions, which created sequences resembling those of 
typical early interactions (Berducci, 2010; Sierra, 2017; Snow, 1977; Vierijärvi, 
1999). This was an important change because when the expressions of children with 
VIAD are embedded in turn-taking sequences, it gives them the opportunity to 
become more communicative and learn the discourse structure of language (cf. 
Berducci, 2010; Kaye & Charney, 1980). In addition, involvement in turn-taking 
sequences changes their roles from recipients to actors (see Smith & Fluck, 2000). 
The findings of this study provide new information regarding the possibilities of 
fostering the participation of children with VIAD at age one. Previous studies have 
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not included such young participants (see Axelsson et al., 2014; Williams et al., 
2020). Moreover, our results suggest that bodily-tactile early intervention may 
provide a means for children with VIAD to enjoy their right to participate (United 
Nations, 1989). This is an important finding because their rights can be easily 
ignored due to their disabilities, fragile health, and lack of knowledge of the 
strategies that they could benefit from. Furthermore, our findings suggest that 
children with VIAD do not need to be at any specific developmental stage to benefit 
from an intervention. Their participation can be fostered with their existing resources 
and through their parents’ actions at all developmental phases.  
Lastly, our results suggest that the increase in the mothers’ use of the bodily-
tactile modality in interactions did not decrease their children’s vocalizations. 
Instead, Emma engaged in longer vocal imitative exchanges during the tactile 
imitation guidance. Overall, the children’s vocalizations consisted of non-canonical 
vocalizations, which are typical at the early stage of vocal development. As their 
potential to develop speech cannot be predicted, it is necessary to provide them with 
alternative means of participation and communication from early on. 
6.1.4 Emotional availability 
The EA results suggest that the children with VIAD and their mothers became 
emotionally more available to each other during the two interventions. At baseline, 
the EA mean scores for sensitivity were at the neutral sensitivity level for the mothers 
of Robin and Thea and at the inconsistently sensitive level for the mothers of Emma, 
Sara, and Alex. Additionally, Campbell and Johnston (2009) found that some 
mothers of blind children without additional disabilities experienced challenges in 
sensitivity. During the interventions, the mean EA scores for sensitivity were 
elevated to the neutral sensitivity level for the mothers of Emma, Sara, and Alex. 
This is an interesting finding because the two interventions in this study were not 
attachment-oriented interventions like the interventions developed by Platje et al. 
(2018) and Dyzel et al. (2023), which did not increase parental sensitivity.      
The mean EA scores for structuring were at the moderately structuring level for 
the mothers of Robin and Thea and at the level of inconsistent structuring for the 
mothers of Emma, Sara, and Alex at baseline. Similarly, Campbell and Johnston 
(2009) found that some mothers of blind children without additional disabilities 
experienced challenges in structuring. During the intervention, the mean EA scores 
for structuring were elevated to the moderately structuring level for the mothers of 
Emma and Alex. However, at follow-up, the mean EA score of Alex’s mother 
decreased back to the inconsistent level of structuring, which suggests that she might 
have needed a longer intervention to maintain her higher level of structuring.     
Discussion 
 119 
The mothers’ mean EA scores for nonintrusiveness suggested that they all had 
“benign” intrusiveness at baseline. Interestingly, previous studies on the mothers of 
deaf or blind children did not report challenges in nonintrusiveness (Campbell & 
Johnston, 2009; Paradis & Koester, 2015). Our findings could be explained from a 
transactional perspective. That is, the mothers could have tried to compensate for the 
lack of participation of their children by increasing their stimulation and guidance. 
Our findings also suggest that during the intervention, the mean EA scores for 
nonintrusiveness rose to the generally nonintrusive level for the mothers of Emma, 
Robin, and Sara. However, the mean EA scores for nonintrusiveness for the mothers 
of Robin and Sara decreased back to the level of benign intrusiveness at follow-up, 
which indicates the need for a longer intervention.    
