In Preschool Children with Visual Impairment, four pages are devoted to how a vision loss affects early development. The discussion broadly addresses the five basic developmental areas: motor, cognitive, language, self-help, and social. In this manual, the emphasis will be on motor development, since that is the area of greatest growth in the first year of life. The other developmental areas will also be discussed but in less depth, since their role in the lives of B-3 year olds becomes important primarily in the second half of those years. The reader is urged to combine the information in both manuals for a broader discussion of early development and how visual impairments impact on that development.
NOTE: When intervention is indicated in the following discussion, the VI teacher should be consulted for ideas and suggestions. "Normal" development (i.e., that of non-disabled children) is used as a basis for discussion. It is assumed that there will be other specialists (e.g., physical therapist, occupational therapist, O&M specialist) on the intervention team.
Many early reflexes are precursors to later skills; they appear early as involuntary reactions to external stimuli, seem to disappear, and later return as voluntary behaviors. The early reflexes seem to he preliminary "practicing" for later I earning. Perhaps they may even be creating early preparatory patterns in the brain. Examples of these precursor reflexes are the early "crawling" and "stepping" reflexes, and the grasp reflex.
Other reflexes serve developmental purposes; they are either self-preservative (as in protective/defensive reflexes) or provide a basis for system growth. Rooting and sucking reflexes, and hand-to-mouth reflex are survival behaviors (facilitating feeding), while the asymmetrical tonic neck reflex (ATNR) creates just the right stimulus (the infant's hands, at the proper viewing distance) for visual practice. The ATNR exists from about birth to 4 months, when it disappears; not coincidently, "hand regard" (baby "discovers" his hands as an interesting visual target) appears around 15 weeks - just before the ATNR disappears. This convenient progression is not accidental; it assures the practicing of emerging visual skills, at just the right time, at just the right distance, with a visual target of just the right size.
When an infant is visually impaired, vision may not be able to act as a motivator or reinforcer. Al tough the early reflexes are present in otherwise intact visually impaired babies, several are not satisfied by visual feedback. When placed in a prone position (laying on the stomach), the visually impaired infant may "object" (fuss); head movement is primarily for survival purposes (to avoid breathing obstruction); there is limited or no visual stimulus to encourage lifting the head and looking around. The prone position may be annoying, uncomfortable, and unsatisfying for a visually impaired infant, but it is a useful position for developing head and neck control - essential developmental achievements. Intervention may be needed, to assure that there is practice in controlling neck muscles.
When the ATNR position produces limited or no visual feedback, the purpose of the reflex is defeated. Either the reflex becomes haphazard and lacks precision, or it continues to be present past 4 months. When vision has not been "practiced" for the early few months, "hand regard" is a meaningless milestone, and may not even occur. Since one of the purposes of "hand regard" is to bring the infant's hands together at midline, a visual impairment may interfere with the achievement of this behavior, and intervention must be provided.
In order to achieve an upright orientation ("sitting alone"), a number of inter-related factors must be present: a complex system of nerves and muscles must be operational; head/neck control must be achieved: arm and hand use must be refined enough to be independent of posture (i.e., sitting must be without hand/arm support); and balance must he achieved. This is no small accomplishment, and will take the greater part of the first year to achieve. Vision has played a big part in the development of the precursor skills (head control, orientation in space, and balance), and impaired vision can just as easily interfere with the development of those skill's. It is important to remember that even a totally blind baby can learn to sit alone; the physical ability and strength are there. It is the motivational factor, and the orientation in space that are most affected by lack of vision. (Indirectly, muscle tone and stamina may also have been affected if the blind baby does not have the opportunity to move and is not encouraged to do so from the beginning.) The VI teacher will have suggestions to minimize any delays in sitting resulting from impaired vision.
It is important that visually impaired babies team to sit at as near a developmentally-appropriate time as possible; their beginning exploration of the world (the floor around them, or the tray of the high chair) depends on the availability of their hands, which must be free to move, independent of the torso. "Sitting alone" (without the use of hands for support) is a major milestone for visually impaired babies, and a critical one for cognitive growth to come.
Standing is the next level of upright posture, and is the precursor to walking. It is a natural attainment for a sighted child, who is visually stimulated to see more of what's "out there." For a blind child, however, standing may represent a frightening lessening of body contact with the environment; once erect, only the soles of the child's feet are rooted in reality. It takes a good deal of encouragement, and a secure emotional environment for a blind child to "let go" of the world he/she has reassured through contact with nearly half of his/her body (back, buttocks, legs) and suddenly only "knows" what touches his/her feet. The process may be slow, and require transitional support (hand holding, under-arm assists, lots of conversation, and-something to hold on to). The end result - independent standing - is an important milestone for a visually impaired child, however, and intervention should be designed to achieve that goal
As has been stated previously, the ability to use hands independently is a crucial skill for a child who must use touch to learn about and explore the world. When a visual impairment interferes with a child's ability to explore his/her world visually, the ability to use his/her hands to "examine" new objects becomes a vital skill. Blind babies may not have the motivation to reach unless intervention is provided. ("Reach-on-sound" does not normally occur until late in the first year, so intervention at a developmentally appropriate time - the early months - must utilize a tactual approach.) When the child discovers that something interesting exists out there," and tries to attain it, the first hurdle has been cleared. The refinement of hand skills (the use of hands at midline to manipulate and explore objects, the development of pincer grasp, and independent finger use) are the next goals to be reached, and much extra practice is needed to achieve these goals at developmentally appropriate times. Intervention is needed, and may make the difference between achieving the goals or not.
