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Terese Pawletko, Ph.D
reprinted from: FOCAL Points, Fall 2002 Volume 1, Issue 2
The journal concerning Optic Nerve Hypoplasia & Septo Optic Dysplasia

As a former teacher of the visually impaired I was struck by the fact that a subgroup of children with whom I worked did not respond to typical interventions used in early intervention with children with significant visual impairment – for instance, multi-sensory approaches, narrating everything that was going on around the child, hand-overhand presentation. In fact, several of these children appeared to “retreat” and/or become distressed (e.g., might engage in stereotypic behaviors, “appear to be deaf”). Literature in the vision field did not provide an adequate explanation as to the cause for these behaviors aside from labeling the mannerisms as “blindisms” and calling them “autistic-like” – the belief being that some of these behaviors were related to the child’s sensory impairment and lack of opportunities to engage in more typical social exchanges. Rarely was the following question raised: “could this child also be autistic?” At the end of this brief introductory article, I hope that you will have a general understanding of the definition of autism and why it is possible for a child to have both a significant visual impairment and autism.

1. What is autism?

Autism is a biological developmental disorder of the brain that impairs communication and the ability to relate to others. It is often referred to as a spectrum disorder given its presentation ranges from mild to severe in any of its features.

2. What causes autism? How is it diagnosed?

Autism is not etiology specific – that is, it has many possible causes including genetics, environmental toxins, metabolic dysfunction, etc. The commonality among all the causes is that it is a brain-based disorder.

Autism is diagnosed by the presence of certain behavioral features – it cannot be diagnosed by a specific blood test or scan. The defining features include: impairments in reciprocal social interaction that is sustained (e.g., impairment in use of nonverbal behaviors; with young children may fail to develop peer relationships appropriate to developmental level; may lack spontaneous seeking to share enjoyment and interests with someone; may prefer solitary activities; limited to no concept of needs of others); impairments in communication marked and sustained affecting spoken language and nonverbal skills (e.g., delay in or lack of development of spoken language; or may have impairment in ability to sustain conversation; or may show repetitive use of language or idiosyncratic language). For those with speech present, may have unusual pitch, intonation, rate, or rhythm to speech.

Grammar may be immature and include stereotyped use of language (e.g., repeating phrases; repeating commercials). Child may have difficulty understanding simple questions or commands. There may be a lack of varied, spontaneous make-believe or social imitative play commensurate with developmental level. Individuals on the autism spectrum also have restricted, repetitive, stereotyped patterns of behavior, interests (e.g., intense preoccupation with dates, phone numbers; electronic equipment; perhaps with parts of objects), and activities; inflexible adherence to nonfunctional routines or rituals; stereotyped/repetitive motor mannerisms, etc. They may insist on sameness and show resistance and/or anxiety over small changes. There may be stereotyped body movements (e.g., flapping, rocking, toe walking, hand posturing).

Finally, these delays or abnormal functioning in one or more of the above areas must be present before the age of three. While not a defining feature, a number of children and adults on the spectrum have hypo or hypersensitive responses to various stimuli (e.g., certain sounds; certain textures including clothing or food; smells).

3. I’ve read about autism but my child does not have every feature exactly as described in the article. Does that mean he/she doesn’t have autism?

Several issues need to be considered here. First and foremost, autism (and its related disorders, including Aspergers, PDD/NOS, for instance) is defined by the presence of the cluster of behaviors – the presence of any one behavior (e.g., flapping) does not mean that a child is autistic. In addition, it is developmental in nature and as a result, it will change somewhat in presentation as a result of the maturational process. What is important is that the cluster of behaviors be present prior to the age of 3. Finally, given it is a spectrum disorder (e.g., child’s level of function can vary on all dimensions including cognitive ability, behavioral presentation, sensory sensitivities, language/communicative abilities, social relatedness) it is highly unlikely that any individual will fit any one description to a “T.”

4. Can a child with a visual impairment be autistic too? I heard that they have “autistic-like tendencies” but not autism. Is that true?

Children with visual impairments can be on the autism spectrum as well. Remember, it is a brain-based disorder so those children with neurological vulnerabilities (e.g., seizure disorders, septo-optic dysplasia, Prematurity associated with bleeds, agenesis of the corpus callosum, congenital rubella syndrome, etc.) may be at increased risk. The literature in the field of visual impairment needs to be more cautious in its use of the terminology “autistic-like” in that it can result in missed diagnosis and/or delay in procuring appropriate services for those children who are on the autism spectrum. Strategies useful for children who are visually impaired and autistic vary considerably from those effective for children who are just visually impaired.

5. Why are we hearing so much about autism now?

Autism is not as rare as was once thought. According to Dr. Marie Bristol-Powers (1999) National Institute of Child Health and Human Development, autism spectrum disorder is not rare as was once thought. Current estimates suggest that 1 in 1,000 individuals fit the definition of "classic" autism and that 1 in 200 individuals fall within the Autism Spectrum, including Pervasive Developmental Disorder and Asperger's Syndrome.

Why the increase?

We now have clearer diagnostic criteria, increased public awareness and “acceptance”, broader definition of autism as a spectrum disorder, more children, tinier and neurologically more vulnerable children are surviving prematurity; and we have the presence of environmental toxins as potential contributors.

