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Visually Impaired Children with Multiple Disabilities

Multiple problems are more common in children with congenital visual impairment than in children who become visually impaired later in life. In different parts of the world 60–80% of vision impaired children have at least one other impairment or chronic illness. Some have more than four impairments, each causing disability. In most countries, visual impairment of multi-disabled children is not registered because only the “primary” impairment can be registered and that is usually intellectual, motor or auditory disability because they are diagnosed early. It is important to be aware of the variations of visual development in the groups of children with several impairments so that visual disability is not interpreted as a behavioral problem or an intellectual disability.

Better health care across the world has ensured greater survival rates for the premature and very low birth weight infants, children with syndromes, and those who have severe damage in accidents. As a result we see an increase in the number of children with visual impairment and additional disabilities, but neither medical nor rehabilitation services have received enough resources for intervention to enable better quality of life for all visually impaired children.

Children with multiple disabilities often have poor assessment and intervention because many practitioners find it hard to imagine the potential for development when they see the combination of several impairments. However, often infants, who did not seem to have almost any potential for development during the first few months, surprise specialists with their skills in many areas.

Young infants

Assessment of the visual field by the therapist.

When assessing a child for the first time it is wise to ask the child’s therapist to start the testing so that the child gets an opportunity to hear the new voice without anything painful happening (as it was usual at the hospital). Infant’s own therapist can perform the first test situations, where she brings an illuminated ball (thin plastic ball on a penlight) from the side toward the mid-line to test the size of the visual or attention field. This infant responded only in the mid-line.

Here is the video from the testing situation:

Note in the video how the therapist is asked to bring the illuminated ball below the hands of the infant, first the better functioning hand then the hemiplegic hand, so that fingers on the ball create a grating pattern, an effective

There was a brief response to the larger fixation stick.

visual stimulus. When the infant is getting accustomed to the new voice the doctor can go on with the assessment.

There was no response to the small fixation stick but the baby did briefly fixate the face picture on the large fixation stick.

Since no accommodation could be measured, near correction was tried and the girl had a brief eye contact with the tester.

Near correction was tried resulting in brief eye contact.

We learned more about the girl’s vision and capacity when her twin brother was examined. The girl showed very clearly that she was accustomed to be the center of attention and she did not like a situation, where the new person was playing with her brother. It was obvious that she had to be able to see and hear more than what the tests had shown; she had opinions and she could express her opinions. What else should a 5-month old infant be able to communicate?

During the examination of her brother, the baby showed that she did not like the situation.

The early activation and continuous support of visual development is especially important in all young infants with hypotonia or hemiplegic conditions. Infants with motor problems can develop their ocular motor functions better if they are included in physiotherapy.

The infant has learned to use her hands together.

Here is the video showing the child’s progress:

Ten weeks after the physiotherapy was started, this infant had learned to use her hemiplegic side quite well, played with both hands in the midline and had good visual communication with her therapist. Note that during this therapy session she turned from her back to her stomach for the first time when trying to get her favorite toy. Visual information was used to entice the infant to try a new motor function.

Right eye is trained during physiotherapy.

When her right eye started to become a lazy eye training was included in her physiotherapy. During training of the less functioning right arm, the baby held a toy and moved it in front of her right eye. The left eye was patched.

During therapies and the visits of an early intervention teacher/worker the use of tactile and kinaesthetic information should be observed to enrich information during interaction. The little hands should be given opportunities to explore faces. Father’s face is exciting to explore: in the morning before the father has shaved, his face can be studied in detail. Then when he has shaved one half of the face, the difference between the two halves of the face is investigated; the comparison is repeated when the other half of the face is shaved. This gives the infant much to ponder during the day until the father comes home, again a bit different. Mothers’ face never changes.


Many tests cannot be used exactly as designed. Some children cannot speak and will point with their eyes, head, hand or foot. Some children will need support for their bodies or head, help in bringing their hands forward or keeping their bodies relaxed in order to use their visual system. Other children will be able to give visual responses only when they are given adequate time and no disturbance of the other senses – no noise or touch. These needs vary from child to child and are learned through observation and conversations with those who work closely with the child. Changes in medication often affect children’s wakefulness and therefore parents should inform orthoptists and ophthalmologists about changes in child’s functioning.