The children’s mean EA scores for the child responsiveness were at the level of 
complicated responsiveness at baseline. During the intervention, the mean EA scores 
of Emma, Robin, Thea, and Alex for responsiveness reached the moderately optimal 
level. As the guidance focused on the mothers, the findings on child responsiveness 
imply that the interventions created positive transactions (Sameroff & MacKenzie, 
2003b). Positive transactional processes were also found in the child involvement. 
The mean EA scores of Emma, Sara, and Alex for involvement were at the somewhat 
non-optimal level at baseline and were elevated to the level of complicated 
involvement during the intervention. The mean EA scores of Robin and Thea for 
involvement corresponded to complicated involvement at baseline. Thea’s mean EA 
scores were elevated to the moderately optimal level in involving behaviors during 
the intervention but decreased back to complicated involvement at follow-up.   
Our findings suggest that the mothers’ increased use of touch during the 
intervention was positively related to EA in the mother-child interactions. Similarly, 
Pipp-Siegel et al. (1998) and Paradis and Koester (2015) found that the mothers’ 
touch was positively associated with EA in interactions with their deaf or hard-of-
hearing children. Moreover, the EA results suggest that VIAD does not automatically 
cause problems in attachment relationships. However, VIAD challenges 
interactional reciprocity; therefore, adaptive responsiveness to a child’s perceived 
needs is important. Our findings indicate that adaptive responsiveness entails 
parents’ systematic use of the bodily-tactile modality in interactions with their 
children with VIAD and their ability to notice and respond to their children’s bodily 
expressions.  
It is important to consider EA when implementing communication interventions 
for families of children with VIAD. Focusing solely on tactile strategies does not 
guarantee emotionally available interactions if the child’s cues and the emotional 
aspect of interaction are dismissed (cf. Barfoot et al., 2017). It is vital that 
professionals consider EA in their interactions with children with VIAD. 
Professionals can, for example, reflect on their own emotional connectedness with 
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children with VIAD and their responsiveness to the child’s initiatives. Emotionally 
available early interactions are essential for the well-being of children with VIAD 
and their parents and may prevent children with VIAD from developing emotional 
and behavioral problems later in childhood.  
6.2 Discussion of the methods 
Conducting a study requires making several choices about methods, which have their 
strengths and limitations. As this study is a multiple case study, the results cannot be 
generalized to the population of children with VIAD and their mothers. For instance, 
it could be that the mothers who volunteered to participate in the study had more 
resources and motivation to develop their interactions with their children than the 
mothers of children with VIAD in general. However, as Yin (2014) argues, instead 
of generalizing the results to populations (statistic generalization) the findings of 
case studies can be generalizable to theoretical propositions (analytic 
generalization).  
The case study design had many advantages. It allowed us to gain information 
about transactional processes and explained how the interventions worked, which 
could be difficult to reveal using other methods, such as questionnaires or 
randomized controlled trials. However, the design of Study I provided limited 
information and control over the characteristics of the mother-child imitations at 
baseline. The longitudinal designs of Studies II–IV were more robust and enabled 
the control of variables during a longer period and the detection of changes in 
mother-child interactions during different phases of the study. However, although 
the number of baseline recordings increased from three to four in Study IV, there 
could have been even more to increase control over the variables.  
Another limitation of Study I is the lack of a follow-up period. Thus, it is not 
known whether Emma’s mother continued using the tactile modality in her 
imitations after the tactile imitation guidance. Moreover, the follow-up periods of 
Studies II–IV are rather short, so it remains unclear whether the mothers continued 
to use tactile strategies with their children with VIAD. However, a longer baseline 
and follow-up require an extended time for data collection, which would have been 
challenging to carry out in this doctoral study because only one researcher collected 
the data. Moreover, even if the mothers were to continue using tactile strategies in 
interactions with their children with VIAD for a longer time, they may not be able 
to support the communicative development of their children on their own. Whatever 
the case, they could benefit from other interventions in which tactile strategies are 
rehearsed and adapted to their children’s new skills and needs.   