6. Is the notion of autism co-occurring in a child with visual impairment new?

Dr. Stella Chess - her observations of children with Rubella noted “…the difference between the autistic and nonautistic rubella children with sensory defects is the use they make of alternative…modes of experiencing. Nonautistic youngsters … are very alert to their surroundings through their other senses, especially exhibiting visual alertness and appropriate responsiveness... also through seeking of affectionate bodily contact. Some are shy, some slow to warm up, some perhaps wary; but one is impressed by their readiness to respond to appropriately selected and carefully timed overtures. …the autistic children neither explore alternative sensory modalities nor manifest appropriated responsiveness. They form a distinct group whose distance from people cannot be adequately explained by the degree or combination of visual and auditory loss, nor by the degree of retardation where this also exists. … whether retarded or not, their affective behaviors do not resemble those of children of their obtained mental age – in fact, there is no mental age for which the behaviors are appropriate.” Chess... P. 116 - 117

Why the controversy? Why the ongoing debate? Confusion in literature

  • Treated symptoms in isolation (e.g., mannerisms)
  • Viewed as indicative of emotional and behavioral problems (e.g., self-stimulatory behaviors; problems of hyperactivity, inattention, impulsivity; disruptive behaviors such as oppositional; problems of social interaction; problems of mood, affect)
  • Viewed as being totally associated with sensory deprivation (e.g., turn inward for stimulation)
  • Viewed as related to mother-child attachment (e.g., in incubators longer; lack of eye contact so hard to read cues; maternal depression further limiting her involvement w/child)

Examples of some of the eye conditions where Autism Spectrum Disorder has been documented

  • Anophthalmia (may occur at critical periods in brain development and yield higher co-morbidity)
  • Lebers Congenital Amaurosis
  • Peters Anomaly
  • Retinopathy of Prematurity
  • Septo-optic dysplasia
  • Congenital Rubella Syndrome

Key thing to remember: autism is a brain related disorder; that estimated that 50% of blind children have LD and 56% of those with severe LD or IQ<50 have autism (Steinberg et al., 2002)

7. What do we do about it?

It is important to begin to advocate for appropriate diagnosis for your children through collaborative efforts between autism diagnostic centers and teachers of the visually impaired, and by advocating with your primary care providers. Cooperative efforts between vision and autism programs will be critical as most of the strategies used for children with autism rely on vision – not always an option for our children and students. For more information you can go to:

and others…

About the author:

Dr. Terese Pawletko has worked with children since 1976, first as a teacher of the visually impaired, then as school and pediatric psychologist. Starting in 1989, after completing a postdoctoral fellowship in Pediatric Psychology at UNC-Chapel Hill, she worked at UNC School of Medicine with chronically ill children, and with autistic students, their parents, and related service providers. In 1997 she joined the staff of the Maryland School for the Blind where she worked with multiply handicapped children with a variety of disabilities including visual impairment, autism spectrum disorders, cerebral palsy, mental retardation, and learning disabilities, as well as training staff to work with these students. While at MSB, Dr. Pawletko and her colleagues developed the first program in the country for children with visual impairment and autism. She is considered a national expert in this area and has presented at regional, national, and international conferences, conducted evaluations of children suspected of dual diagnosis, and provided consultation to and training of parents and service providers.

Terese's contact information:
Snail mail:
Terese Pawletko, Ph.D.
33 Johnson Lane, Eliot, Maine  03903

Winter 98 Table of Contents
Versión Español de este artículo (Spanish Version)

Editor's Note: I have collected a number of requests and resources for support. I hope that you will take time to peruse these and consider contacting some of these support resources.


The Outreach Department continues to reach out to our Spanish speaking families by updating our network list of families. Several names have been added over the past few months (even someone from Argentina!) so an updated address/telephone list will be mailed to all the families in our network. Resource information, also, will be included in this mailout. Parent to parent contact has proven to be a supportive and effective way to train parents to become advocates for their children. If you know of a Spanish speaking parent with a visually impaired child, please encourage them to call Jean Robinson at (512) 206-9418 or (800) 872-5273 to register their family on the network.

DBMAT (Deafblind Multihandicapped Association of Texas)

We would like to reach out to families of both children with deafblindness and children with visual impairments with additional disabilities. We will be hosting a special gathering at the February Deafblind Symposium in Austin. Please come and join us for this special evening and meet Ralph Warner, President of the National Family Association of Deaf-Blind (NFADB). If you can't make it, give us a call to get information and support at (972) 281-1904.

Sibling On-line Support Chat

We have a new, fresh look to our Sibling On-line Support Chat, and I am inviting everyone to come check us out! We plan to have guest speakers join us for future on-line sibchats, and I would love to hear any suggestions you might have for who I could connect with. Go to this site <> and follow the "yellow brick road." If you have questions drop me a line at <> or this address <>. From Marianne Tucker, Sibshop Coordinator for Tampa Bay.

Hydroxyglutaric aciduria

Our baby-girl has been diagnosed with this disease. She is now 5 months old, has some brain inaccuracies, dilated cardiomyopathy, and now and then has seizures. According to our physician, there are only 8 patients with this disease, but according to my internet sources there are many more children affected by this illness (at least 28). I am starting a homepage for this disease, which will be released soon to try and get in touch with as many families as possible. If parents wish to exchange information, they can let me know. From Micky Geerts, mom to Sabina at email <>.

Deafblind Teen Wants to Chat

I'm a junior in high school and I would like to connect with other deafblind teens. I'm getting ready to go to college in a year or two and would love to talk with others making similar decisions about college. If you would like to chat, too, send an email to <> and it will be forwarded to me.

