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Helping the Visually Impaired or Blind Mother Breastfeed

by Cynthia Good Mojab
From: LEAVEN, Vol. 35 No. 3, June-July 1999, pp. 51-56

We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time

Understanding the impact of vision loss on breastfeeding can help a Leader assess and accommodate the needs of mothers.

Visual impairment and blindness pose real but not insurmountable challenges to the breastfeeding mother. When a mother who is visually impaired or blind contacts LLL for help with breastfeeding, she is likely to be referred to a sighted Leader. Yet most Leaders have little or no experience with visual impairment and blindness. The interaction of the Leader and the visually impaired or blind mother will be mutually rewarding and yield a positive breastfeeding outcome when the Leader is open to learning how vision loss can affect breastfeeding.

Variations in Vision

Approximately three percent of the population in the US is visually impaired or blind (Packer & Kirchner 1997). Visual impairment spans a wide spectrum of visual ability and is classified in the US by categories based on the type of activities in which a person can be expected to engage, degree of corrected visual acuity and visual field (Helveston & Ellis 1984, as cited in Whaley & Wong 1991).

Partially sighted includes visual acuity between 20/70 and 20/200. In other words, the partially sighted person may be able to see at 20 feet what the fully sighted would be able to see at 70 feet to 200 feet. The near vision of a partially sighted person is usually better than the distance vision.

The legally blind person has a visual acuity of 20/200 or less and/or a visual field of 20 degrees or less in the better- seeing eye.

Travel vision includes visual acuity of 20/400 which permits travel in unfamiliar surroundings but which may prevent the use of printed material.

Light perception involves only being able to perceive light which is an important aid in mobility, but does not permit the use of printed material.

A person with no useable vision at all is considered blind.

The spectrum of vision loss results in varying consequences for breastfeeding. For example, the woman who is visually impaired may or may not be able to visually use printed information regarding breastfeeding, independently navigate with ease in an unfamiliar LLL meeting location, learn from watching other mothers nursing their babies and see her own baby's breastfeeding position and latch-on. The mother who is blind must access all breastfeeding information and support using entirely nonvisual means.

First Encounters

Many Leaders have not had experience helping a visually impaired or blind woman seeking breastfeeding information. A Leader may react with a range of emotions from awkwardness and pity to respect and acceptance.

Awkwardness is a natural feeling that indicates more information and experience are needed. A sincere statement asking the mother what she needs could help.

Jane, I’m not quite sure how to handle this situation. Do you have any suggestions?

This is likely to be met with a smile and the needed information. Sighted people commonly feel the urge to provide more help than a blind or visually impaired person actually needs. If you think the mother may need assistance ask if you can be helpful and how.

Pity is a signal that one feels a difference in status and may be the result of unquestioned assumptions or stereotypes that can be replaced with accurate information. The mother who is blind may be overwhelmed by a recent loss of sight, may have come to terms with a loss of sight many years ago or may never have experienced sight.

While sensitivity to the mother’s level of comfort with her visual impairment or blindness is always appropriate, vision loss should never be equated with helplessness or lack of useful knowledge and skill. Extensive educational and rehabilitation services are available today. For example, canes and dog guides permit independent mobility in and out of one’s home. Information can be accessed in large print, with the aid of magnification lenses, on audio tape, in braille and by using computer screen reading programs with voice synthesizers. A visually impaired or blind person is as capable of meaningful and accomplished living as a sighted person, including attaining education and employment, socializing and raising a family. Sighted and visually impaired or blind mothers are more alike than they are different. Respect, acceptance and a willingness to learn are more appropriate and constructive than pity.

The visually impaired or blind mother may approach a Leader or Group with apprehension and a hesitance to ask for help. Her apprehension may be due to negative experiences with others involving misconceptions, prejudice or discrimination. She may have been advised not to have children or have been treated as though she were an incompetent mother solely because she is blind (Brewster 1979). She may not know any other visually impaired or blind mothers who have breastfed. If she has internalized misconceptions about motherhood and vision loss she may begin to doubt her own capacities. A hesitance to ask for help may stem, in part, from a cultural heritage emphasizing independence (Triandis 1994, 1995) and to the difficulty of attaining independence when one is visually impaired or blind.