It was found to be a good decision to implement the interventions at home and 
collect the data through video recordings. Considerable amounts of information 
Discussion 
 121 
regarding the interactions could have been lost if the data had been collected in other 
ways, such as through questionnaires or interviews. Moreover, triadic work was 
shown to be a concrete and rewarding way to implement the intervention, which 
corresponds to the findings of Metell (2015). Besides theoretical knowledge, being 
able to intervene in patterns of interaction may require modeling and close 
collaboration with parents (cf. Rensfeldt Flink et al., 2023). However, the two 
interventions in this study also included an element of discussion and video 
feedback, and we cannot know which part of the intervention was the most effective 
and useful for the mothers.   
Mixed methods were used to analyze the video data from different perspectives, 
which can be regarded as a strength of this study. First, the imitation coding 
procedure, the bodily-tactile coding procedure, and multimodal CA provided a 
bottom-up approach for the data, whereas the EA Scales assessed the interactions 
from a top-down perspective. Second, the bodily-tactile coding procedure evaluated 
individual behaviors, whereas multimodal CA and the EA Scales could be used for 
investigating dyadic interactions. The imitation coding procedure provided 
information on both individual behaviors and dyadic interactions. Third, where 
longitudinal CA and the imitation coding procedure captured changes in turn-taking, 
the EA Scales measured changes in emotional reciprocity. It was found that the 
imitation coding procedure and the bodily-tactile coding procedure were useful 
methods for measuring changes in accessibility. Similarly, longitudinal CA and EA 
Scales were appropriate methods for investigating changes in reciprocity. The 
findings with different methods provided similar outcomes of positive changes in 
mother-child interactions during the interventions, which strengthens the construct 
validity of this study (see Yin, 2014, pp. 45–47). Moreover, the findings related to 
different methods provided a deeper understanding of the changes in mother-child 
interactions than any single method could have provided alone.    
The imitation coding procedure was useful for detecting changes in the imitative 
exchanges between Emma and her mother. However, more precision in the coding 
could have clarified the results. For instance, some of the mother’s vocal-tactile 
imitations included a non-imitative tactile element (e.g., the mother would touch 
Emma’s nose with her own nose during her vocal imitation), and some provided the 
same imitative information in the vocal and tactile modality (e.g., the mother 
imitated Emma’s vocalization by “speaking to her hand” in such a way that Emma 
could perceive her articulatory movements in a tactile way). It could have been 
useful to separate the two types of vocal-tactile imitations to explore the potential 
differences in Emma’s responses to these imitations. For instance, the analysis could 
have revealed whether the increase in Emma’s responsiveness was due to her 
mother’s increased use of touch in general or the possibility of perceiving her 
mother’s imitations in two modalities.   
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The bodily-tactile coding procedure captured changes in the mothers’ use of 
tactile strategies. It is unlikely that any other procedure could have been used in the 
coding because the categories were data-based and sensitive to the content of the 
intervention. The fact that the categories were data-based also strengthens the 
validity of the bodily-tactile coding procedure. However, a limitation of the coding 
procedure is that the categories themselves did not reveal how the mothers were able 
to convey the intended meanings to their children through the tactile strategies. The 
results provide only suggestive information on this point.  
The CA-based findings on turn-taking and sequence organization in typical 
conversations provided a valuable perspective for analyzing and understanding 
atypical interactions. The knowledge of typical parent-infant interactions was 
especially fundamental as an aid to understanding how sequences are created in early 
interactions. Without this knowledge, analyzing atypical interactions would have 
been challenging. The sequential analysis revealed changes in turn-taking during the 
intervention. It uncovered that the mothers also began to apply their intrinsic 
conversational rules in the bodily-tactile modality when they became more aware of 
this resource during the intervention. Moreover, the sequential analysis was able to 
demonstrate the characteristics of the children’s bodily expressions and how these 
expressions were co-constructed in the multimodal interactions. In early intervention 
studies, it is essential to find methods that have the potential to capture the effects of 
the interventions. Longitudinal CA provides a means for this as the microanalysis 
can capture small changes in reciprocity over time. Detecting changes in turn-taking 
could be easily lost with other methods, which often evaluate individual behaviors 
instead of interactions. Thus, although CA is a time-consuming method, it is a tool 
for discovery and is useful for planning interventions and demonstrating their effects 
(e.g., Warnicke et al., 2024).    
