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Parent brochures from the Blind Children's Center, Los Angeles, CA: (4120 Marathon Street, P.O. Box 29159, Los Angeles, CA 90029)

Parent publications from NAPVI: (P.O. Box 317, Watertown, MA 02272)

References and Reading

Batshaw, M. & Perret, Y. (1981). Children with handicaps: A medical primer. Baltimore: Paul H. Brookes.

Bishop, V. (1991). Preschool children with visual impairment .(unpublished manuscript).

Bishop, V. (1996). Teaching visually impaired children. Springfield, IL: Charles C. Thomas.

Caplan, F. (Ed.) (1976). The parenting advisor . Garden City, NY: Anchor Books.

Catalano, R. & Nelson, L. (1994). Pediatric ophthalmology. Norwalk, CT: Appleton & Lange.

Collins, M. (1992). Parental reactions to a visually handicapped child: A mourning process. (unpublished doctoral dissertation). Ann Arbor, MI: University Microfilms International. (#8217840).

Ferrel I , K. (1985). Reach out and teach. New York: American Foundation for the Blind.

Isenberg, 5. (1989).The eye in infancy. Chicago: Year Book Medical Publishers, Inc.

Jordan, J. , Gallagher, J. , Hutinger, P., & Karnes, M. (1988). Early childhood social education: Birth to three. Reston, VA: Council for Exceptional Children.

Kastein, S., Spaulding, I. & Scharf, B. (1980). Raising the young blind child. New York: Human Sciences Press.

Pogrund, R. , Fazzi, D. & Lampert, J. (Eds.). (1992). Early focus: Working with young blind and visually impaired children and their families. New York: American Foundation for the Blind.

Rogow, S. (1988). Helping the visually impaired child with developmental problems. New York: Teachers College Press.

Trief, E. (Ed.). (1992). Working with visually impaired young students: A curriculum guide for birth - 3 year olds. Springfield, IL: Charles C. Thomas.

Ulrich, S. (1972). Elizabeth. Ann Arbor, MI: The University of Michigan Press.

Return to the Main Menu of Infants and Toddlers with Visual Impairment by Virginia Bishop

There are some assumptions that are basic to an understanding of how the visual system contributes to early development (and can impede development if dysfunctional). They are important to any discussion of visual impairment and young children, and must be understood if a philosophical foundation for intervention is to be established. Each assumption will be discussed separately, but, like building blocks, they should support each other in establishing a knowledge base.

Vision is the primary data-gathering system of the human organism.

Of all the senses, vision provides the most information to the brain. It is both a near and distance sense, and can integrate the information it gathers. Hearing is largely a sequential sense (gathering one piece of information at a time), and relies on vision to give meaning to sounds. Touch can only provide information within arm's reach (thus, is a near point sense), and can only collect data sequentially; it relies on the brain to integrate the data into a meaningful whole. Taste and smell are immediate senses and have a much narrower range of information-gathering abilities. Only vision can perceive shape, size, color, distance, and spatial location - all in one glance. The other senses together cannot provide equal information to the brain.

Vision is the feedback system for all other developing systems in the young child.

The infant's early development depends on vision, since all of the body systems require visual feedback for practice and refinement. When the visual system is impaired or dysfunctional , the other body systems do M have a monitoring tool to assure their smooth and timely development. Every other body system can be delayed in developing when vision is severely impaired or absent. Early intervention can minimize or eliminate most delays but must be provided at the appropriate time - not after a delay occurs. It is the VI teacher who can make the appropriate suggestions for intervention activities, but must be an early member of the intervention team to do so.

You cannot wait until a vision loss has caused a developmental delay to bring in the VI teacher.

Current practice suggests that early intervention may be based on a deficit model. That is, strategies address delays. The time to intervene is before the delay occurs; the goal is to prevent the delay, if possible. That is why the identification of a vision problem, as early as possible (through vision screening and follow-up treatment) is essential. As soon as a visual problem is identified, the VI teacher should be called upon to be a member of the IFSP team. The sooner intervention can be provided, the more likely it is that delays can be minimized or prevented.

Vision happens in the brain, not in the eyes.

The visual system is made up of an ocular system (the eyes and eye muscles) connected to a perceptual (understanding) system - the brain. Each without the other is diminished in function. It takes both eyes and brain for vision to occur. When either system is dysfunctional or defective, the visual system becomes impaired and cannot provide adequate visual information for the infant or child. Thus, brain damage will have implications for visual function, and ocular defects can have impact on cognitive function. The two systems are inter-related, inter-connected, and interactive. This is a basic concept essential to early intervention.