A mother may also hesitate to go against well-meaning family members or health care providers who have advised her not to breastfeed due to their misconceptions about her physical limitation and/or breastfeeding. The visually impaired or blind mother may also hesitate to ask for help because she may already feel overwhelmed by the unusually large amount of conflicting advice she may be receiving from others who assume that she knows little about child care because she cannot see. Conveying acceptance and mother-to-mother support may help the mother feel more comfortable requesting help with breastfeeding.

Understanding the Mother's Needs

For a mother to fully benefit from the breastfeeding information and support available from LLL, her needs must be understood and accommodated. Depending on her degree of vision loss, a mother's needs may include assistance with traveling and communicating as well as non-visual methods of learning to breastfeed. When a Leader learns that a mother has partial or no vision it may be helpful to gather more information. The following questions can be considered:

  • What are the limitations of her vision? She may use specific classifications (partially sighted, legally blind, travel vision, light perception) or she may use different terms to describe her vision loss. Use whatever language she uses after clarifying its meaning. For example, a woman who is completely blind may describe herself as “visually impaired.”
  • What methods does she use to access printed information: large print, magnification lenses, audio cassette recordings, sighted reader, braille, computer screen reading program with voice synthesizer?
  • What methods of travel does she use: no assistance needed, sighted guide, dog guide, cane?
  • What forms of transportation does she use: public transportation, rides from others?
  • If the woman is visually impaired, does her near vision permit her to see another mother breastfeeding a baby or her own baby's breastfeeding position and latch-on? At what distance?
  • How long has she been visually impaired or blind and has she had sufficient time to develop compensatory methods for her vision loss?

There is no need to ask every mother all of these questions. Some of the answers may be obvious; some may be irrelevant given the nature of her breastfeeding question or interaction with the Leader or Group. Let the situation be your guide.

Communicating

Body language is a major component of in-person communication (Sue 1990). It is common for a sighted person to feel uncomfortable when conversing with visually impaired or blind person, in part, because the visual cues she is accustomed to are missing. Communicating all information verbally, as in a telephone conversation, is necessary when talking with blind mother. In addition, the following techniques are helpful:

Identify yourself when you speak. It may take the mother time to learn to recognize your voice, especially in a large group of other voices. The blind mother will appreciate knowing who is in the room with her and who is talking. Speak to her when you enter the room and introduce her others:

Hi Sally, it’s Maura. Andrea and Maeve are sitting in the middle of the room with their babies. Oh, Elena just arrived with her new baby! Have you met Elena?

Speak directly to the blind mother Asking, “Sally, would you like some juice?” is more respectful than “Mary, would Sally like some juice?”

Speak with normal volume, speed and tone of voice. Some sighted people unintentionally speak differently to a blind person. Never assume hearing loss.

Convert gestures, visual aids and visual demonstrations into verbal descriptions or physical demonstrations. The location of toilet facilities can be described instead of gestured, a banana instead of a photo of a banana can be used as a visual aid, the use of a sling and various nursing positions can be physically demonstrated with a willing baby or a doll. Always obtain a mother's permission before touching her or her baby.

Introduce yourself and initiate conversation. A blind mother sitting next to you has no visual way of knowing whether you are looking in her direction, busily nursing your baby, reading a meeting notice or available for conversation. She also has no visual way of knowing who is seated next to her if you are not speaking or if she is not yet familiar with your voice. You can help her feel more welcome by taking the initiative in conversation.

Inform the mother when it is her turn. Many Groups use a round robin format (mothers speak in sequence going around the room) for introductions or other activities. You can help the blind mother sitting next to you participate by informing her when it is her turn.

Respectfully tell the mother if she has misunderstood you. Much of the sighted person's communication is done with facial expression and other body language. If the blind mother does not appear to be aware that she has misunderstood, it may be because you have only provided her with unseen visual cues. Communicating the problem verbally will help resolve it.

Your Group can more effectively communicate breastfeeding information when your library includes books on audio tape and/or in braille. Books and pamphlets published and/or approved by LLLI and articles from NEW BEGINNINGS are available on tape and in braille through the Coordinator of Resources for the Blind and Visually Impaired (see “Additional Resources ” at the end of this article), Members of your Group can also volunteer to read (on tape or in person) pamphlets and tear-off sheets for the mother if they are not already available on tape or in braille. Be sure to coordinate audio taping with the Coordinator of Resources for the Blind and Visually Impaired so that the audio taped information will then be available to other mothers.