Sibs want Penpals

My 4 other children feel left out. I would love parents of deafblind children to have their other kids snail mail to my kids. It will help with grammar, penmanship, friendships, stamp collecting and maybe some mutual feelings. John is 12 years old, James is 10, Maureen is 8, and Brian is 6. Send mail to 25 Woodard Road, Monroe, NY 10950. Dawn and John Slaka at <>

TO: Classroom Teacher

FROM: Vision Itinerant Teacher

RE: Students Using a Monocular

A monocular is a small telescope which enables a visually impaired student to see print, pictures, diagrams, maps, faces and demonstrations when (s)he is seated at his/her desk. The following are some facts and adaptations which need to be considered if a monocular is being used:

  1. A monocular severely restricts the visual field. The student will be taught by the vision teacher to scan to pick up all visual information and increase their visual memory so they can copy more quickly and efficiently.
  2. A monocular is typically used for distance tasks only.
  3. Copying while using a monocular is laborious, and it will take the visually impaired child longer to copy from the board/charts, etc. You can adapt by modifying the length of the assignment. Some ways of doing this include:
    1. assigning even or odd numbers of problems
    2. allowing the student to write only the answers to questions rather than re-copy entire sentences, questions, and/or paragraphs
  4. When a student is using a monocular, walking up to the board/chart should be discouraged. This annoys other students and severely hinders speed, continuity of thought, and proficiency when reading or completing an assignment.
  5. Singling out a visually impaired student's desk (to place him/her closer to the board) is discouraged due to social reasons. A monocular will enable the child to sit within the group at all times.
  6. Monoculars break easily and should be worn around the neck when in use and stored in a case otherwise. Please encourage young children to keep their monoculars out of sight when the room is empty.
  7. Encourage the child to take the monocular to other school events, e.g. assemblies, film presentations.
  8. Do not allow other children to handle the monocular.
  9. Do not allow the monocular to be taken home with the child unless arrangements have been made with the vision itinerant teacher.
  10. A child who is using a monocular should be seated facing the boards/charts to allow straight-on viewing. This also enables the child to rest his/her elbow on the desk while he is looking through the monocular.

By Gigi Newton, INSITE Specialist and Kate Moss, Family Specialist, TSBVI, Texas Deafblind Outreach

Originally published in Summer 2001 edition of See/Hear Newsletter

Importance of vision and hearing to development and learning

Although every one of our senses plays a role in early development, vision and hearing certainly seem to lead the way. Much of early parent/child bonding has to do with the child's ability to make eye contact and sustain a gaze with his parents, respond to their voices by gurgling and cooing, and to be comforted by the sight and sound of them. Much of the reason an infant tries to move is because he sees or hears something that intrigues him. He learns that things and people exist in the world primarily because he sees and hears them come and go. He visually tracks an object he pitches to the ground or hears it hit the floor. That tells him the object still exists, even though it is not in his hands any longer. When she cries she can hear Daddy calling to her or see Momma walk into the room. She can inspire her parents to linger and play with her by cooing and making eye contact, the earliest form of conversation. He learns about size, shape, color, functions of objects, social interactions, and so much more just by listening and looking at the world at work. Early development has critical links to a child having full use of his/her vision and hearing. When these senses don't work perfectly or not very well, everything is impacted.

It's hard to tell a parent there may be vision and hearing issues

Professionals working with infants and families may have a hard time suggesting that there is a problem with a child's vision or hearing. This is especially true when the family is already dealing with their child's other medical or disability issues. After all, a family can only deal with so much at one time. Because infants are much harder to test for vision and hearing loss, many mild impairments (or sometimes even major impairments) may not be diagnosed quickly. Subjecting the family to another round of testing is always a hard call.

Learning about hearing and vision loss immediately is critical

As we said earlier, much of the sensory information that is vital to children's development comes through the senses of vision and hearing. During the first three years of a child's life major neural networks are being formed in the brain. Much of this development comes from distance senses, i.e., vision and hearing, which allows us to know about things and people in the world even when we are not in physical contact with them. After the first three years, development of these neural networks becomes slower. Skills that may be gained in early intervention cannot be made as quickly when the child is older.

For these and other reasons, children should be regularly checked for vision and hearing problems. We know that even mild problems with these senses can have major impact on learning. A mild hearing loss in a noisy home or daycare center can result in a child who misses critical bits of information. He may miss sounds that let him develop normal language and speech patterns. He may miss instructions his parents or babysitter gave him and appear to be misbehaving. He may become withdrawn because he is not sure what is expected of him. If he has a visual field loss he may constantly be stumbling over things. This has great impact on self-concept. A child who is sensitive to light may not enjoy or feel secure playing out of doors.

Every child, with or without a disability, should have regular and periodic vision and hearing checks. If the child is severely disabled, this can be even more important since their other senses may not be as useful in compensating for what they miss visually and auditorially. In fact, this is so important that schools complete vision and hearing screenings at regular intervals throughout the remainder of the child's educational career. These types of screenings are even more critical from birth to age three.

Parents should trust their intuition

Parents know more about their child than anyone else does. Often we meet parents who tell us that they knew something was wrong with their child's vision and hearing before any of the doctors mentioned it. In fact, many have been told that they shouldn't go looking for trouble or that their child would "grow out of it."