You don't conserve vision by not using it.

You cannot "save" vision; it must be used to be effective. Moreover, it must be practiced to become most efficient. The most critical time for visual "practice" is in the first few years of life, when the eye-brain connections are being made. Early intervention activities during those early years can help establish good visual patterns that utilize maximum available vision.

Age-of-onset is a critical factor in visual impairment.

Visual impairments that exist at birth (i.e., are "congenital") are more likely to cause developmental delays than visual problems that occur later. The identification of visual defects or diseases, as early as possible, can have long-term advantages for the child, since immediate treatment and early intervention may minimize the deleterious effects. Visual conditions whose effects occur later (as in a progressive disease or defect) may allow the earliest development to progress normally, with intact or useful vision present to assist in the process. Even several months or a year of useful vision (even when impaired) can imprint visual patterns in the brain; such visual memory can provide spatial references that will become essential to orientation and mobility later.

At least 60% of the current population of disabled children, B-3. have multiple disabilities, and visual impairments are very likely to be among those disabilities

Since the visual system is neurologically based, any defect in, or disease of, the neurological system (including the brain) can also affect vision. Many disabling conditions involve the brain (e.g., brain damage, mental retardation, cerebral palsy), and a high number of these children may also have vision problems. Keeping in mind that the visual system depends on the brain for understanding of visual stimuli, it is evident that when the brain does not function as it should, the visual system cannot function adequately either. No amount of visual stimulation, training, or therapy can change the way the brain processes if the capability is not present. The one exception to this rule is in cortical visual impairment (CVI): because of the "plasticity" of the young brain, visual intervention may be effective in improving visual function, but the "rule of thumb" is usually "the earlier the better." The prognosis for increased visual function is better for a two year old than for a five or six year old.

Development occurs in sequential steps, but the timing varies with the individual child.

Most early childhood "experts" agree that early development progresses in an orderly fashion. Body systems mature in time for developmental milestones to occur. Eyes and hands become coordinated in time for reach to become a functional skill. Muscles in the neck, arms, and torso gain sufficient strength and coordination to allow sitting. Motor coordination and visual acuity develop in time for locomotion (creeping and crawling) to happen. Individual differences are in the timing, not in the sequences. Developmental "norms" are based on when most children achieve milestone skills, but there is temporal latitude (range of months) incorporated into the norms. With intervention, otherwise intact visually impaired children can achieve the same milestone skills as sighted children; it might just take a little longer. Current research (Project Prism) suggests that early intervention for visually impaired infants and toddlers is effective.

Development proceeds in an organized, predictable way

It has been observed repeatedly that the progression is: from head to tail (or top to bottom - cephalocaudal), near to far (proximodistal), and gross to fine. The brain controls the head and neck before the torso, which is before the arms and legs. Arm movement is refined before hand movement, and torso/hip movement before leg movement. Gross movement is learned before fine motor skills (e.g., hand and finger control ) and walking. This progression is as true of visually impaired children as it is of normally sighted children; the timing - and the need for additional practice - are the only adjustments in the process. Visually impaired children may need appropriate intervention and extra practice (and may take longer) to achieve their skills, but are usually (in the absence of other disabilities) physically capable of reaching developmental milestones in a timely fashion.

The early years - from birth to age 6 - are especially critical developmental years for visually impaired children.

Although there is increasing research to support the importance of the early years for all children, visually impaired youngsters are at even greater risk for developmental delays entire learning experience of a visually impaired child. It is crucial that VI specialists (both VI teachers and O&M specialists), parents and early childhood personnel work cooperatively with young visually impaired children, in order to build the skills and provide the experiences that will make best use of the potential in these children. (Occupational therapists and/or physical therapists may also be part of the critical team.)

There are "windows of opportunity" for development and learning.

Educators have long accepted the concept of "readiness" in learning (although it is not necessarily universally practiced). Beginning reading depends on a mature visual system, the recognition of similar/different written configurations, and motivation. Beginning math instruction relies on the acquisition of one-to-one correspondence, conservation, and symbolic decoding. Phonics is a reading approach that is most effective during the first three years of school. So it is for vision. The first 6-8 weeks of life are critical in stimulating retinal function; defective vision that prevents this stimulation during that time period (as in congenital cataracts) can cause impaired vision for life, despite treatment. "Vision stimulation" as an intervention technique may be most effective during the first year or two of life, both chronologically and developmentally, and may be ineffective later on; the "window of opportunity" may have passed by the time a child is school age. When eyes are not in alignment (allowing fusion to occur), a permanent vision loss (amblyopia) can occur if the condition is left untreated. Age two is the peak time for treatment, and the prognosis for improvement (i.e., alleviating the amblyopia) lessens a little with each passing year; after about age 7 or 8, prognosis for improvement is almost nil . The VI teacher can recommend appropriate techniques and timing, for individual situations.