A blind woman may have access to a braille computer, braille printer or a computer screen reading program that would permit her to read or hear text on electronic file such as meeting notices, meeting reminder postcards, Group newsletters and announcement sheets, a congratulatory note on the birth of her baby or reference citations related to a breastfeeding question. If she and the Group also have access to email, she can receive these messages through the internet and then read them in braille or listen to them using her computer screen reading program. Group publications can also be enlarged on a copier if the mother can read large print.

Making Meetings Inclusive

Regular attendance at LLL meetings is challenging for some mothers. Babies and toddlers may not cooperate, a car may not be available, public transportation may not be convenient or a mother may just be too tired. Visually impaired or blind mothers face additional challenges. Driving is not an option and public transportation may be overwhelmingly difficult. Lack of transportation to a meeting may prevent the visually impaired or blind mother from ever attending or keep her from coming back. She may have a long history of feeling that her inclusion at an event is just too inconvenient for others. It may be very hard for her to ask for a ride, especially repeatedly.

Organizing a group of women who are willing and able to provide a ride can create flexibility and more convenience for everyone. Group members should be encouraged to politely say “no ” if they are not able to act as drivers. Then another option can be arranged without unspoken feelings of resentment or frustration.

Like transportation to the meeting, mobility at the meeting site poses special challenges for the visually impaired or blind mother. When the mother arrives, it can be helpful for someone to introduce herself and invite the mother to stay with her during the entire meeting, especially the mother's first meeting. When the Leader makes this invitation, the mother will quickly learn the Leader's voice and be able to distinguish it from among the many other voices at the meeting. The mother will also then be able to easily identify the voice that is presenting LLL information amid the variety of opinions and experiences being expressed.

Group members who may not have any experience interacting with the visually impaired or blind can observe the appropriate attitudes and behaviors of the Leader. Asking the mother how the meeting can be made more comfortable for her lets her know that Group members are willing to learn and are open to suggestions.

Describing the meeting space can also be helpful, especially if the mother has never been at a meeting or in that location before.

Jane, we ’re meeting today in a large room with chairs arranged in a circle. Most of the crawling babies are sitting in the center of the circle with their mothers right now. We have a play area in the corner to your left for our active toddlers. There is a table immediately to your right for our Group ’s library books and sign-in sheet. How can I help you sign in?

Navigating through an unfamiliar space with crawling babies and running toddlers will be made much easier for the blind mother when someone offers to be her guide. She may use both her hand on your elbow and her cane to skillfully and comfortably follow where you lead. Announcing major changes in the territory, such as stairs, as you approach them can be helpful, as well as slowing down and pausing just before encountering steps. However it is not necessary to describe every detail.

Ask the mother to instruct you so that you can be an effective sighted guide. If you are relocating to another area - for example, for refreshments or to look at the Group Library books - you can help the mother feel more welcome and involved by inviting her to join you. Regardless of the degree of her vision loss, she can still participate in a discussion of the library ’s contents, book topics, and whether there are audio tapes available. Inform her when you are leaving since she cannot see that you are gathering your things or that you have walked away.

The mother may appreciate friendly help with her own baby or toddler. In her own home, she knows where things are, what areas are baby proof, who is in her home and how her child is likely to interact with family and friends. It is easier for her to keep her child safely and happily engaged at home than in a strange place among unseen children and mothers. The blind mother is not likely to be offended by gentle redirection of her own child back to her with a non-judgmental explanation of what necessitated the action. Respecting potential differences in the parenting methods of visually impaired or blind mothers can also help the mother feel welcome at a meeting (Cookson Martin, 1992).

A blind mother may use a crib or play pen more than most mothers in your Group, so that she can keep her crawling baby safe while she is occupied with a task. She may be especially appreciative of her baby's sling as she must keep at least one hand free for the use of a cane or to feel her way. She may also be more likely to keep her baby near her at night, either in bed with her or in a crib in the same room, to facilitate night nursings.

Breastfeeding Education

Sighted mothers can learn about breastfeeding in a variety of ways, including reading, talking with health care providers, breastfeeding counselors and breastfeeding mothers, watching other mothers nurse or looking at photographs and drawings. The visually impaired or blind mother must rely primarily or solely on sound, touch, smell and taste. Describing and demonstrating the breastfeeding process in adequate detail may require some thought and creativity.

Breastfeeding literature is generally written with drawings and photographs that show what the text does not fully say. Therefore, breastfeeding information that is recorded on audio cassette, transcribed into braille, or accessed with a computer screen reading program may not be completely clear to a mother who cannot see the missing visual aids.