Parents should trust themselves when they feel there is something wrong with the way their baby uses his vision or hearing. They should feel comfortable insisting that vision and hearing are tested, especially if their child is at high risk for vision and hearing loss.

Red flags

There are many red flags associated with vision and hearing loss. Below are the syndromes, diseases and conditions, listed on the Texas Deafblind Census, that put a child at high risk for deafblindness. Children with these etiologies should be watched closely for vision and hearing problems.

Syndromes, Diseases and Conditions


  • Congenital Rubella
  • Congenital Syphilis
  • Congenital Toxoplasmosis
  • Cytomegalovirus
  • Fetal Alcohol Syndrome
  • Hydrocephaly
  • Maternal Drug Use
  • Microcephaly
  • Neonatal Herpes Simplex


  • Asphyxia
  • Direct Trauma to the Eye and/or Ear
  • Encephalitis
  • Infections
  • Meningitis
  • Severe Head Injury
  • Stroke
  • Tumors
  • Chemically Induced

Related to Prematurity

  • Complications of Prematurity


  • Aicardi
  • Alport
  • Alstrom
  • Apert
  • Bardet-Biedl
  • Batten Disease
  • Chromosome 18, Ring 18
  • Cockayne
  • Cogan
  • Cornelia de Lange
  • Cri du Chat
  • Crigler-Najjar
  • Crouzon
  • Dandy Walker
  • Down
  • Goldenhar
  • Hand-Schuller-Christian
  • Hallgren
  • Herpes-Zoster (or Hunt)
  • Hunter (MPS II)
  • Hurler (MPS I-H)
  • Kearns-Sayre
  • Klippel-Feil Sequence
  • Klippel-Trenaunay-Weber
  • Kniest Dysplasia
  • Leber's Congenital Amaurosis
  • Leigh Disease
  • Marfan
  • Marshall
  • Maroteaux-Lamy
  • Moebius
  • Monosomy 10p
  • Morquio
  • Norrie
  • NF-Neurofibromatosis (von Recklinghausen Disease)
  • NF2-Bilateral Acoustic
  • Neurofibromatosis
  • Optico-Cochleo-Dentate
  • Degeneration
  • Pfieffer
  • Prader-Willi
  • Pierre-Robin
  • Refsum
  • Scheie (MPS I-S)
  • Smith-Lemli-Opitz
  • Stickler
  • Sturge-Weber
  • Treacher Collins
  • Trisomy 13 (Trisomy 13-15, Patau)
  • Trisomy 18 (Edwards)
  • Turner
  • Usher I
  • Usher II
  • Usher III
  • Vogt-Koyanagi-Harada
  • Waardenburg
  • Wildervanck
  • Wolf-Hirschhorn (Trisomy 4p)

Sometimes the child's etiology is unknown or the child may have only one diagnosed sensory loss. Professionals working with infants and young babies, as well as parents, should be aware of the red flags that may indicate a problem with either vision or hearing.

Hearing Loss

At Risk Factors

  • Malformation of the ear, nose, and throat
  • Rubella during pregnancy
  • Rh incompatibility
  • Family history of hearing loss
  • Apgar score from 0-3
  • Severe neonatal infections
  • Meningitis
  • Low birth weight (under 3.3 lbs.)
  • Hyperbilirubinemia
  • Ototoxic medications
  • Severe respiratory distress and/or prolonged mechanical ventilation (10 days or more)
  • Neurodegenerative disorders
  • Childhood infectious diseases such as mumps and measles

(Hearing, Speech and Deafness Center website,, June 2001)

Behavioral Indicators

  • The child does not stop moving, does not quiet in response to speech, and/or does not arouse from light sleep to sudden loud noises.
  • At about 4-7 months, the child does not turn to sounds and voices or give an indication of detecting a sound source by eyes widening or blinking, fussing or quieting, increasing or decreasing overall activity level, changes in breathing or sucking patterns.
  • There is a lack of babbling, cooing, grunting, or the child stops these behaviors and does not progress to speech.
  • The child does not respond to familiar sounds (such as mom's and dad's voices) by cooing/gurgling when he cannot see them.
  • The child does not use speech at an age when most children are beginning to use speech (approximately 9-12 months).

(SKI-HI Institute, 1998)

Vision Loss

At Risk Factors

  • Family history of vision loss (Retinoblastoma or Albinism)
  • Malformation of the ear, nose, and throat
  • Prematurity and low birth weight less than 3 lbs.
  • Birth trauma/head trauma
  • Anoxia
  • Cerebral Palsy
  • Congenital viral or bacterial infections (Rubella, CMV, Syphilis, Group B Streptococcus Infection, Toxoplasmosis, Chicken Pox, HIV)
  • Meningitis, Encephalitis, Hyperthyroidism, Microcephaly

Behavioral Indicators

  • The child does not have eyes or eyelids that look typical.
  • The child does not recognize caregivers' faces or smile in response to their smiles around the age of 3 months.
  • He does not get excited when he sees his bottle or other familiar objects he likes.
  • At 4-6 months, the child's eyes do not seem to move together when following an object or person.
  • The child may turn or tilt his head in unusual positions when looking at an object.
  • The child may hold an object very close to his eyes.
  • The child may over-reach or under-reach for objects (accurate reaching usually occurs around 6 months).

What do you do?