Hearing is not an equal motivator in encouraging "reach:"

It is often assumed that a sound-making lure can be substituted for a visual stimuli in encouraging a visually impaired infant to reach for an object. This is an erroneous assumption, however, since there's a mismatch in timing between when an infant is physically ready to reach (by about 5 months) and when auditory processing ability can attach some meaning to sound (the last quarter of the first year). Since the development of reach is critical for severely visually impaired infants (they will use their hands to explore their environment, and to attach meaning to their world), it should be a primary goal for all visually impaired infants. The VI teacher will have some ideas or suggestions to help motivate a visually impaired infant to reach out.

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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.

Reflexive behaviors:

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.

Upright posture:

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

Hand use:

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.


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In discussing multiple disabilities, especially in young children, it is important to gain a perspective about the interactional factors in multiple impairments. Each disability does not act in isolation (and should not be managed in isolation). There is a hierarchy of impact that might be best explained by a comparison to a submarine (see image below). When operating "on instruments" (sonar, radio, periscope), the captain must rely on what his instruments tell him about the surrounding environment. His periscope gives "straight ahead" visual information (or side vision, if the periscope is turned); the sonar tells what might be "out there" at a distance; the radio antenna permits incoming verbal information (receptive language) or allows out-going responses (expressive language). The motor mechanisms allow the captain to maneuver his submarine ahead, make turns, stop, reverse, rise, or descend. The captain must take in all of the information given to him, make sense of it, and make decisions that affect the whole submarine and its crew. Survival may depend on the experience, knowledge, and data processing ability of the captain.

The best captain in the world is hampered in decision making when one or more of his information gathering systems is defective or disabled, but at least he has the ability to draw conclusions based on what information he has, or has stored from past experience. The more data-gathering systems are malfunctioning, the harder it is to make wise decisions. As long as the motor system is intact, he can maneuver, allowing for incomplete data. If the motor system also malfunctions, the captain may have a difficult time making progress of any kind; he may know where he wants to go, but can't seem to get there. Obviously, the more severe or serious the malfunction in any system, the more difficult it is to make progress, and greater the reliance is on the better-functioning systems.

If it is the captain who is ill, tired, or (for whatever reason) unable to function properly, it doesn't matter how intact the motor and data-gathering/communication systems are, they will not be used efficiently or effectively. They may appear to be somewhat disabled because the captain is unable to make-full and best use of them. This submarine may make some progress, but it may be slow, occur in unpredictable spurts and directions, and may never quite get to where it wants to go. If the captain's malady is incurable and permanent, the submarine may never make it to harbor - at least not on schedule.

So it is with the human organism. An intact brain can make innumerable compensations for impairments in vision, hearing, speech and language and motor abilities, enabling the person to function reasonably well. The more impairments, and the more severe they are, the more compensations, modifications, and adjustments are needed. But, with effort and perseverance, it is possible to become a contributing member of society. However, when the brain is damaged, defective, or otherwise malfunctioning, the other body systems will not be used effectively or efficiently, no matter how intact; they will appear to be poorly developed.[see note] In the case of vision, functional vision skills may be more closely linked to developmental level than chronological level, but intervention - especially in the early years - can have positive long term results. This is an important concept in evaluation of vision, since the potential for improved functioning will also be related to developmental level.

Note: A thorough and ongoing evaluation by the program team can help to identify whether delays are more related to brain malfunction that to visual impairment. When in doubt, provide intervention; the VI teacher should be involved until it can be demonstrated that activities to improve functional use of vision are ineffective.

Multiple disabilities in an infant or young child require the coordinated efforts of multiple experts" (one from every identified disability area). Because of the interactive, multiplicative effects of multiple disabilities, it is essential that intervention and/or programming efforts be focused cooperatively on functional tasks. Whenever possible, intervention should be aimed toward minimizing or preventing developmental delays. Since there seems to be an ever-increasing number of infants and young children with multiple disabilities, the cooperative approach to early intervention seems to have the best potential for enhancing the potential of these children.