The selection of toys is critical for VI infants & toddlers. Attention should be given to texture and sound in addition to appearance (many plastic toys are unappealing tactually and are not appropriate for children who are blind or who have low vision). The VI teacher can help with ideas for toys that are interesting to explore tactually.
Language and communication:
The normally sighted child coos, cries and "babbles," and begins to imitate sounds he/she has heard; the visually impaired baby does the same. It is when words begin to have meaning that the visually impaired child is at a disadvantage, because he/she does not see the object to associate a label , or name. The months between I year and 3 years are when toddlers are acquiring a vocabulary of what exists in their worlds. Language intervention between ages I and 3 (and beyond) is critical for visually impaired toddlers; they must have opportunities to explore and manipulate their world if their language is to become meaningful and useful It is not enough to describe an object verbally to a visually impaired child; insofar as possible, he/she must poke it, probe it, pat it, bang it, mouth it, throw or drop it, and compare it to other objects in order to build vocabulary of nouns and describers. The visually impaired child must be "motored through" (participate in) physical actions like jumping, hopping, skipping, leaning, bending, and exploratory actions like rubbing, "touching lightly," scratching, and searching efficiently. The use of gestures (which are seen and imitated by sighted children) must be specifically taught to visually impaired children if they are to learn to use gestures to communicate needs or feelings. Although blind children may use their hands in special ways to communicate (e.g., open-close to indicate "give me"), they must learn that words or gestures can also achieve the desired ends. The acquisition of a meaningful vocabulary may be the single most important language skill for a visually impaired child, since higher levels of learning will be based on the use and manipulation of words as ideas. It cannot be stressed too strongly how important the early acquisition of a meaningful vocabulary will be during later educational experiences.
Research has suggested that, in intact children, intelligence is at least half set by age 4, and as much as 80% complete by age 8. More important, learning style and cognitive differences appear as early as 18 months to 3 years. It is nearly universally accepted that experiences in the preschool years - especially during the 1-3 year period - will form the basis for later learning. When a child has a disability, especially a visual impairment, it is even more critical to build cognitive potential as early as possible.
Object permanence is the first level of measurable cognitive behavior; for visually impaired children, 11people permanence" (the knowledge that a particular and significant person will return after disappearing) may occur before object permanence, since most objects do not provide sensory feedback when removed from arm's reach. When auditory cues are able to be used as lures and reinforcers, the association of an object's sound-producing quality, its label , and its remembered tactual qualities can lead to the acquisition of "object permanence; "this usually occurs late in the first year or shortly thereafter.
Cause and effect - the next significant cognitive factor - is largely a visual experience; the infant sees a door being opened, a faucet being turned on, or water disappearing down a drain; "empty" has meaning when the child sees that all of the milk has been drunk from a bottle or cup. The visually impaired child does not experience this incidental leaning, and must have structured experiences to provide equal understanding (e.g., feeling water come out faucet when turned on, feeling the water go down the drain, or producing an effect with a toy him/herself (e.g. , ringing a bell , pulling a string on a "See 'n' Say" toy). ) Verbal explanations we not enough; the visually impaired child must participate to learn. In order to classify by properties (e.g. , sort, match, compare), the visually impaired child must have ample opportunity to explore and manipulate objects. Remembering that tactual information (and much auditory information) is taken in one bit at a time, repeated exploration and manipulation is necessary, if the visually impaired child is to store enough data in his/her brain to retrieve when comparisons and conclusions are needed. The major task of the 1-3 year old visually impaired child is to acquire information and store it for future reference. Language development and play are closely related to cognitive development during this time period, as label's are attached to experiences, and experiences repeated. It should be apparent that intervention to develop the cognitive ability of a young visually impaired child will be largely providing experiences, opportunities, and explorations.
Much of the early social contact between an infant and his/her mother is visual: eye contact, social/ reciprocal smiling, observation of facial expressions. For the visually impaired infant, who may not be able to make eye contact, or observe a face, social contact must be physical (tactual) and auditory. I his is often disconcerting to a care-giver, who misses that visual contact. Intervention can explain the need for a substitute social interaction.
When an infant is able to respond to language receptively (e.g., responds to his/her name, understands "no," and begins to obey commands), the individual self emerges and choices (to do or not to do) are available. Although most choices will be made in favor of obedience, or pleasing the caregiver, it is a good idea to begin providing opportunities for decision-making that encourage independence and autonomy. Small decisions (what to eat, what to wear, which toys to play with) should be left up to the child when feasible, so that he/she learns that he/she can exert some measure of control over what happens. Too many young blind children learn dependence by not having choices to make, and it interferes with the development of independence later.
Although play turns out to be a social skill later, it begins as an experience. In the early months, play is exploratory and experimental ("What can I do with this?"). When "pretend" becomes a play strategy, visually impaired children often perseverate at the exploratory level; they do not know how to play with a representational object because they have never seen the real thing. Toys should be selected with this in mind. If pretend play is expected, then provide the experience with the real object first. Textures and sounds may be more important than colors and details. Actually placing a toy in a blind child's hands can quickly reveal his/her level of understanding of what that toy can do. (Is the play appropriate? Or is the child still banging, poking, shaking, or throwing the toy?) For children who have low vision, high contrast in colors should be part of the selection criteria for toys. Visually impaired children may play independently (as opposed to cooperatively) longer than sighted children. The concepts of "sharing" and "taking turns" are largely visually based, and must be specifically taught to visually impaired children before they can interact with peers in a play situation. "Play" is presumed to be a natural skill for children, but it may need to be part of an intervention program for visually impaired children.