It can be helpful for the Leader to consider how breastfeeding is done in the dark. The experience of nursing at night can yield much information which can be put into words as though one were speaking on the phone. In addition, using a doll or a willing baby and mother to demonstrate various breastfeeding positions can help the visually impaired blind mother make sense of the words she has been hearing.

Experienced breastfeeding mothers who are visually impaired or blind can also be a valuable source of information and support for the new mother. They may have suggestions of special techniques that they found personally helpful in breastfeeding . Check with other Leaders, your District Advisor/Coordinator and your Professional Liaison Leader see if there are mothers in your Area who are willing to be contacted by phone. LLLI maintains a list of specialty Leaders with personal and/or counseling experience with breastfeeding and visual impairment or blindness (see below).

When the visually impaired or blind mother contacts LLL during pregnancy, the Leader can discuss with her benefits of coordinating breastfeeding support well in advance of her due date. For example, the mother can talk with her physician or midwife about breastfeeding and document his or her support of the mother’s intention to breastfeed including keeping her baby with her and caring for her baby on her own after the birth (Brewster 1979). She can make an appointment to talk about breastfeeding and blindness with the supervisor of the obstetrics ward if she is planning on giving birth in a hospital or clinic. Such advance arrangements can help avoid stress, provide support for breastfeeding, reduce possible misconceptions about visual impairment or blindness among the mother’s health care providers, and make it easier to resolve breastfeeding questions or problems related to visual impairment or blindness.

Learning about breastfeeding during pregnancy is useful preparation for any mother. However, having an experienced nursing mother observe positioning and latch-on soon after birth can build confidence and help the new mother avoid the pain of engorgement, sore nipples and mastitis. Like sighted mothers, the visually impaired or blind mother may have received conflicting and/or inaccurate advice during her baby’s first nursings. In addition, the blind mother cannot see how her baby’s nursing compares to a drawing in a book. A Leader could offer to make a home or hospital visit during the early days of breastfeeding and make tentative arrangements with the mother before the birth.

Suggestions to Consider

The following suggestions may help the Leader effectively share her breastfeeding knowledge while encouraging the visually impaired or blind mother creatively apply her non-visual skills to the experience of breastfeeding. Encourage the mother to experiment so that she can find what works best for her and her baby.

Prioritize. A visually impaired or blind mother may hope or expect to be breastfeeding well using any position with no assistance sooner than it can actually happen. She may underestimate the amount of time and practice it can take to learn to position and latch on her baby independently. In addition, she may not anticipate that her baby could need a great deal of help staying awake long enough to nurse well, that she might develop sore nipples or a breast infection, that her baby's sucking might become confused with the use of bottles, pacifiers or nipple shields. She may feel frustrated with the number of things she must learn in such a short period of time. If difficulties occur, encourage the mother to identify which aspects of breastfeeding are the most important to improve first. A step-by-step approach may require patience, but it is usually less overwhelming and more effective than working on too many things at once.

Use words more than hands to help. Sighted health care providers, family members or friends who are helping a visually impaired or blind mother with breastfeeding may be very tempted to position the baby themselves, place the mother's breast in the baby's mouth or arrange pillows for the mother. While this type of help may get breastfeeding established quickly, it also makes the mother dependent on others and may leave her feeling discouraged, incompetent or afraid to be alone with the baby. When a sighted person makes verbal descriptions and suggestions instead, the mother can choose to take action herself or request physical assistance. In this way she will more quickly develop the skills that she needs to breastfeed her baby independently.

Consider starting with the football hold. This nursing position provides good access to the baby's face, lets the mother use the hand supporting her baby's head to feel how actively his jaw is moving when he sucks and may allow her to use her free hand more easily than she could with other nursing positions. Once she is comfortable nursing in this position, she may find it easier to apply her new skills at latch-on and positioning to other positions. For similar reasons, the cross cradle hold may be a good second position to try.

Try nursing with a baby sling. When the baby is lying in the sling with his head away from the shoulder pad and strap, the mother has good access to his face and can use both her hands for positioning and latch-on. Once her baby is comfortably nursing, one or both of her hands may be freed for navigating and she can nurse anywhere she and baby may go. Keep in mind that it can take quite a bit of time for a mother and baby to learn how to nurse with a sling.