The flexibility of the EA Scales made it a useful method to investigate changes 
in the “emotional climate” of the participants over different phases of the study. 
Another strength of the EA Scales is that the assessment is not overly time-
consuming. However, the EA Scales may not detect micro-level changes in 
multimodal interactions between children with VIAD and their parents. It is also 
important that the EA assessor is familiar with the assessed group, the characteristics 
of the participants, and the therapeutic strategies to avoid incorrect results and 
conclusions. Overall, EA appears to be a useful construct for the VI field. So far, 
studies have mainly identified challenges in the social-emotional development of 
children with VI/VIAD and used questionnaires for data collection (see Alimovic, 
2013; Dale et al., 2014; Lang et al., 2017). The EA Scales provide an observational 
tool to measure the quality of adult-child interactions. Moreover, the EA framework 
is helpful for planning emotional support for families of children with VIAD.  
Discussion 
 123 
Overall, the reliability of the results was good. In Study IV, the low reliability 
connected to the coding of tactile noticing for Sara’s mother could be due to her 
personal way of using frequent touch in interactions with Sara. In future studies, the 
reliability of tactile noticing could be improved by encouraging mothers to use more 
articulated touches for noticing in interactions with their children with VIAD.  
6.3 Theoretical significance of the study 
The validity of the theories behind this study, especially Trevarthen’s theory of 
intersubjectivity (Trevarthen, 1979; Trevarthen & Hubley, 1978) and the 
transactional model of development (Sameroff & Chandler, 1975) can be evaluated 
against our findings (see Marková, 2011; Yin, 2014). First, the findings indicate that 
it is possible to assess and enhance primary intersubjectivity in interactions between 
children with VIAD and their mothers. Damen et al. (2014) drew similar conclusions 
in their study, in which they evaluated the effects of a high-quality communication 
intervention for an adult with CDB. Second, the findings suggest that the 
intervention aimed at mothers resulted in positive changes in their children’s 
participation, which provides evidence for the value of transactional processes 
(Sameroff & MacKenzie, 2003b). Moreover, the results highlight the importance of 
sensory accessibility for increasing positive transactions between children with 
VIAD and their parents. Our results suggest that positive transactions increase when 
children with VIAD can access contextual information in interactions and their 
parents’ expressions through the bodily-tactile modality, and their parents 
acknowledge their children’s bodily resources for participation. These findings also 
support Bruner’s (1975) theory of pragmatic language development and the 
theoretical foundations of tactile strategies (e.g., Chen & Downing, 2006). Overall, 
our findings shed empirical light on the theoretical principles related to accessibility 
in designing early interventions for children with VIAD and their families.  
In this study, the concept of interactional reciprocity was theoretically 
understood to include two dimensions: turn-taking and emotional reciprocity. 
Reciprocity was investigated from a holistic theoretical perspective, which is unique 
to this study, whereas in earlier studies, reciprocity was mainly studied from a single 
perspective. Interestingly, our findings suggest that bodily-tactile early intervention 
increased both dimensions of reciprocity. Thus, the results supported our theoretical 
understanding of reciprocity and revealed a potential means to enhance it in 
encounters with children with VIAD. Our findings also contribute to EA theory. In 
parent-child interactions, it can be challenging for children with VIAD to access their 
parents’ facial expressions, such as smiling, which necessitates conveying emotional 
expressions through other modalities. As the vocal modality alone may not be 
sufficient to convey emotions to children with VI (Dyck et al., 2004; Minter et al., 
Sini Peltokorpi 
124 
1991), children’s access to parents’ expressions and actions through the bodily-
tactile modality may increase EA in parent-child interactions. Moreover, parents 
need to be aware of their children’s bodily means of expressing their emotions and 
engagement.    