Use of eye glasses

When near correction is found helpful, the use of eye glasses is started in communication situations and during therapy. If the side parts of the glasses are thin and don’t bother the infant during head movements, glasses can be used during the whole day. Since strabismus often develops in infants with brain damage, therapists can keep an eye on the infant and inform the ophthalmologist at the first signs of squinting (strabismus). Training of the less used eye can be included in the infant’s therapy.

When planning spectacle correction, it should enable the use of the best visual image at a distance relevant to the child. Spectacles known as reading correction for a very close distance is useful for tiny infants; an unusually long distance from the eye to the foot is necessary later for students who use their feet to type. We should consider also the typical position of the child’s head and use supports to maintain these positions when selecting spectacle frames. In many medical services children with intellectual disabilities do not get spectacles. Spectacle corrections are especially important for these children who have so few options for compensating the lack of spectacles. Finding the optimal spectacle correction is often challenging and requires thinking out of the box.

Spectacle corrections, when given, may not be accepted. There are several reasons.  If a high minus correction is given as full correction, the dramatic change in the size of objects and distances may be too much to be tolerated. Hyperopic correction (= plus glasses) may be 1-2 dioptres over-corrected, sometimes more if the child’s visual sphere (cognitive sphere), within which the child can use vision is limited. It is then important to notice that when the child starts to pull the plus glasses away this can be due to an increase in the cognitive space and thus bifocal or monovision glasses may be needed (monovision = one lens is fitted for close distances and the other for distances up to a meter). The introduction of a spectacle correction may be easier if the infant has used empty spectacle frames first. Problems with glasses are individual; some children accept full correction of astigmatic error and spherical correction, some children do not.

Some infants with intellectual disability and myopia learn to use the “pin hole” effect to see clearly. They turn their head and look through the small hole created by the edge of the pupil and the corner of the eyelid. A small hole (pinhole) effectively compensates for refractive errors and gives a clear enough image for orientation. The child sees where to go and once close enough to the object can see it quite well because of myopia, nearsightedness. In cases like this, glasses may be acceptable only outside. This phenomenon is quite common in children with Cornelia de Lange Syndrome. If you have difficulty in believing this paragraph, make a small hole in dark coloured paper, take your glasses off if you need them to see at close distances or take “wrong” eye glasses that blur your vision and look through them and the small hole, keeping it close to your leading eye. You are likely to see enough to read, not as well as with your spectacles, but well enough to see many important details.

In the correction of refractive errors the functional visual sphere should be kept in mind and the spectacle correction fitted to function within that sphere. Distance glasses become useful only when the cognitive sphere of the child increases to include objects at greater distances.

If a child does not accept spectacles, all demanding tasks must be kept at the distance where the child sees best, and within the dimension of the uncorrected visual acuity for that distance. Families and caretakers should get information so that they are aware of this distance. In developing countries there are too many infants and young children with severe physical disabilities fitted with big and thick spectacle lenses that then press against the child’s cornea as these children spend most of the day lying on their side or back.

Visual activation

Visual stimulation as passive stimulation is appropriate when an infant/child is barely aware of vision. Once the response is obtained, the goal of intervention is to develop the child’s interest in actively using vision and a confidence in the vision as a source of information about the world. This is not learned through watching blinking lights in a dark room. It is learned by enabling the use of vision through the day in a variety of situations and for a variety of reasons – to better understand communication, to learn about toys, to understand information from other senses, to explore spaces and observe the effect of her actions on the world.

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Filed under Children with impaired vision, Multiple disabilities, Video, Visually impaired children

Development of Vision Impaired Children without other Impairments

Editor’s note: This is another chapter that was not included in the upcoming textbook by Dr. Hyvarinen.

Prematurely born babies with retinal damage may stay weeks in incubators, which decreases interaction with parents and other adults.