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Babies who are born "too soon" or "too small" are at risk for many complications. Those who are born "too soon" are called premature; they are born before the 36th week of gestation (i.e., at least a month early). An infant (who may be full-term - 40 weeks or more) who weighs less than 5 1/2 pounds is "too small," or dysmature. The implications for disabilities are somewhat different for these two groups

In a premature infant, body systems or physical characteristics may not be fully developed, and the more premature the less developed. There is less muscle tone (the infant is more likely to lie in an extended (position than in a flexed position), the respiratory system (ability to breathe) is not fully developed, the brain may not be ready to control breathing yet, and an immature nervous system may inhibit the feeding process (sucking). The baby may also experience jaundice (a yellowing of tissue because the liver is not yet able to regulate the secretion of bilirubin) , hypoglycemia (not enough glucose in the blood), and hypothermia (an inability to maintain body temperature because there is not enough insulating fatty tissue). Advanced medical procedures are able to manage these factors in many premature infants, but careful monitoring (usually in a neonatal intensive care unit, or NICU) is necessary until the child's body systems mature enough to function independently.

In a dysmature infant, the chances of respiratory distress are less, but the baby may still experience hypothermia, hypocalcemia (not enough calcium in their blood), and hypoglycemia. The incidence of developmental disabilities is higher in low birth-weight babies. Dysmaturity is more likely in babies whose mothers had poor nutrition during pregnancy, or were chronically ill, and adolescent mothers are at particularly high risk for low birth-weight babies.

Current neonatal intensive care units try to duplicate womb conditions for premature and/or low birth- weight infants. The lighting may be reduced with blankets over the incubator or crib, or gauze over the infant's eyes. Noise is controlled (kept under 50 db). Infants may be ' swaddled" (wrapped, to maintain skin contact). Indirect and continuous contact with the child's natural mother may be maintained by placing a bandanna worn by the mother (and saturated with her unique odor) lightly over the infant's face or eyes. The baby's own states may be monitored so that treatment occurs at the most receptive times (usually the "alert" stage). (The "states" are: deep sleep, REM sleep, drowsiness, alertness, fussiness, crying.) Self-regulation on the part of the baby is the desired goal. ("Neurobehavioral stability" is the term used to describe this self-regulation.)

Caregivers are taught to watch for signs of distress or agitation in the infant (changes in skin color or breathing patterns; "visceral" signs such as drooling, limpness, hyperextension, arching, stiffening, flailing of arms or legs, startle reflex) Caregivers are also taught how to alleviate the stress or agitation, by speaking quietly, moving slowly, supporting the infant's shoulders, giving the infant's feet something to push against, and swaddling.

Among infants who have experienced respiratory distress and required ventilation, a number will develop an eye condition with the potential for severe visual impairment. Retinopathy of prematurity (formerly called retrolental fibroplasia) occurs primarily in premature infants born at 23-28 weeks gestation, or in those weighing less than 1000 grams (about 2 pounds 3 ounces), although it has also occurred in some full -term infants. The condition is related to retinal blood vessels, which are not fully developed in premature infants. Although oxygen was long believed to be the culprit in causing the disease, it is not a sole factor; the exact cause (and best treatment) of ROP has yet to be discovered (even after over 50 years of study). Current guidelines for perinatal care recommend that all infants born at less than 30 weeks of gestation, or who weigh less than 1300 grams at birth, should be checked for ROP before leaving the hospital, regardless of whether they were exposed to oxygen.

ROP has a wide range of impact. In as many as 90% of infants who develop the disease, it resolves itself with no treatment. In the infant whose ROP does not spontaneously resolve, cryotherapy may help prevent its progression, but hundreds of children still end up severely visually impaired (many of them blind). Whenever low birth-weight or prematurity are mentioned in medical records, the possibility of ROP should be investigated, to be sure it was either ruled out or identified. If ROP is listed as a visual diagnosis, a careful analysis of the eye report should reveal the extent of the disease (i.e., which stage). Since functional vision can range from useful to useless, a diagnosis of ROP should always be cause for referral to the VI teacher.

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In the early months of life, the visual system is still maturing; it is not fully developed at birth (and is even less developed in the premature infant). From birth to maturity, the eye increases to three times its size at birth, and most of this growth is complete by age 3; one third of the eye's growth in diameter is in the first year of life. Some knowledge of normal visual development is necessary if abnormalities are to be noted. The following information gives indicators of normal visual development in young children from birth to three years.

In a premature infant: (depending on the extent of prematurity) The eyelids may not have fully separated; the iris may not constrict or dilate; the aqueous drainage system may not be fully functional; the choroid may lack pigment; retinal blood vessel's may be immature; optic nerve fibers may not be myelinized; there may still be a pupillary membrane and/or a hyaloid system. Functional implications: lack of ability to control light entering the eye; visual system is not ready to function.