If there is a concern about vision or hearing, your ECI program should make a referral to the appropriate medical professional. We would like to encourage ECI personnel to work closely with their Teacher of the Visually Impaired, Teacher of the Deaf and Hearing Impaired, and/or TCB Children's Caseworkers in helping the families prepare for the doctor visits. These professionals have much to offer to the process. They can usually share the names of doctors, audiologists, and vision specialists who have more experience working with disabled children. Often they can guide the ECI professional and parents in compiling a list of concerns related to the way the child uses his vision and hearing. More importantly, they can provide parents with information about the types of testing that may be done and how to help prepare the child for testing. This level of support can be provided before an actual vision or hearing referral has been made.

Parents and professionals must keep a close watch on a child's progress related to vision and hearing. Hearing and vision issues must not be ignored, especially if the child has other disabilities. When a problem is suspected, no time should be lost in following up on the concern. We owe it to our children not to lose that critical window of time between birth and age three. When early intervention can make such major differences in life-long functioning, they can't afford to wait.

References and Resources

  • Hearing, Speech and Deafness Center website,, June 2001. Early identification of hearing loss. From Communication Update, published on HSDC Website, copyright 1996-99.
  • Moss, Kate. Syndromes which often result in combined vision and hearing loss. Texas School for the Blind and Visually Impaired website,, 2001.
  • SKI-HI Institute, 1998. Auditory development. Understanding Deafblindness: Issues, Perspectives, and Strategies. SKI-HI, Utah State University, Logan, Utah, p. 21.
  • Texas School for the Blind and Visually Impaired website,, June 2001. Primary identified etiology - deafblind.

Movement in space provides infants with Stimulation. Movement promotes increased interaction with and understanding of their environment. Physical movement promotes interactions with others and with their environment, as well as intrinsic pleasure. Children with visual impairment may need extra guidance to promote coordinated and fluid movements, as they often lack the appropriate motivation to move and to explore.

Many things affect movement:

primitive reflexes 
(automatic reactions to external stimuli)
(body alignment that promotes optimal movement)
(muscles that are in a balanced resting state of tension)
(adjusting position when the body's center of gravity is not within the base of support)
(muscle power to perform activity and maintain stability)
advanced reflex reactions
(automatic postural adjustments and righting movements) 
rotational skills 
(moving one portion of the trunk while keeping the rest stationary) coordination 
(smooth transitions from one position to another)
sensory integration
(organizing input from various sensory systems before making a response)
motor planning 
(logically carrying out a sequence of actions resulting in the successful completion of a motor task)
(moving from place to place independently)
conceptual understanding 
(understanding of body parts, body position in space objects, and objects in space).

Concerns for Children with Visual Impairment

  • Vision is a strong motivator for infants to lift their heads and go after' something they see. Children with VI will need extra encouragement to move and explore.
  • Infants with VI often dislike the prone (on their tummy) position. Prone positioning and the rotational movements into and out of prone (and into and out of hands-knees) are important for building strength and stability. Therefore, it is important that infants experience the prone position (tummy time') in positive ways from early infancy.
  • All children, but esp. children with VI learn through experiences. Provide lots of movement experiences. Do activities with your child, not to your child. Provide a large variety of these experiences. Include crawling through tunnels and onto couches, stepping in and out of boxes or buckets, crawling or walking on uneven surfaces. Help them see' their changing and varied environment.
  • Attach language to motor play. When crawling up (or down) on the couch, say "we're going up," "we're going down."
  • Provide REAL objects when talking about them (give him a real orange to play with, not a plastic one)
  • Children learn many motor skills by imitating others. Children with VI do not have this opportunity to observe and imitate. They will need to be taken through new experiences in a hand-over-hand fashion.
  • Lack of vision may lead to reduced interest in repetitive motor play. Attaching bracelets with bells to wrists or ankles can provide additional interesting stimuli for the infant.
  • Children need predictability in their surroundings. Items in their environment should be kept constant, and children should be encouraged to learn where things are located. Children should never be picked up and carried and placed in new surroundings, they should assisted in moving into a new area, so they can understand how the new area is set up. If they learn to be confident in familiar areas, they will be more secure in unfamiliar environments.
  • Children with VI are lacking the ability of "seeing" anticipatory cues in their environment. It is important to give them cues before moving them, placing something in their hands, or when feeding them. These cues can be verbal or tactual.
  • Play all the singsong handclap games with your child. This type of fun, movement, game is important for learning concepts of where is a head, shoulders, knees, toes (song); hands clap together (patty-cake); objects are permanent (peek-a-boo). They also encourage sitting balance as they are using their hands for play, not for balance propping. They also encourage using hands together, and reaching.

Developmental Sequence

  • Lift head while lying on their belly (prone) by 3 months
  • Sit with support by 6 months
  • Play with feet by 6 months
  • Roll over by 6-8 months
  • Sit without support by 8 months
  • Start trying to crawl by 8 months
  • Reach in all directions from sitting without falling over by 9 months
  • Pull to standing by 9-12 months
  • Walk alone by 12-18 months
  • Crawl upstairs by 12 months
  • Kneel alone by 15 months
  • Crawl (backwards) downstairs by 18 months
  • Run well by 2 years
  • Squat to play by 2 years
  • Kick a ball by 3 years

Taken from:

Sensory Motor Activities for Early Development by Hong, Gabriel, & St. John, l996

Developmental Guidelines for Infants w/ Visual Impairments by Lueck, Chen, & Kekelis, l997

 Expanded Core Curriculum - The expanded core curriculum (ECC) outlines the core content areas for all students with visual impairments and deafblindness that are the focus of the support provided by a teacher of students with visual impairments and certified orientation and mobility specialists.