Although most infants and young children with vision loss have at least one other impairment or chronic disease there is a small group that has only impaired vision or blindness caused by changes in the eyes or visual pathways or in the visual processing networks without other changes in the function of the brain. Impaired vision affects development of: Communication, Interaction, Motor functions, Spatial concepts, Orientation in space, Object permanence, Language, and Incidental learning.

Infants with early symptoms

Infants with obvious abnormalities in the structures of the eyes are usually diagnosed at birth or during the first days of life. Cloudy lens, cataract, should be diagnosed if present at birth because it usually requires an operation without a delay, at least a consultation by a surgeon who is specialized in operating congenital cataracts. Congenital glaucoma and tumors like retinoblastoma are also conditions that require early diagnosis and treatment and thus, also early intervention should be started.

In infancy, medical diagnosis should be made without delay and medical or surgical treatment started AND at the same time the infant has a developmental emergency and his family a great need of support, information and guidance.

It is important to support the early interaction, to “help the parents to fall in love with their infant” during the often traumatic period of clinical investigations (Sonksen PM 1983 and 1989). Parents need immediate counseling by an experienced worker who can describe the response patterns of a visually impaired infant. The emotional stress may lead to depression in the mother: therefore the mothers of disabled children should be considered as patients during and after the diagnostic period and treatments and supported in the demanding care of their infants.

Assessment of visual functioning for early intervention should be an integral part of the initial diagnostic investigations and the family should not be sent home without a plan and a connection with the rehabilitation/early intervention team. Parents should meet with a rehab team member already in the hospital to experience it as a normal part of the care.

The Leo Learns by Doing video is a helpful tool for anyone who interacts with a visually impaired child. Parents, caregivers, relatives, teachers, doctors, and any other person who would like to contribute to the connections with a visually impaired child can find this information valuable. This video tells a story about a visually impaired child named, Leo, and his parents who visit with his vision teacher. The vision teacher shares step-by-step techniques with Leo’s parents to allow for Leo to develop and strengthen his non-visual senses and skills.

In some hospitals the Intensive Care Unit nurses are trained to discuss with mothers the special features of the care of visually impaired infants (see Leo Learns by Doing sold by Good-Lite) and how not to misunderstand a severely visually impaired infants interaction, for example if the baby turns her face away from the face-to-face contact, it could mean that she has turned her ear closer to the mouth of the mother. If the baby’s hands are gently pressed on the mother’s face and the mother talks slowly and  clearly, the baby is likely to come back to the face-to-face contact.

A similar difficult interaction situation is related to poor motion perception: the baby perceives the moving lips as unpleasant blur in the lower part of the face of the mother and turns his head away as long as the mother speaks. In this situation baby’s hands on the mouth cover the blur and give him the information that the voice comes from the mouth.

Experimental work in the 1970s (Hyvärinen J et al 1978) showed that vision impairment affects the development of brain. If vision is prevented from having its dominant place as the avenue of information, it does not get its normal representation in cortical functions but tactile and auditory information take over the nerve cell groups that normally combine information from vision and other modalities. This finding is the scientific basis for starting early intervention really early. It should start as soon as there is suspicion of impairment and not waiting for a definitive clinical diagnosis because it may take years or will remain unknown.

The competition between vision and tactile information has sometimes been misinterpreted so that tactile information should not be used in early activation of an infant with poor vision. This is a serious misunderstanding. Tactile information supports the development of vision in all infants. Infants get the confirmation of the form and the surface quality of visual objects through tactile and haptic information using mouth and hands. The use of all senses, modalities, should be active and well balanced from the beginning.

Activation of visual functioning entices the infant to move, explore with hands, reach out and grasp, feel the concrete form of objects that he has seen. By giving infants plenty of opportunities to combine visual experiences with information from other modalities, even limited visual functions may be enough to support good visual functioning in many activities.