At birth: The irises of Caucasian infants may have a gray or bluish appearance; natural color develops as pigment forms. The eyes' pupils are not able to dilate fully yet. The curvature of the lens is nearly spherical. The retina (especially the macula) is not fully developed. The infant is moderately farsighted and has some degree of astigmatism. Functional implications: The newborn has poor fixation ability, a very limited ability to discriminate color, limited visual fields, and an estimated visual acuity of somewhere between 20/200 and 20/400.

By 1 month: The infant can follow a slowly moving black and white target intermittently to midline; he/she will blink at a light flash, may also intermittently follow faces (usually with the eyes and head both moving together). Acuity is still poor (in the 20/200 to 20/400 range), and ocular movements may often be uncoordinated. There is a preference for black and white designs, especially checkerboards and designs with angles.

By 2 months: Brief fixation occurs sporadically, although ocular movements may still be uncoordinated; there may be attention to objects up to 6' away. The infant may follow vertical movements better than horizontal , and is beginning to be aware of colors (primarily red and yellow). There is probably still a preference for black and white designs.

By 3 months: Ocular movements are coordinated most of the time; attraction is to both black and white and colored (yellow and red) targets. The infant is capable of glancing at smaller targets (as small as 1"), and is interested in faces; visual attention and visual searching begins. The infant begins to associate visual stimuli and an event (e.g., the bottle and feeding).

By 4 months: "Hand regard" occurs at about 15 weeks; there is marked interest in the infant's own hands. He/she is beginning to shift gaze, and reacts (usually smiles) to familiar faces. He/she is able to follow a visual target the size of a finger puppet past midline, and can track horizontally, vertically, and in a circle. Visual acuity may be in the 20/200 to 20/300 range

By 5 months: The infant is able to look at (visually examine) an object in his/her own hands; ocular movement although still uncoordinated at times, is smoother. The infant is visually aware of the environment ("explores" visually), and can shift gaze from near to far easily; he/she can "study" objects visually at nearpoint, and can converge the eyes to do so; can fixate at 3'. Eye-hand coordination (reach) is usually achieved by now.

By 6 months: Acuity is 20/200 or better, but eye movements are coordinated and smooth; vision can be used efficiently at both nearpoint and distance. The child recognizes and differentiates faces at 6', and can reach for and grasp a visual target. Hand movements are monitored visually; has visually directed reach." May be interested in watching falling objects, and usually fixates on where the object disappears.

Between 6 and 9 months: Acuity improves rapidly (to near normal); "explores" visually (examines objects in hands visually, and watches what is going on around him/her). Can transfer objects from hand to hand, and may be interested in geometric patterns.

Between 9 months and a year: The child can visually spot a small (2-3mm) object nearby; watches faces and tries to imitate expressions; searches for hidden objects after observing the "hiding;" visually alert to new people, objects, surroundings; can differentiate between known and unfamiliar people; vision motivates and monitors movement towards a desired object.

By 1 year: Both near and distant acuities are good (in the 20/50 range); there may be some mild farsightedness, but there is ability to focus, accommodate (shift between far and near vision tasks), and the child has depth perception; he/she can discriminate between simple geometric forms (circle, triangle, square), scribbles with a crayon, and is visually interested in pictures. Vision lures the child into the environment. Can track across a 180 degree arc.

By 2 years: Myelinization of the optic nerve is completed. There is vertical (upright) orientation; all optical skills are smooth and well coordinated. Acuity is 20/20 to 20/30 (normal). The child can imitate movements, can match same objects by single properties (color, shape), arid can point to specific pictures in a book.

By 3 years: Retinal tissue is mature. The child can complete a simple formboard correctly (based on visual memory), can do simple puzzles, can draw a crude circle, and can put 1" pegs into holes.

Note: See also "Normal Visual Development" in Preschool Children With Visual Impairments, p. 33.

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Vision screening should be part of the evaluation/intake process following each new referral. It should also be an ongoing process for all young children. At any point where a vision problem is suspected, referral for medical evaluation is essential, to identify or to rule out the presence of a visual impairment. When in doubt, refer.

Vision screening for infants and very young children is largely subjective and observational , since most preverbal children cannot tell the evaluator that there is something wrong. Moreover, they do not know how vision ought to function, and are unaware of any problems. It falls upon the observer to notice appearances or behaviors that might suggest abnormal visual function.

To assist the evaluator in the task of identifying visual problems in young children, a series of procedures has been developed. They include a parent questionnaire (to identify "at risk" factors or functional behaviors that might indicate the presence of a visual impairment), an appearance checklist (which is totally observational and a set of functional procedures (which should help to determine whether the child's visual functioning is developmentally appropriate). Formats and descriptions follow. (Note: The forms in this Manual contain the same content as the required ECI forms, but are arranged in a "user friendly" format.)