Family Connect - Family Connect provides a series of videos for families of children with visual impairments and deafblindness.

Making the Sensational Happen - Video from the Blind Children's Center of Los Angeles.

Paths to Literacy - This website is the result of a joint project between Perkins School for the Blind and Texas School for the Blind and Visually Impaired (TSBVI). By combining our resources and expertise, we hope to assist educators and families in the quest to provide literacy experiences for children who are blind or visually impaired.The information on this site ranges from a basic overview of literacy to various stages of development and special challenges, as well as an exploration of different media (print, braille, auditory strategies). We encourage you to add your ideas and questions, so that this will be an interactive hub of resources.

Perkins Scout - Perkins Scout is a searchable database of carefully evaluated online resources related to blindness and visual impairment.

Perkins Webcasts - Perkins series of on-demand webcasts are presented by experts in the field of visual impairment and deafblindness. Whether your interests are professional or personal, you will find topics of interest.

Project SPARKLE - Website for parents of children with deafblindness that provides informational training modules.  To access this website you must first contact your state deafblind family support consultant to get a username and password; in Texas this is Edgenie Bellah - 

Texas School for the Blind & Visually Impaired On-The-Go Learning - Parents can find a wide range of videos and web-based broadcasts on a variety of topics on TSBVI's On-The-Go Learning site.

This year I had a blind student in kindergarten. One of the table jobs the class did each week was cut out pictures of objects beginning with the letter of the week and paste it on a page for an alphabet book. I developed a list of real objects, small and flat enough to be pasted in a book, for my student to use.

Each week he would cut out his real object and paste it onto a piece of braille paper. At the end of the year, I put the pages in a large-ring binder. It was a wonderful book for him.

As an outgrowth of that list, I expanded to a listing of real objects that would fit in a manipulative tub. From there, I added body parts, actions, animals, concepts of position, foods and things (too big for a book or tub). Terri Bohling - 

Download Alphabet chart in RTF (465k)

