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Toby uses switches to develop his understanding of cause and effect. This helps him learn to make choices and extend his communication.

A photo of Toby

Toby has spastic diplegic form of cerebral palsy and controlled hydrocephalus. The term spastic refers to tightening and stiffening of the muscles and diplegic means that it affects his legs. Hydrocephalus is a condition where there is a build up of fluid around the brain. Toby wears glasses to correct his sight in one eye but has a visual field defect affecting the other, which means that sees a narrowed area with that eye. He has partial hearing, and wears a hearing aid.

Toby can crawl and sit independently and appears to have good fine motor skills. He attends a non-maintained nursery three days a week and is supported by his key worker.


Toby is unable to speak. His communication skills are at an early stage of development and his visual and hearing difficulties make communication more challenging.

Toby is very motivated by sound and enjoys musical and noisy games and activities. This is important information when beginning to think about communication as enjoyable activities provide great communication opportunities.

Cause and effect

In order to identify ways to support Toby with his communication it was important to establish whether he had an understanding of cause and effect. More details about cause and effect can be found in the Communication section of the resources. Switch activities are a good way to establish cause and effect.

Toby had previously been introduced to using a switch to control battery operated toys. He seemed to enjoy the ‘click’ of the switch and it appeared that he was enjoying this sound more than the action of the toy. Knowing that Toby enjoyed music and noises, he was introduced to activities on the computer.

Toby is learning about cause and effect. He is playing on the computer. When he presses the switch, the picture changes and he can listen to a tune.

Toby using a switch attached to a computer

Toby was introduced to a laptop with simple cause and effect software. The press of the switch would cause music to play and animations to be displayed on the screen. This grabbed Toby’s attention more than the switch toys and meant that Toby focussed his attention on the computer activity rather than the switch. Different switches were considered. Because Toby has a visual impairment it was important to position the laptop and switch where he could see them. The switch was placed on an angled mount, which discouraged Toby from resting his hand on the switch.

Toby explored different simple ‘Cause and Effect’ software activities. He needed to be encouraged to stop pressing the switch once the reward had been activated (this was typically an animation with motivating sound).

Toby grasped this skill very quickly. He would press the switch, then watch and listen. Toby also enjoyed ‘Build’ programmes. These would reveal part of a picture or story with each press of the switch, ending with a final animation. Toby enjoyed this and often rocked in response to the musical reward. Although his initial responses were to focus exclusively on the sounds, he increasingly became interested in the laptop screen.

Dinosaur computer drawing
Dinosaur computer drawing
Dinosaur computer drawing
Dinosaur computer drawing
Dinosaur computer drawing
Broken dinosaur computer drawing

Toby used a switch to help him understand cause and effect. Sometimes switches are used if a child has a physical disability, but Toby’s motor control was good enough for him to try other ways of controlling the computer.

Toby was given a touch screen. His fine motor skills were good enough for him to be able to reach all areas of the screen, but he needed to learn that touching different areas of the screen would make different things happen. Also, as Toby has a visual impairment, the screen needed to be placed in a position that would allow him to see it easily and reach it comfortably. To help develop his understanding and also use these skills for communication, Toby used the computer for some choice making activities.

Toby was presented with a choice of two items. To help him understand that he needed to make a choice, he was presented with a photograph next to a blank cell. To begin with Toby chose the blank cell, but he soon learned that the photograph was the right response.

Toby was encouraged to choose the photograph of himself.

A choice of 2 diagram

Toby was then offered a choice of two cells, but this time both contained images. Toby consistently made the right selection and responded well to his success.
Choices diagram

Activity created in ChooseIt! Maker 2, Inclusive Technology Ltd

Toby has been learning about choices and how to use a touch screen.


In order to find suitable Augmentative and Alternative Communication (AAC) methods for Toby it was important to think carefully about his visual and hearing abilities. Many AAC strategies rely on using sight and sound and it was unclear how much meaning Toby was gaining from visual (picture) and aural (sound) messages.

Toby’s work on the computer demonstrated that he could recognise photographs, but that they needed to be visually simple with contrasting shades and colours. It also showed that he was hearing some sounds. In order to build on Toby’s existing skills he began to use a BigMack.

A BigMack is a simple communication aid. A single message can be recorded on to the BigMack which is played back when pressed.

A BigMack plays a recorded message when pressed. Photo of a BigMack

Toby used the BigMack in different situations at home and at nursery. Simple messages were recorded for Toby and a photograph was placed on the top of the BigMack to indicate what the recorded message was.

Toby appeared to enjoy pressing the BigMack, but it was unclear whether he understood the spoken message or phrase. This would be necessary in order for Toby to use it to communicate.

To try and find this out, Toby was offered a choice of two BigMacks.

In Nursery Toby is encouraged to make a choice of snacks at break time. A switch to make a choice about lunch

Toby was given a choice of yoghurt and banana at snack time. He doesn’t like banana very much, so this was helpful to see if he understood the choices offered to him. Toby was shown the two BigMacks and listened to the choices. He was then offered them both so that he could make a selection. If Toby chose the banana he was given it as this helped him to learn about choices.

At this stage, Toby was given lots of opportunities to practise making choices. He would choose between two real objects or toys along accompanied by a visual (picture) and auditory (word) prompt to help him understand the choices he was being offered.

Photographs of people were also used. Toby would choose who he wanted to play with or who he wanted to sing him a song. To support Toby’s visual skills, images needed to be very clear. Toby wears glasses to correct his vision, but it was still necessary to ensure that he could easily tell the difference between the images used.

Toby is continuing to work on making choices as a means of communication. From these early choices a more comprehensive communication system can be developed.

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