Inactivity and arousal

Infants and children observe and process sensory information most effectively in a quiet alert state. In a normally developing infant, visual information functions as an activator of brain functions. When visual information flows into the brain, it is used for seeing but simultaneously it also activates the ascending reticular formation, a network of neurons that then activates the brain cortex, which causes arousal.

When eyes are opened, light enters the eyes (small black arrow) and activates the retinas. From the retina visual information flows (black curved arrow) into the special neuronal network called ascending reticular formation that in turn activates the brain cortex (white arrows) causing arousal and supporting the maintenance of a wakeful alert state, which facilitates learning.

When eyes are opened, light enters the eyes (small black arrow) and activates the retinas. From the retina visual information flows (black curved arrow) into the special neuronal network called ascending reticular formation that in turn activates the brain cortex (white arrows) causing arousal and supporting the maintenance of a wakeful alert state, which facilitates learning.

In severely visually impaired infants, as less than normal amount of visual information enters the brain, there is less than normal activation of the reticular formation resulting in reduced alertness and a drowsy state and their usual reflexive movements are sparse. The baby is not learning to know his body, which again decreases opportunities to start touching objects, reaching for and exploring them. Lack of normal amount of exploring leaves the visual information without tactile and haptic confirmation and thus visual world remains abstract with a weak structure. The mutual support of vision and motor functions is often so weak that without carefully planned activation sensory deprivation seriously delays the general development.

Impaired vision affects the development of orientation in space and moving through two separate mechanisms:

1) If the image is blurred or distorted or is limited in size because of changes in the eyes and visual pathways, it decreases information about the structure of the space. If the vision loss is in the processing of information, directions, distances, awareness of space, and orientation in space may not develop without grasping their internal relationships.

2) In infants, who have quite normal neurological functions, impaired vision delays development of motor functions unless the infant’s motor development is supported.

Head control can be trained by holding the infant across the thighs, over the shoulder and supported on a rolled bath towel. This decreases the delay in motor development by strengthening the muscles of the neck and shoulders so that the baby can start to lift herself on straight arms and train balancing. When an infant is sitting on lap facing the adult, lifting knees in turn and tilting the infant can train balancing and saving reflexes.

New born infants in intensive care units

Infants who are in incubators or after the operation stay in the intensive care units should be kept next to the body of the personnel and parents as soon as possible. The parents are often surprised to see how their hand resting on the sleeping infant’s shoulder calms the child so that the heart rate and blood pressure variations decrease.

Simple geometric forms with good contrast interest young infants.

In the beginning of the care in the incubator the infants are often so sleepy that their visual activation is not feasible. When they start to be awake, simple pictures can be placed in the incubator or crib. When strong visual stimuli, especially pictures of face are introduced, infants need to be carefully observed for increase in heart rate and breathing. Inhibitory mechanisms are not well developed in young infants so too strong stimulation should be avoided.

If the pictures are made of plastic they are easy to wipe clean. Since tiny infants do not touch them they last for years in good condition. The pictures do not need to be black-and-white but should have high contrast and some glistening details.

Visually impaired infants in incubators do not see nurses or doctors coming and are often frightened when suddenly there is a painful stick or a longer unpleasant or painful procedure like cleaning the nose and throat with suction or a vein puncture that requires several trials. Quite young infants learn to recognize a certain way of tapping the incubator that precedes a painful procedure as a warning sign. This reduces the sudden, pain induced increase in blood pressure that may cause bleeding in the fragile vessels of the brain of a prematurely born infant.

Play situation with therapist. A light Styrofoam ring was decorated with black tape to create a visuo-tactile plaything. Note the comfortable position of the baby and the therapist for effective visual communication.

Some visually impaired newborn babies keep their head turned on the shoulder until they become aware of vision and their hands, which is sometimes misdiagnosed as torticollis. It disappears sooner if the mother or early intervention specialist uses her face (with good make-up) as the visual stimulus and brings the hands to the mid-line to touch each other, then to touch infant’s face and adult’s face in turn.

Awareness of mid-line through visual and tactile information often helps the infant to develop both visual and motor functions. The head may turn to the mid-line during the first trial but usually does not stay there before the awareness of vision is stronger.