Use fingers to help with latch-on. The visually impaired or blind mother can use her fingers in a variety of ways to help the baby locate her nipple and latch on correctly. The mother can place the tip of her index finger on her nipple, use her finger to touch the baby's mouth to stimulate the rooting reflex and then quickly withdraw it as the baby latches on. Alternatively, the mother can use a finger to guide her baby's chin and help keep his mouth open a bit wider or a bit longer to facilitate latch-on.

The mother can also try using a modified “C” hold. In this hold, the mother places her thumb where one corner of her baby's mouth should be when he is latched on correctly. She places her index finger where the other corner of her baby's mouth should be. The mother's nipple is centered between her thumb and index finger and her hand is cupped under her breast. The correct position of her fingers can be determined with experimentation and/or verbal feedback from a sighted helper. Once the baby is latched on and sucking well the mother can move her hand back to the standard “C” hold to support her breast as needed. There are as many ways to use fingers during latch-on as there are mothers and babies. Encourage experimentation so that the mother can discover what works for her.

Limit visitors. During the early weeks, too many visitors may interfere with the time, practice and rest the visually impaired or blind mother may need to get breastfeeding going well. Frequent visitors may also result in conflicting advice and inaccurate information that can come from too many people trying to be helpful. Encourage the mother to identify visitors whom she finds supportive and those whose visits she would like to postpone until breastfeeding is well established. She also might find it more restful to have limited “visiting hours” instead of having guests come and go all day long.

Be creative. Work with the mother to come up with creative approaches to whatever challenges she is facing. She is already skilled at doing this in every other aspect of her life as she continually adapts to living in a primarily sighted world. Encourage experimentation - that unusual idea just might work! For example, the mother may be tired of relying on the baby's father to assess how wet her newborn's diapers are to be sure the baby is getting enough milk. The mother can create her own wet diaper standard by pouring 2 to 4 tablespoons of water into a clean diaper and sealing it in a plastic bag. She can then place any wet diaper in an identical plastic bag and compare their weight and feel.

Think positively. Trust, touch and time will help the visually impaired or blind breastfeeding mother overcome the usual and unusual challenges of the early weeks of breastfeeding As the mother grows with her baby, she will learn to understand his movements, sounds and smells as well as learn to trust her developing capacity to meet his needs. The mother will use touch to learn to position and latch on her baby, to feel how his jaw moves when he is sucking well, to feel how he roots when he has lost her nipple or needs to burp, to feel how he smiles when he is full and content. In time, baby will develop more strength and coordination as well as become more alert and effective at sucking. The sighted baby will also learn to find his mother’s nipple visually. The mother's experimentation and practice will gradually help her develop the skills and confidence she needs to breastfeed independently using a variety of positions. Patience, perseverance, and accurate rate information and sensitive support will help the nursing pair find their way.

Learning Together

When approached by a visually impaired or blind mother the Leader may think it would be best to immediately refer her to another Leader with more specialized experience. However, the mother-to- mother support of LLL is accessed through the local Group Leader not through a Leader who may live miles away. When a Leader seeks out resources first, she will be able to use her own knowledge to effectively assist the visually impaired or blind mother.

If the Leader rather than the mother contacts a specialty Leader, the Leader will have the needed information if a similar situation arises in the future (Baker 1998). Referring the mother to a specialty Leader or the Coordinator of Resources for the Blind and Visually Impaired will be most effective when the Leader has first contacted them herself.

When a Leader is open to learning, she demonstrates a concept important to every mother: it's all right to be inexperienced and need more information. Regardless of one's degree of vision, breastfeeding and mothering are adventures in living that naturally include continually learning from our babies and from each other.

LLLI Coordinator of Resources for the Blind and Visually Impaired

Betsy Grenevitch is the LLLI Coordinator of Resources for the Blind and Visually Impaired. She has been a Leader with the Atlanta- Emory Group in Georgia, USA, for five years, has eight years of experience breastfeeding her three children and is blind. She welcomes contact by phone or email from both Leaders and mothers to talk about breastfeeding and visual impairment.

Betsy maintains a collection of LLL approved and or published books and pamphlets in braille and on audio tape for purchase and lending. She also coordinates the transcription of books and pamphlets into braille as well as their recording onto audio tapes. Volunteers are needed to read LLL books onto audio tape. Contact Betsy for guidelines (see “Additional Resources ” at the end of this article).