Lastly, theoretically, this study provides information on children with VIAD and 
their mothers as interactive units. It presents a dialogical perspective on their 
interactions and clarifies how the actions of the participants are interdependent in 
sense-making (Marková et al., 2020). Hence, the findings of this study also 
contribute to the theory of dialogism in that they support the idea of extended 
dialogism (Linell, 2017), which acknowledges that exchanges between individuals 
are not limited to verbal or sign language. Extended dialogism considers several 
types of sense-making activities, such as bodily-tactile play routines. Our findings 
challenge presumptions related to the asymmetry of interactions (Linell, 2017). That 
is, although there are asymmetries in maturity, skills, and sensory-perceptual and 
cultural access to the world between children with VIAD and their parents, our 
findings suggest that their participation in interactions does not necessarily need to 
be asymmetrical if they are provided with support for interactions from early on.    
6.4 Clinical implications 
The findings of this study suggest that the participation and communication of 
children with VIAD develop from within dyadic and multimodal parent-child 
interactions, which is in line with previous studies (e.g., Gregersen, 2018; Preisler, 
1991, 1995). Thus, the findings underline the relevance of family-directedness and 
collaboration with parents in implementing interventions for children with VIAD 
(see Breemer, 2025). The individual variation between children with VIAD indicates 
that it is challenging to use norm-based or group-based intervention approaches in 
interventions. Instead, there is a need to base and individualize the intervention with 
reference to the most robust research-based and theoretical principles that operate in 
early communicative development. We and other researchers (Metell, 2015; Rogow, 
1982) found early play routines to be useful contexts for developing turn-taking 
between children with VIAD and their mothers. However, parents may not have 
implicit knowledge of how to use play routines or tactile strategies systematically in 
interactions with their children with VIAD. Therefore, learning these strategies can 
empower parents and provide them with new insights into their children’s resources. 
Our findings indicate that it is important to initiate home-based intervention at 
an early age. However, as none of the participants had received systematic home-
based support for the parent-child interactions, the results suggest that currently, the 
interventions may begin too late. There may be several reasons for this, including 
low expectations of professionals, children’s fragile health, lack of knowledge of the 
Discussion 
 125 
strategies that children with VIAD could benefit from, limited opportunities for 
specialization in different fields, and a small number of children with VIAD, all of 
which challenge specialization. The findings of this study call for changes in current 
practices. An intervention that is provided early enough can help children with VIAD 
to participate and use their full potential in their development. This right belongs to 
them, just like any other child (United Nations, 1989). The optimal time for early 
intervention is during the first months when the earliest interactive behaviors of 
children with VIAD are challenging to interpret, and their parents feel a need for 
support (Cress & Marvin, 2003). Parents should be the first caretakers involved in 
the intervention for children with VIAD because they are typically the most 
important people in their children’s lives and have the greatest impact on their  
development. Moreover, infancy is likely to be the easiest time for a home-based 
intervention because typically, one of the parents takes care of the child at home. 
When the immediate environments of children with VIAD change, and they become 
a part of larger social contexts in day care, the support naturally needs to include this 
situation.  
Our results indicate the importance of early intervention focusing on the 
participation of children with VIAD through all their resources. What is crucial in 
this process is that the intervention helps children with VIAD develop their roles 
from observers to actors (cf. Ratner & Bruner, 1978; Smith & Fluck, 2000). 