Development in interaction despite severe vision loss

The lack of normal eye contact can affect communication because the signals are wrongly read as disinterest. Therefore the parents need support and guiding in communication with their infant. It is important that this aspect of early intervention starts during the first examinations even if the diagnosis is not yet confirmed. The problem in communication and interaction is present and should be diagnosed and treated.

This infant with cloudy corneas did not open her eyes. Therefore she looked sleepy but the little hands and feet were very active.

One of the first things parents and caretakers should learn in the early interaction with severely visually impaired infants is to watch the whole body for messages, especially hands and feet of the infant (Fraiberg S and Fraiberg L 1977, Dik M 2006).

When assessing ‘Vision for Communication’, contrast sensitivity is one important function to measure. Much of communicative information is at low contrast levels. The faint shadows on the face that convey expressions are low contrast information in motion, especially on very fair or very dark faces. Therefore, when assessing vision for communication, contrast sensitivity is one important function to be measured (see Normal Visual Development).

If contrast sensitivity is low, contrast needs to be enhanced by make-up, lip liner, eyeliner, spectacles etc. Holding the infant close increases the size of the picture on the retinas of infants (geometric magnification).

Poor motion perception at high speeds of motion may disturb communication even if an infant seems to see the slow moving Pepi-picture (Pepi game is in the GAMES section of www.lea-test.fi), i.e. the infant has following movements and follows the movement of the picture in the test. Lip movements are short and at high speed. If they are not perceived, the lower part of the face of a parent is seen blurred or disappear and thus communication loses an important component. The blurring or disappearing of lips may be so unpleasant to look at that an infant turns his gaze from the face of the adult, which can be interpreted as an autistic behavior.

Infants usually copy facial expressions quite early (imitation) and start to respond in a meaningful way to many expressions at the age of a few weeks. If these responses are not present, either the infant does not see the facial expressions clearly enough or the cortical analytic functions have not developed. If an infant seems to have problems in recognition of facial expressions despite of otherwise normal vision, specific communication therapy is necessary to help the infant develop participation in social interactions. At the same time parents, siblings and caretakers should learn to accept loss of face recognition (face blindness) as an integral part of the infant’s functioning: verbal explanations should be given in every communication even when later the child starts to build a language bridge toward other children in play situations.

Diagnosis of face blindness is often delayed although it would be possible to notice the lack of face recognition at the age of 9–11 months at the latest, by which age most children show clearly differentiated behaviors when approached by family members compared with strangers. A simple question “When you come to your baby, does she recognize you before you say something?” should be a part of health examinations because it would lead to early referral for further investigations.

Numerous types of illuminated toys and special large rooms with lights and sounds are used as passive stimulation. However, the studies of brain functions have shown that passive stimulation such as large projected pictures cause little activity in visual pathways. Contrast edges like stripes when moving are effective. One of the most effective images is a human face moving slowly in front of the infant. When this is combined with singing, talking and touching the face with the little hands the infant has an interesting multimodal stimulus.

Early meaningful visual activation and interaction during medical care is the key to supporting visual development when a child has a visual impairment. Since the infancy is such a sensitive period, and yet the maintaining health requires dealing with several adult caregivers, it takes creativity to achieve good environment for each child in terms of development of communication and interaction.

Development of body awareness and spatial concepts

An infant with normal vision has seen his feet numerous times before he experiences them as part of himself and learns to move them intentionally. An infant with impaired vision needs similar experiences through touch and if possible, combined with vision. Every time the child is dressed, his hands should be made to touch his legs and feet. Later he should be helped to bring his toes to his mouth and to clap his cheeks with his feet. A big ball hanging just above the infant activates the use of hands and feet to grasp it and thus to form a small space with his own body, the first egocentric space.

An infant with normal vision can examine an object from different directions and combine the visual information with that sensed with his mouth and hands. Also, when an object falls from his hand he can still see it near him. When a blind infant touches objects with his hands, he has greater difficulty learning to identify them, as he may not touch the same part each time. The concept of object permanence is much harder to develop when fallen objects disappear and are found after irregular time intervals. The little hand should be helped in its search to find a toy that fell and to examine the toy carefully for all details, which can be used for later recognition. If toys are given back to the infant, they are experienced as an extension of the adult person.