The Parent Questionnaire should always be administered as part of the intake process and May be used at any time thereafter if a vision problem is suspected later; certainly vision screening should be an ongoing process for children aged B- I and may be repeated at the 6 mos. re-evaluations. One or more "at risk" indicators, plus one or more absent visual behaviors (at age-appropriate levels) should be cause for referral for medical follow-up. Since the Appearance Checklist focuses on indicators of disease or malformation, any positive indicator on this list is reason for referral for medical evaluation. Since the Informal Screening ,.Procedures are subjective, referral for medical follow-up is recommended when the evaluator is uncertain that behaviors were performed correctly (if at all). It is better to refer unnecessarily and find out there is no problem than not to refer and find out (too late) that there is a problem.

In working with very young children, time is an important factor. Development occurs so rapidly in the first year of life that not providing follow-up treatment or intervention can be costly in terms of developmental delays. The VI teacher should be alerted as soon as a vision problem is suspected, and referral for a 1-tinctional Vision Evaluation made as soon as medical follow-up has been achieved. The Functional Vision Evaluation will be the deciding factor when intervention is needed. Although the medical report is an essential document for the files. it is the Functional Vision Evaluation that will determine the visual status for educational purposes. This cannot be stressed too strongly. When in doubt, REFER.

Note: ECI Policy says that if an eye report is already available at intake, the screening procedures (including the questionnaire) are not necessary; referral to the VI teacher at the local school district is made as soon as a visual impairment has been identified on the eye report. It is only when there is no eye report among the medical records that the vision screening questionnaire and testing are used.

Parent Questionnaire

Family History:

Does anyone in your family have a severe vision loss or eye disease? ____Yes ____No (e.g. , albinism, amblyopia, cataracts, glaucoma, strabismus, retinoblastoma)

____Yes _____No If so, what___________________________________________

Did the child's mother have any serious infections or diseases during pregnancy? ____Yes ____No (e.g., rubella, cytomegalovirus, toxoplasmosis, syphilis, herpes)

____Yes _____No If so, what:_______________________

Did the child's mother use drugs or alcohol during pregnancy?

____Yes _____No If so, which:_______________________

Was the child's mother exposed to any environmental hazards during pregnancy? ____Yes ____No (e.g., chemicals, radiation) ___ Yes ____ No. If so, what:

Birth History:

Was the child born prematurely? ____Yes ____No

If so, how early was he/she? _______________________

What was the child's birth weight: _______________________ (3 pounds or under is cause for concern.)

Were there any post-natal infections? ____Yes ____No (e.g., Meningitis, encephalitis hydrocephalus, prolonged fever, convulsions)

_____Yes _____No If so, what:

Was there any kind of head trauma at birth (or shortly thereafter)?

_____Yes _____No If so, describe:_______________________

Other Relevant History:

Has any syndrome been identified? ____Yes ____No

If so, what: _______________________

Has cerebral palsy been identified? ____Yes ____No

Has any neurological disorder been identified? ____Yes ____No (especially the occurrence of seizure activity) ____Yes ____No

Does your child take any medications? ____Yes ____No (e.g., anti-convulsive medication) ____Yes ____No

If so, what:_______________________

Has a hearing problem been identified or suspected? ____Yes ____No

Do you have any concerns about your child's vision? ____Yes ____No

If so, what: _______________________

Functional Skills:

Functional skill is followed by "Age of normal achievement" in parenthesis.


Does your child look at your (or the caregiver's) face, even momentarily? ____Yes ____No (1 Mo.)

Does your child look at his/her own hands? ____Yes ____No (3-4 mos.)

Does your child look at toys? ____Yes ____No (3-4 mos.)

Does your child notice small objects e.g., raisin, Cheerios, lint)? ____Yes ____No (4 mos.)

Does your child watch people at least 6 feet away? ____Yes ____No (6 mos.)

Does your child look for toys that have been dropped? ____Yes ____No (9 mos.)

It your child interested in pictures or picture books? ____Yes ____No (12 mos.)


Does your child bat at objects that are suspended above him/her? ____Yes ____No (3 mos.)

Does your child try to reach out and gasp toys or objects? ____Yes ____No (6 mos.)

Does your child try to pick up a small object? ____Yes ____No (e.g., raisin, Cheerio, lint) (8 mos.)

Does your child try to grab at your glasses or jewelry? ____Yes ____No (9 mos.)