Alphabet Book Objects, Manipulatives and Other Things
LetterObject BookManipulative TubDemonstrate
        Body PartActionAnimalPositionConceptFoodThing
A Aluminum Abacus Apricot Arm   Ant     Apricot Ashes Airplane
Arrow Acorn Apple Ankle         Asparagus Ax April
  Airplane Asparagus           Apple August  
B Bean Book Bowl   Bow (motion) Bird       Boat Bread
Bag Ball Box     Butterfly       Beard Brick
Bandaid Banana Bow (tie)     Bat       Bike Brush
Barrette Basket Bone     Bear          
Book Bell Block     Bugs          
Button Berry Beanbag                
C Comb Candle Can   Crawl Cricket   Corner Cake Clock  
Cotton ball Cassette Candy   Cry Cat       Computer  
Candle (b-day) Camera Cap   Cut Cow       Compact disc  
Cardboard Clay Car   Clap         Cover  
Crayon Cookie Corn   Cough         Claw  
  Crown Cup             Calendar  
D Dot Dice Dinosaur   Draw Deer       Door Drag
Diamond (shape) Dog collar Dollar   Drink Dog       Day Drawer
  Dress Daisy   Drop Dolphin       Desk Drip
  Doll     Dig Donkey       Dirt Drill
          Duck       Drum December
E Envelope Egg   Ear Exercise Eagle   Edge Egg    
Eggshells     Elbow Echo  Eat Elephant          
8     Eye Empty            
F Feather Film Flag Face Fall Fish Front Flat Flour Family February
Fork Flashlight Flower Foot Fast Fly   Full Food Fat Friday
4 Football Frame Finger Find Frog       Farm  
5 Fur   Fist Fill Fox       Field  
      Fingernail Fold         Fire  
        Fly         Floor  
        Float         Fence  
        Follow         Fence  
        Freeze         Freeze  
G Gum Gift Glue   Gallop Goose       Game Ground
Glasses Glove Grape   Giggle Goat       Garage Guitar
Glove Grapefruit     Give         Gate Grass
                  Girl Garden
H Hair Hammer Hat Hand Hang Hen High Half Hamburger Hall Hole
Heart Helicopter Helmet Head Hear Hippo   Hard Honey Handle Hill
Hanger Horn   Heel Hide Horse   Heavy   Happy Helicopter
      Hip Hurry         Heat  
I In Ivy Iris Iris Imitate Iguana Inside Inch Ice Cream Ink Incline
Ivy       Imagine Insect   Inside   Iron Ivory
Inch       Inhale         Infant  
        Itch         Indian  
J Jellybean Jar Jacket Jaw Jog       Jam Jeans  
        Jump       Jelly January  
        Jerk       Jellybean June  
        Join         July  
K Key Kernel     Kick Kangaroo     Ketchup Kite  
        Kiss Kitten     Kiwi Kindergarten  
          Koala       Kitchen  
L Lace Lock Lime Leg Laugh Lamb Layer Large Licorice Love Lump
Leather Leash Lollipop Lip Lay Ladybug Left Loud Lemon Ladder Lullaby
Lavender Licorice Lily Lap Lead Leopard Line Light Lettuce Lake Lens
Leaf Lemon Lilac   Listen Lion Last Little Lime Lamp Ledge
  Lettuce     Lean Lizard   Long Lollipop Lid Lunch
        Leave Llama   Loose Lunch Lawn Library
        Lick     Less   Leaf Letter
        Lie     Little   Loaf  
M Macaroni Magnet Mouth Muscle Measure Monkey Middle Many Milk Melt  
Match Marble Mask   Mix Mouse   Most Marmalade Metal  
Marshmallow Magazine Mail   Move Moose   Much Melon Model Mustache
Mitten Marigold Moccasin   March Mosquito     Mint Month Map
  Mint Mug   Mash Mule     Muffin Mud Monday
    Mustard     Mole     Mustard Music Mat
                  March May
N Nail Newspaper Nut Neck Nod Nest Next Narrow Nut Name New
Needle Net Nylons Nose Noisy   Near None Nutmeg Night No
Name Badge 9   Navel Nap         November  
Noodle     Nostril Nibble            
O Oval Overalls       Octopus Over Open Omelet Oil October
Oatmeal Oak leave       Ostrich Out Other Onion Office Old
          Otter   Off Orange Opera Outdoors
          Owl   On Oatmeal Organ Outline
          Orangutan   Old   Oak tree Oven
          Opossum   One   Orchid  
          Ox   Only      
P Pebble Paper Plate Palm Pass Panda   Pair Peach Page Pants
Pen Pocket Puppet   Pat Parrot   Pile Pancake Paint Pajamas
Pin Purse Puzzle   Peel Peacock     Pea Pan Petal
Paper Powder Pipe   Pet Penguin     Peanut Picture Plant
Paintbrush Plug     Pick Pig     Pepper Poem Pot
Paperclip       Play Polar Bear     Pie Parachute Pattern
Patch       Please Pony     Pizza Pedal Piano
Peg       Point Puppy     Popcorn Pillow Playground
Pencil       Pull Parakeet     Potato Pole Powder
Penny       Press Paw     Pudding Pansy Petal
Postcard       Push       Pumpkin Pipe Police
Putty       Pour       Pickle Pulse  
        Pump       Prune    
Q Quarter Quilt     Quiet Quail       Quack  
        Quick         Question  
R Rectangle Radio     Race Rabbit Right Rough Radish Refrigerator Rain
Ribbon Ring     Raise Rat   Round Raisin Rake Road
Rice Rope     Run Reindeer   Row Raspberry Robot Rhyme
Rock Ruler     Reach Reptile     Rhubarb Room Rose
Ruler Rattle     Read Rhino       Rubber Rug
Ring Racket     Rest Robin       Ramp Razor
Rubber Band Rose     Ride Rooster       Recess Recipe
        Roar Raccoon          
        Roll Ram          
S Seed Saucer     Swallow Seal Second Sharp Salad    
Shell Scarf   Shoulder Sit   Say Shark Side Short Salt Sail School
Soap Scissors   Skin Skip  Sew Sheep   Shut Sandwich Shelf Sand
Spoon Shoe   Skull Scratch Snail   Slow Soup Screen Shirt
Star Sock     Scream Snake   Small Spaghetti Scale Season
Square       Search Spider   Smooth Snickerdoodles Sign Seat
Stick       Shake Sweep Squirrel   Soft Squash Seesaw Sink
Straw       Share  Sort Swan   Square Sour Shade Sheet
String       Shout  Sing     Straight   Skirt Shower
6       Sleep  Spill         Slice Song
7       Slide  Smell         Sour Stairs
        Smash         Step Statue
        Smile  Spin         Stem Store
        Sneeze         Story Stove
        Splash         Street Student
        Squash         Summer Sum
        Squeeze         Sunshine Sweater
        Stand         Sweat Saturday
        Statue-game         September Sunday
        Stay  Swing            
        Stop  Stretch            
T Triangle Tongs Train Teeth Talk  Tap Tail Third Tall Tomato Table Teacher
Tissue Tweezers Timer Tears Tear  Tie Tiger Through Thin Tangerine Television Temperature
Terri Telephone Thread Thumb Tired Toad Toward Tiny   Thirsty Time
2 Towel Toy Toe Trip  Taste Turtle   Top   Tent Tire
10 Tub Tube Tongue Tiptoe     Thick   Tree Trumpet
Tape T-shirt Tennis ball   Turn  Twist     Tight   Trunk Teepee
Twig Tape recorder Tie   Taste     Together   Tower Tuesday
  Tissue     Throw         Thursday  
U Umbrella Umbrella Undress     Unicorn Under     Unhappy Uncomfortable
Under   Undo       Up     Underground United States
    Unfold       Upside down        
V Valentine Vase Video                
Velvet Vine Visor           Vanilla Volume (sound) Vending Machine
Velcro Veil Vest           Vegetable VCR     Van Violin
                Vinegar Violet Vacation
                  Vitamin Vacuum cleaner
W Wax Wool Web Waist Wait  Wrap Whale   Wet Waffle Wagon Warm
Wire Wallet Whistle   Wake Wolf   Wide Walnut Wall Water
Watch Walnut     Whisper Worm   Whole Watermelon Weather Week
        Wave  Wind Weasel     Wheat Wheel Wheelbarrow
        Wash  Walk Whisker       Win Wind
        Weigh Wing       Wish Window
        Whistle Woodpecker       Wing Wood
        Write         Winter Wednesday
X   Xylophone               Xerox X-ray
Y Yarn Yardstick Yo-yo   Yawn Yak   Yesterday Yolk Yellow Yes
        Yell     Yard Yeast You Year
        Yodel       Yogurt    
Z Zipper       Zip Zebra   Zero Zucchini Zinnia  
Zigzag       Zoom            

Chrissy Cowan, TVI
Texas School for the Blind and Visually Impaired

Designing Educational Environments to Optimize Vision

As you work with students with low vision, there are general adjustments that can be made to classroom environments that will enhance visual functioning. The following should be considered for each individual student, based on information from a functional vision evaluation.