The concept of egocentric small space starts to develop when the hands meet in mid-line. This concept of space widens into the larger allocentric space when the child learns to seek things in his surroundings and above him and when he learns to recognize his parents’ and siblings’ voices at a distance. A severely visually impaired child has great difficulties in trying to perceive three-dimensional spaces. He needs a lot of time and help to learn to understand space through the use of hands, body, and by listening to echoes. This can be done through adapted play areas such as a resonance board, a play mat, or a “little room.”

Whenever possible the child should be helped to explore also the upper parts of the door frames, ceiling, lamps, fans and larger objects’ upper parts outside. We should remember to function as these children’s eyes and add visual details to their auditory – tactile, visually limited world, make them aware of objects and people standing still, at dinner table what other family members are eating etc. As soon as the child can use magnifiers and a small telescope they should be used to widen his visual sphere.

A normally sighted child has seen the numerous objects in his home hundreds of times before he recognizes them and has an internal name for them. A visually impaired child needs the same foundation of experiences to be able to build his concepts of the surrounding world. Exploring the movement of a door or window is not an autistic repetitive movement but a careful exploration combining tactile and kinaesthetic information from the hands with auditory information, changes in the air currents on the face and building motor memory of the movement. The concept of space and the ability to orientate are prerequisites for learning to move. Otherwise walking becomes a motor function dependent on an adult’s guidance.

The twin sister can function as the eyes of a child with impaired vision.

Learning to recognize different parts of the home requires numerous explorations of all structures. All members of the family can participate in this part of learning during normal play situations where slightly older infants and children seem to have the best communication level. On the other hand, the older generation of the family may have time to explore the whole house. The ceiling and other structures up in the rooms remain abstract concepts until they are touched.

The information obtained through hearing is different from visual information. It is momentary, does not form a meaningful whole and cannot be perceived a second time. It is more difficult to try to get to know the surrounding world through hearing than by looking at it again and again. Repeating auditory information, most preferably at lower frequencies like the ”tik-tok” of a large “grandfather’s clock” functions as an auditory lighthouse for a child with severe vision loss.

Children need training in order to learn to listen, to use hearing effectively and may become masters in exploring spaces and interpreting environments through auditory information. Short clicks with tongue or fingers or high pitch single cough are effective ways to create echoes that reveal the size of the room, the number of people or the type of furniture.

Motor development widens the visual sphere

A large, colorful balloon of special material makes soft rattling noise when moving.

For a six-week-old normal infant vision becomes important in learning about the surroundings. From the third month of life it is the most important sensory channel for distant information. If this channel is defective or lacking, the child must construct his world with the information available through hearing, touch, motion, smell and taste.

Such a simple thing as a balloon functions well in early learning. If the balloon is tied to the wrist or ankle of the infant, it moves when the hand or foot happens to move. Thus an important learning experience is possible: “I moved my arm and something happened near to me (the infant does not have a name to the

The sound of the balloon helps the infant to locate it and follow its movements.

large softly rattling ball but stores the visual image in his memory). I moved my arm again and the same thing happened. I moved again and nearly same thing happened.” This is a classical learning situation creating much activity in the brain of the child.

If there is very little vision, we need to choose toys that glisten, move and are also tactily interesting.

Objects with good contrast close enough and the luminance at the optimal level facilitate visual search and fixation. Sometimes it is helpful to dim the lights in the room and shine a focal light on the toy within reach of the infant. (For more, go to www.lea-test.fi, then click on “Stimulation of Vision” and then “Usual playthings.”)

A child could see the LEA-doll and the small plastic “pizza” well enough to feed the doll in UV-light and after this experience to bring this new activity to play situation in room light.