Does your child reach into a container and try to pull out an object? ____Yes ____No (12-18 mos.)


Does your child notice an interesting object at least 5' away and indicate an interest/desire to have it? ____Yes ____No (by pointing, having arms, babbling, making hand movements) (6-7 mos.)

Does your child move, by any means, towards an interesting object at least 5' away? ____Yes ____No (7-8 mos.)


Does your child react differently to different faces or people? ____Yes ____No (6 mos.)

Does your child react to facial expressions (e.g. , smile, frown, "funny face")? ____Yes ____No (10- 12 mos.)


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Eyelids: (check all those that apply)

_____swelling of either eyelid

_____drooping of one or both lids


_____discharge (either watery or pus-like)

_____excess blinking

_____scaley or crusted appearance

White part of eyes: (check all those that apply)

_____yellowish appearance

_____bloodshot, reddish appearance

_____mucous discharge

_____excess tearing


_____obvious discomfort (e.g., itching)

Eyeballs: (check all those that apply)

_____appear to be excessively large

_____appear to be unusually small

_____appear to be "sunken" into the eye socket

Eyes: (check all those that apply)

_____appears to be a "cloudy" film over the front of the eye

_____pupil appears cloudy or whitish

_____abnormal constriction or dilation of the pupil(s)

_____Check here if the child's eyes appear normal (i.e., none of the above were observed); this is to assure that appearance was noted.

See also: "Signs of Eye Trouble in Children" in Preschool Children with Visual Impairments.


Table of Contents

From Infants and Toddlers with Visual Impairments by Virginia Bishop

Pupillary Response: The pupil of the eye is actually a hole surrounded by a circular muscle (the iris). The iris controls the amount of light entering the eye by making the pupil larger (dilation) or smaller (constriction) . Since it is an automatic response, doctors often use the pupillary response test to check whether the automatic nervous system is working. The pupillary response test involves shining a light at the child's face (never directly into the eyes) and watching what the irises do; they should make the pupils smaller when the light is shining on the face; they should make the pupils larger when the light is taken away. In infants, the pupillary response is less pronounced than in older children. (The dilator muscle does not reach full maturity until the child is about 5 years old.) Medications that relax muscles can also make the iris less responsive, and the pupillary response an unreliable test. In children with dark irises, it may be difficult to differentiate pupils from the irises.

Blink Response: The eyelids automatically close when an object approaches unexpectedly and rapidly; this reflex is a protective behavior. When used as a diagnostic tool , it is usually after other tests have been unsuccessful ; since the blink response is an automatic reaction, it only indicates that the eyes are reacting to a gross threat. If used in a vision screening protocol, it should be a final measure (i.e., not among the initial procedures), since it may be perceived as threatening by the child. The probability is that other screening tests will have elicited enough information about visual functioning that the blink response measure will be unnecessary.

Convergence: When visual attention shifts from distance to nearpoint, the eyes automatically converge (move slightly towards the nose). (This assumes that the eyes are normally aligned and automatic brain control is operational . ) Convergence can be elicited by having a child maintain attention on an object as the object is brought towards the face. The eyes should move inwards until the object is about 3"-5" from the face. Since ocular muscles are not usually fully coordinated until about 6 months of age, convergence testing is inappropriate before that time. After 6 months, the ability to converge should be present, but eliciting the behavior may depend more on whether the child is interested in the object and will attend long enough to demonstrate convergence

Muscle Balance: The two eyes are meant to operate in alignment (moving together and in the same positions). If they are not in alignment (not "straight"), or are unable to move at the same speed and direction at the same time ' the brain receives images from the two eyes that are too dissimilar to fuse into a single image, and double vision" (dyplopia) occurs. There are several ways of testing for muscle balance:

  • Corneal Light Reflex: When a penlight is held about 12" from a child's face and pointed at his/her forehead, the reflection of the light should be at exactly the same location in each eye. If it is not, the eyes are not "straight" and referral is indicated. (This test is most reliable for children 6 months of age or older.)
  • Cover Test: As the child looks at an object (or light), held about 12" from the child's face, quickly cover - then uncover - one eye. If there is a latent muscle imbalance, the covered eye will "wander" while covered, and move back into alignment when uncovered. Repeat with the other eye. If in doubt, repeat the test. Not many children fail this test, but it is worth performing if only one child is discovered who needs referral
  • Tracking: Although this procedure is usually listed by itself, it is actually a measure of how well the eyes work together. Since eye muscles move the eyes, it is indirectly a measure of ocular muscle balance. The child looks at an object (or a light, or a face) and follows it with his/her eyes as the object is moved to the left, to the right (crossing midline), up, and down. Infants younger than 6 months of age may not be able to perform this entire test satisfactorily, since their eye muscles may not be fully coordinated yet, but they may be able to follow a slowly moving target for short distances. Between 6 months and a year, smoother tracking may be elicited, however many children cannot yet separate eye and head movements. The examiner should watch the child's eyes and note whether they seem to be moving in a coordinated manner.