A current project is the transcription of the THE WOMANLY ART OF BREASTFEEDING, 6th edition, into braille.

Free Mail for the Blind and Visually Impaired

In the USA, information in media such as braille, large print, audio cassette recordings and electronic text file on computer diskette may be mailed postage free to people who are blind or visually impaired. The sender should write or stamp “Free matter for the blind and physically handicapped ” in the upper right hand corner of the package in place of postage stamps. The recipient must arrange in advance with her local postmaster by providing acceptable proof of vision impairment. For more information contact your local US Post Office. Similar programs may exist in other countries.

Additional Resources

  • A list of specialty Leaders with personal or counseling experience with visually impaired breastfeeding mothers is available to Leaders, health care professionals and mothers. Contact: LLLI Education Department, 957 N. Plum Grove Road, Schaumburg, Illinois 60173 USA; phone 847-519-7730; fax 847-519-0035
  • More than 40 books, 30 pamphlets and various articles from New Beginnings are available for purchase and loan on audio tape and in braille. All materials are approved and/or published by LLLI. Topics include breastfeeding, parenting, birth, nutrition and more. The list of publications is available in printed form and on audio tape. Orders may be placed by phone, email or audio tape. The US postal service requires no postage for sending materials for the blind and visually impaired. Contact: Betsy Grenevitch, LLLI Coordinator of Resources for the Blind and Visually Impaired, 1055 Seville Drive, Clarkston, Georgia 30021 USA. Phone 404-297-9313; email blindangel at onebox.com [editorial note: this has been updated from the printed document].
  • Conference session audio tapes are available for purchase from LLLI and for loan from some LLL Area Libraries. Contact: For purchasing information, contact LLLI. P.O.Box 4079, Schaumburg, Illinois 60168-4079 USA. Phone 847-519-9585; fax 847-519-0035. For lending information, contact your District Advisor/Coordinator or Area Librarian.
  • What to Do When You Meet a Blind Person (brochure); A Different Way of Seeing: An Open Letter to Children About People Who Are Visually Handicapped (brochure). Contact: American Foundation for the Blind, 11 Penn Plaza, Suite 300, New York, New York 10001 USA. Phone 212-502-7600; email afbinfo at afb.org; Web site http://www.afb.org/afb.
  • Do You Know a Blind Person? (brochure). Contact: National Federation of the Blind, 1800 Johnson Street, Baltimore, Maryland 21230 USA. Phone 410-659-9314; Web site http://www.nfb.org.
  • When You Meet a Blind Person (brochure). Contact: American Council of the Blind, 1155 15th Street, NW, Suite 720, Washington, DC 20005 USA. Phone 202-467-5081 or 800-424-8666; fax 202-467-5085; email ncrabb at acb.org; Web site http://www.acb.org.
  • A variety of books on audio tape and in braille, tape recorders and record players can be borrowed at no charge from the Talking Book Program through the Library of Congress. Contact: Talking Books, National Service for the Blind and Physically Handicapped, 1291 Taylor Street, NW, Washington, DC 20542 USA. Phone 202-707-5100.

Bibliography

Baker, K. Leader specialty file. What is it? How does it work? LEAVEN, JunJul 1998; 62.

Brewster, D. You Can Breastfeed Your Baby . . . Even in Special Situations. Emmaus Pennsylvania: Rodale Press, 1979.

Cookson Martin, D. LLL and the mother who is blind. LEAVEN, Sept/Oct 1992; 67-69.

Gorman, J. The seeing glass. Good Housekeeping, June 1997; 224:6:193 (13).

Mohrbacher, N. And Stock, J. BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois: LLLI, 1997.

Packer, J. and Kirchner, C. Who ’s watching?A profile of the blind and visually impaired audience for television and video. New York: Amer Found for the Blind, 1997.

Sue, D. Culture-specific strategies in counseling: a conceptual framework. Prof Psych: Res and Pract 1990; 21:6:424-33.

Sullivan, T. Tom Sullivan: His parents never took "no" for an answer. Except Parent April 1995; 25:4:22(4).

Triandis, H. Culture and social behavior. New York, New York: McGraw-Hill, 1994.

Triandis, H. Individualism and collectivism. Boulder, Colorado: Westview Press, 1995.

Whaley, L. and Wong, D. Nursing Care of Infants and Children. St. Louis, Missouri: Mosby, 1991.

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