Providing a young child with VIAD with an actor’s role is a strong base for their 
communication and language development and later (AAC) interventions (Smith & 
Fluck, 2000), and it may prevent them from developing a passive role in 
communication (Cress & Marvin, 2003). However, it would be useful to know 
children’s level of participation in early social games and their play skills before 
using an intervention (see Smith & Fluck, 2000). Otherwise, there is a risk that the 
strategies will not be appropriate for children’s “zone of proximal development” 
(Vygotsky, 1978). Currently, there does not appear to be such an assessment tool for 
evaluation. Nevertheless, the recently developed layered communication model 
(Wolthuis et al., 2019) and the Tactile Working Memory Scale (Nicholas et al., 2019) 
can provide important information on the abilities and needs of children with VIAD. 
Moreover, the findings of this study indicate that multimodal CA could be a useful 
method in clinical work for gaining information about turn-taking in parent-child 
interactions and analyzing children’s expressions that are challenging to interpret. 
However, when considering clinical work, the transcription method should be 
considerably simplified. 
The findings of this study raise serious concerns about current clinical practices 
in Finland. First, there appears to be no systematic way to identify children with 
CDB. Only by identifying CDB can the families of children with CDB be treated 
equally in terms of services, regardless of which part of the country they live in. In 
Sini Peltokorpi 
126 
addition, it would be critical to identify children with less severe dual sensory loss 
and other children with VIAD who need tactile strategies as a means to develop their 
participation, voice, and cognition (United Nations, 1989). Currently, these children 
may be classified as children with multiple disabilities, children with ID, children 
with profound intellectual and multiple disabilities, or something else. Under these 
broad classifications, children with VIAD and their families are provided with 
general services, and their special needs are easily lost. Professionals providing 
interventions for children with ID or multiple disabilities may also lack knowledge 
about tactile strategies, which restricts the content of the support they can provide. 
Moreover, parents of children with VIAD may not be aware of the expertise related 
to tactile strategies or have the resources to request it. Second, it appears that the 
national healthcare services do not have units or centers with expertise in providing 
systematic guidance for the use of tactile strategies for families of children with 
VIAD. Some third-sector providers (e.g., the Finnish Deafblind Association) have 
knowledge of tactile strategies, but it appears to be coincidental which families find 
their way to these services. Moreover, the children who are under their services are 
often older than 3 years, so this type of support rarely covers the earliest years of 
childhood. Third-sector providers play an important role in providing 
complementary services, but they are not responsible for organizing early 
interventions for the families of children with VIAD.    
It would be ideal if there were one or more specialized centers/units that could 
develop, provide, and coordinate specialized assessments related to the use of the 
sense of touch in communication and learning (see Andersen & Rødbroe, 2000). The 
assessments could provide information on whether the bodily-tactile modality is a 
primary or complementary sensory modality of learning for children with VIAD. 
The specialized centers could also include other evaluations and interventions for 
children with VIAD, educate professionals, and provide practical guidance for 
families of children with VIAD. Third, there should be more opportunities for SLPs, 
psychologists, vision personnel, specialists in the deafblind field, and other 
professionals to specialize in early intervention for children with VIAD and the use 
of tactile strategies. Lastly, collaboration between professionals is vital for achieving 
the best outcomes in assessment and early intervention (Ely et al., 2020; Ely & 
Ostrosky, 2018; Luo et al., 2022).   
6.5 Future research 
There are several areas that need to be addressed in future research. First, it is 
important to learn more about the early vocal development of children with VIAD 
and to discover how many of them can develop speech. Furthermore, their silent 
mouth movements during interactions deserve scientific attention. Second, the 
Discussion 
 127 
physical activity and movements of young children with VIAD need to be studied in 
an interactional context. For instance, the timing and type of children’s movements 
during play routines require in-depth analysis. Moreover, it is important to 
investigate the potential developmental continuum from movements to gestural 
expressions in longitudinal studies. Third, it is essential to learn more about the 
possibilities for children with VIAD to express themselves through unaided and 
aided AAC and to determine the best ways to learn these systems. For instance, it 
would be valuable to investigate whether one tactile signing system is more helpful 
for children with VIAD to acquire new signs than another. 