Fixation: This term refers to the ability of the child to look at an object for at least several seconds (2-3 seconds). The variable factors are the size of the object and the distance at which it is viewed. Objects should be silent. Two viewing distances are used: Nearpoint (8" 18") and distance (10'). Three sizes of objects are used: a 4" object for both nearpoint and distance; a I " object at nearpoint, and a smaller object (e.g., a raisin or Cheerio) at nearpoint. A child less than 6 months may be unable to do all of these tests satisfactorily, since acuity may not be good enough; using a black and white target may improve the chances for success. After about 6 months, a child should be able to locate and look at all three targets at nearpoint, and should be able to attend to larger objects at 10'. Around a year, the child should be able to complete all tests for fixation satisfactorily. Shifting Gaze is an extension of fixation screening. It simply requires the child to look from one target to another of equal size and complexity at about 12" from the child, and about 12" apart.

Eye Preference: This is a negative screening procedure, since the child should not be using one eye in preference to the other; he/she should be using both eyes simultaneously. If there is evidence of a preferred eye (noticeable head turning or head tilting, or consistently holding a toy to one side to look at it), the child should be referred.

Fields Testing: This procedure requires the child -to maintain attention to an object or face "front and center" while another object is brought from behind the child slowly into the line of vision in an arc from the left, from the right, from above, and from below. When the child notices the moving object, a head turn is almost automatic. Obviously, the test is difficult for young children who have difficulty maintaining the "front and center" orientation for any period of time. In addition, some children will attend to the examiner's hand, rather than the "front and center" head position, and results will be unreliable.

General Rules: Screening procedures should be practiced before applied. 7bere are ways of combining procedures so that entire screening time is less than 15 minutes. More important than the actual screening procedures is the examiner's ability to observe visual behaviors. It may be possible to collect information through observation that will provide indicators of a visual impairment before screening occurs, thus shortening the time needed to do the screening. For example, a child who brings all objects to his/her face for viewing will be unlikely to perform distance tasks; or, the child whose eyes are never steady will have difficulty tracking and will probably fail the corneal reflection test.

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Young children are difficult to test in any way, because they have the capacity to ignore the evaluator or to choose not to cooperate. When multiple disabilities are present, the process is even more difficult, because the child may be non-verbal or non-communicative. For these reasons, there are a few guidelines for those who would do vision screening with young children.

1. Speed is essential! A young child will not wait for the examiner to "get his act together." Young children also have a very short attention span, and lose interest quickly in repetitive activities. The secret is to keep testing activities short, fast, and interesting. It may be necessary to spend several sessions in completing tasks; 10- 15 minute sessions are as much as many young children can endure.

2. Learn to observe. Watch how the child approaches activities and how vision is used. Look for unusual visual behaviors (head turns or head tilts; holding materials very close or very far away, or at unusual angles; closing or covering one eye). Look at the child's eyes; are they moving together? Steady? Jumping or "jiggling?" Don't be concerned if a child needs to turn his/her head as well as his/her eyes: the ability to use eyes independent of head turning is a maturity factor, and some 5 year olds can't yet do it! Watch how a child walks around; is it a hesitating, careful stepping because he/she is not sure what obstacles are in the way? Are the child's hands used as "probes" to feel what's ahead?Does the child bump into things alot? Is hesitancy or an awkward gait a physical (motor) problem, or is it because the child doesn't see well? Look for My unusual behavior that might be related to poor vision

3. Let your plan evolve with the child. Take your cues from the child -whether he/she wants to "play,"work," or be entertained; what things interest him/her; whether the child has recently had medication (or is about to receive it), is hungry or sleepy, is well or ill, is rested or cranky. Not observing a child's cues can sabotage the best plan for assessment, and you'll get nothing.

With these general guidelines in mind, a plan for screening vision can be developed.

  1. Grouping similar tasks can save time
  2. Having someone else record responses can also save time, but if the examiner is alone, have a check list on which to make notes or record responses.
  3. Have materials ready and operational. (If you plan to use a penlight, make sure it is in working order ahead of time!)
  4. Use a relaxed approach (children sense when you're unsure of what you're doing).
  5. Enjoy the experience, and enjoy the child!

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