Consider the Etiology

Familiarize yourself with the characteristics of the most predominant visual conditions resulting in low vision and their effects, such as retinitis pigmentosa, ocular albinism, retinopathy of prematurity, optic nerve hypoplasia, cortical visual impairment, cataracts, coloboma, nystagmus, central scotoma, glaucoma (this list is not complete). A current (October 2015) web resource for this is “Visual Impairment”. For each etiology, look for such things as:

Effects of Light

Examples: cataracts cause light to be scattered over the retina meaning that bright light and glare will usually cause problems for the student, whereas the student with retinitis pigmentosa (RP) will require high illumination. Glare for some would be disastrous. Overhead lighting might be too low/high, depending on the etiology. Illuminated screens (any type of lighted display) would be difficult for some, necessary for others.

Field Deficits

Examples: students with Stargardt’s Disease can have a central acuity loss, making staying on a line of print difficult without specific training. Students with retinitis pigmentosa tend to lose the peripheral field, thus making large print and/or enlarged maps/charts/graphs/photos difficult to scan.

Eye Motor

Examples: students with nystagmus tend to have problems shifting gaze from one target to another (typical of copying assignments).

Consider Posture

A work surface and/or computer work station that is poorly arranged in regards to lighting would reduce visual efficiency. Whereas marketed reading stands straighten the student’s posture and elevate the reading material, students typically need to write on the same (slanted) surface. Look on occupational therapy websites, such as, for a writing stand that does not have the ridge at the bottom which makes writing uncomfortable. Or, use a 3 inch 3-ring binder turned sideways to slant work at an angle.

Consider Organization

It takes the student with low vision longer to find things. Students need to access their materials quickly, so storing for quick retrieval is necessary. Consider a small, stick-on battery operated closet light that you press for inside desks and other darker spaces. Backpacks will need folders and other organizational containers to keep papers organized, and smaller objects in desks should have dedicated containers. The TVI will need to check and reinforce that an established system is used consistently.

Consider Lighting

For Work Surfaces
With some eye conditions, a lamp might be necessary to put light precisely where it is needed. If an outlet is nearby, the APH lamp is wonderful. Another option is a battery powered OTT light that can be moved from room to room. When positioning the light, make sure the student’s head or hand does not occlude the light, or that the light is shining on the student’s face.

Students with albinism or cataracts might have difficulty with too much ambient light and/or glare, which can cause headaches and have a “wash-out” effect on certain materials. Tinted lenses might be beneficial for some, or a light blue filter placed over the reading surface could change the contrast (watch for glare off of shiny surfaces). Avoid seating that is directly under harsh overhead lighting or near a large window.

Overhead Projector Screens and Interactive White Boards
When the target surface is lighted or bright, students with lighting issues may have difficulties. The classroom lighting can be adjusted to accommodate, or in extreme cases, the student may need to have a desk (print) copy if significant copy work is required. There are apps available that connect the student’s tablet with the teacher’s computer or the interactive white board that would provide a clearer copy for the student.

Consider Writing Tools and Materials

Provide adapted paper and writing tools, and adjust lighting and positioning of materials (see writing slant board above) if needed. Examples of writing tools include drafting pencils (or #1 soft lead, available in art/craft stores) and fine point felt tip pens, such as a Flare® pen. Students may perform better with bold line paper, or commercially available wide ruled notebook paper with darker lines (compare these at the grocery store—some are darker than others). Gradually move toward fewer adaptations as the student becomes more proficient.

Consider Optical Devices

Assuming the student has been seen by a low vision specialist, start by making sure the prescribed optical devices are on hand and the student has learned how to use them correctly. Devices that tend to be handed to students by well-intentioned people should be avoided (e.g., full page magnifier, bar magnifier). Electronic near devices are best used for “spot” viewing, and will slow the student down when reading longer passages.

If a video magnifier (CCTV) is in the room, find out if it is being used consistently. If it is not (perhaps due to portability, placement, too much enlargement) consider retraining the student on a handheld or stand magnifier. There are now products available from APH and Education Service Center, Region 4 that are designed for teaching optical device use. Refer to Looking to Learn: Promoting Literacy for Students with Low Vision, D’Andrea and Farrenkopf, Eds., AFB Press.


Texas SenseAbilities - a free newsletter provided by TSBVI and DARS-Division of Blind Services provides articles from parents, individuals with visual impairment and deafblindness, programming information and strategies, updates on resources and training in English, Spanish, braille and large print as well as electronic formats.

Deaf-Blind Perspectives - Deaf-Blind Perspectives is a free publication with articles, essays, and announcements about topics related to people who are deaf-blind. Published two times a year (Spring and Fall) by The Teaching Research Institute of Western Oregon University, its purpose is to provide information and serve as a forum for discussion and sharing ideas. The intended audience includes deaf-blind individuals, family members, teachers, and other service providers and professionals.