As the incidence of children with VIAD is low, it is challenging to conduct 
intervention studies involving a large number of children. To carry out such research, 
collaboration between different countries is needed. However, it is equally important 
to conduct case studies that test the theoretical principles of this study. Longitudinal 
studies are also needed to capture the effect of bodily-tactile early intervention in 
reciprocal processes over time. In addition, future studies could investigate longer 
interventions at later stages of tactile communication development. Scientific 
research is also needed to develop assessment tools for evaluating the stage of 
participation of children with VIAD in early interactions with their parents. Bruner’s 
(1975) theory of pragmatic language development provides an important basis for 
this type of development (see also Smith & Fluck, 2000). Further, there is a need to 
know more about parents’ experiences related to early interventions. For instance, it 
is necessary to investigate whether bodily-tactile early intervention empowers 
parents in interactions with their children with VIAD. If so, it would be important to 
learn more about the process of empowerment. Lastly, the benefits of bodily-tactile 
early intervention and tactile strategies should be studied in other populations, such 
as children with multiple disabilities. 
More studies are required to explore tactile strategies from different perspectives. 
First, it is essential to learn more about the natural use of tactile strategies by studying 
how blind and deaf mothers use touch in interactions with their infants and toddlers. 
This information would be relevant for developing guidance for parents of children 
with VIAD. Second, it is important to learn more about how the complexity of 
bodily-tactile play routines impacts the participation of children with VIAD. For 
example, it could be that the easiest games for children to join are play routines, 
which have a simple structure consisting of only one movement (e.g., swinging). 
Moreover, it is essential to explore how position and motor skills influence children’s 
embodied participation (see Fiss et al., 2023). It would be useful to conduct this type 
of research in collaboration with physiotherapists. Third, it is important to learn more 
about the effects of hand-under-hand guidance on the participation and development 
of children with VIAD. Fourth, it is crucial to learn how joint attention can be 
established through the sense of touch in interactions between children with VIAD 
Sini Peltokorpi 
128 
and their caretakers. Fifth, parents’ tactile noticing responses should be explored to 
determine whether they increase children’s engagement in interactions or the 
intentionality of their actions. Sixth, the benefits of tactile anticipatory cues should 
be investigated. For instance, it is important to discern which types of tactile 
anticipatory cues are the most informative for children with VIAD (touch versus 
movement) by studying their responses.   
EA between children with VIAD and their parents requires further research. 
First, it is important to explore whether there are changes in parent-child EA 
depending on the children’s age or their communication skills. Second, it is essential 
to know whether bodily-tactile intervention for parents of older children with VIAD 
could foster their EA. Third, it is necessary to evaluate EA in interactions between 
children with VIAD and their other caretakers, such as kindergarten teachers or 
therapists. Lastly, it would be useful to investigate whether the coder’s knowledge 
of children with VIAD has an impact on EA assessment.   
The literature review suggests that only a little research has explored 
interactional sequences connected to mothers’ questions to their typically developing 
infants, and most of the existing studies were conducted in the 1970s. Thus, it is 
worth refocusing on this important research topic in typical and atypical early 
interactions. Sequences involving parents’ questions are optimal for gaining 
information on turn-taking patterns in parent-infant interactions.   
It is critical to gain research-based knowledge of the identification of CDB in 
Finland. First, it is essential to know how many children have been identified as 
children with CDB and the criteria for identification. It is also important to gain 
information about the services provided to families of children with CDB and 
discover if normally hearing children with VIAD and their families can access them. 
Second, there is a need to know more about the timing and content of early 
interventions for children with VIAD (e.g., the children’s age at the beginning of the 
intervention, the parents’ involvement, and the guidance related to tactile strategies). 
Conducting an international study in which questions about identification and 
services for families are investigated across several countries—for instance, the 
Nordic countries—would make it possible to compare current practices and develop 
them further. This type of research is crucial for evaluating how the rights of 
individuals with disabilities are realized in practice —for instance, their freedom to 
receive information and express ideas on an equal basis with others through all forms 
of communication, including tactile communication (United Nations, 2007).    
Finally, the United Nations Convention on the Rights of Persons with 
Disabilities declares that States Parties must ensure that “education of persons, and 
in particular children, who are blind, deaf or deafblind, is delivered in the most 
appropriate languages and modes and means of communication for the individual, 
and in environments which maximize academic and social development”(Article 42, 
Discussion 
 129 
United Nations, 2007). This right presupposes that the teachers in kindergarten and 
school and the staff at specialized housing units are skilled in tactile signing and 
other tactile strategies. It would be illuminating to investigate how this right is 
realized in practice. 
6.6 Conclusion  
This doctoral thesis provides insight into interactional reciprocity and the potential 
ways to promote it in early interactions between children with VIAD and their 
mothers. A special goal of the two interventions was to make interactions more 
accessible for children with VIAD through the bodily-tactile modality and to support 
their mothers in reading and responding to their children’s bodily and gestural 
expressions. The findings of Study I suggest that when a mother of a 3-year-old child 
with CDB added tactility to her imitations during the intervention, it positively 
impacted the tactile and emotional responsiveness of the child, the length of their 
imitative exchanges, and the EA in the mother-child interactions. Likewise, the 
results of Studies II–IV suggest that early intervention increased the mothers’ use of 
the bodily-tactile modality in interactions with their children with VIAD, as well as 
their interactional reciprocity. The positive changes in the children’s participation 
resulted from changes in the mothers’ interactive behaviors as they began to provide 
more time and space for their children to take turns and to respond to their children’s 
bodily and gestural expressions. Moreover, EA between children and their mothers 
increased during the interventions. Overall, the findings of this study suggest that 
bodily-tactile early intervention can encourage children with VIAD to participate 
through movements and gestures and to increase reciprocity in early interactions.  
Participation in reciprocal interactions provides children with VIAD an opportunity 
to learn the discourse structure of language, which is the basis for their further 
communication and language development. Moreover, the increased engagement of 
children in interactions is essential for their emotional well-being and quality of 
life—as well as that of their mothers.  
 130 
Abbreviations 
VI visual impairment 
VIAD  visual impairment and additional disabilities 
CVI cerebral visual impairment  
CDB congenital deafblindness 
EA  emotional availability 
CP cerebral palsy 
ID intellectual disability 
AAC augmentative and alternative communication 
dB decibel  
SLP speech-language pathologist 
CA conversation analysis 
 
 131 
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Appendix 
Multimodal Transcript Conventions  
 
The following conventions were developed by Lorenza Mondada (2018, 2022).  
 
* * Descriptions of embodied actions are delimited between  
+ +  two identical symbols (one symbol per participant and per type of action)  
  that are synchronized with correspondent stretches of talk or time indications.  
*--->  The action described continues across subsequent lines  
--->*  until the same symbol is reached.  
>>  The action described begins before the excerpt’s beginning. 
--->> The action described continues after the excerpt’s end. 
.....  Action’s preparation  
----  Action’s apex is reached and maintained.  
,,,,,  Action’s retraction  
the  Participant doing the embodied action is identified in small caps in the margin.  
fig  The exact moment at which a screen shot has been taken  
#  is indicated with a sign (#) showing its position within the turn/a time measure. 
((sighs)) Transcriber’s descriptions 
Other 
[ Beginning of overlap 
] End of overlap 
.hh Inbreath 
(0.5) A pause and its duration in tenths of seconds 
(.) Micropause (less than 0.2 s) 
°yes° A silently pronounced word  
mu: A stretch (a colon indicates lengthening of a sound) 
mum-  A cut-off word 
MOVES  Bodily-tactile actions are described in capital letters. 
MAGPIE Sign or gesture 
/Voi että/ The children’s smiling is indicated below their bodily-tactile actions, and 
/smiles--/  the corresponding time during their mothers’ speech is marked with a slash until  
the end of the smiling.   
 
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