When “black light”, UV-light, is used to increase contrast, infants use eye glasses that absorb UV-light so that only the reflected visible light enters the eyes. Most disco lights like UV-light fixtures emit low intensity UV-light, which is less than the UV-exposure on a sunny day. Infants’ thin cornea and clear lens absorb less UV light than adult persons’ eyes and thus exposure to UV and blue light can enter the retina, which should be avoided, especially if an infant has aphakia or retinal degeneration. Since infants observe interesting objects very close they need to have strong reading lenses when exploring high contrast details. This is often not considered and the infant has too weak near correction.

When the hand touched a tactile line, the infant watched his hand for the first time with wrinkles on his forehead.

A visually impaired infant may not find his hands at the age of three months like a sighted infant. An infant with normal vision spends hours every day looking at his/her hands at different distances. This builds the concepts of space by combining visual and motor information from the movements. The visually impaired infant’s hands should also find each other.

To have confirming tactile information about the visual “something” he brought his hands into the mouth for the first time.

We can help the hands to find each other in the mid-line by supporting the movement of the arms so that the hands meet. The hands should become the “second eyes of the visually impaired child.”

The face of an adult is one of the most interesting objects both visually and tactily, especially father’s face. During communication it is important to get so close to the infant that the short arms and little hands can reach to the adult’s face.

Lightboxes facilitate use of sight limited to perception of light and its projection.

This infant noticed when the light box was placed near her on the floor and crawled to it. She placed her hands on the light box and after a short while started to lift her fingers, one finger at a time, thus simultaneously getting visual, tactile, proprioseptive and motor information about her hands for the first time.

The book “Show Me What My Friends Can See” by Patricia Sonksen and Blanche Stiff (1991) contains nice examples how to guide hands and arms to reach out. As long as the hands and arms move aimlessly at the shoulders, they should be often guided to touch each other in the mid-line. Bringing hands to mid-line may help the infant to bring the gaze to mid-line.

An infant with normal sight keeps contact with adults by looking at them while they are moving. A blind or severely visually impaired child maintains similar contact only through tactile information. Hearing cannot convey the same experience of closeness and affinity. The visually impaired infant should be held on lap or in the baby sling as much as possible so he can learn to know himself in relation to adults, and learn to sense their movements.  Parents should also talk to the child when moving around, telling where they are going and what they are doing. Use of consistent expressions is important in supporting development of language.

Incidental learning

Incidental learning through vision is an important part of each day of a normally sighted child. She can watch the mother taking a mug and a package of chocolate drink, mixing the drink with hot water, adding some milk and bringing the mug to her. When she has seen it a few times, she knows the procedure and knows to expect the drink. A child who cannot see clearly enough to see the details, sees the mother moving and hears several sounds, may smell the chocolate powder if close enough. To learn what actually happens, the child needs to get a verbal description of the activities and objects used during each activity repeatedly, not just once.

A visually impaired child may also have difficulty understanding what actually happens around him, for example when he is fed. An infant should be given a spoon as soon as he can hold it and be allowed to bang it against the table, plate and food. She will learn the connections between the feeding and the different noises the spoon makes. It is important for the infant to examine all kinds of foods, with his hands and of course with his mouth. Finger feeding is a good way of learning to eat.

A plaything that falls from the hand entices a sighted child to move to get it. A blind child is not stimulated the same way by the fall of a toy or by toys lying just outside his reach. It is difficult to create play situations that will foster creeping and crawling. A sighted baby may function as a model for a visually impaired infant at this stage. Some visually impaired children learn to move quite late and may learn to walk first and crawl later. An infant who learns to walk before crawling needs plenty of balance training, which otherwise he would have acquired during crawling. Balance training should be practiced every time the child is sitting on an adult’s knees by lifting one knee at a time so that he infant is tilted slightly. The large CP-ball is handy in balance training.

The motor development of visually impaired infants is delayed in nearly all cases of severe impairment. Static motor capabilities like sitting and standing develop often nearly normally if the child’s balance and saving reflexes (righting reflexes) have been trained. On the other hand, transitions to dynamic motor capabilities like crawling, moving “on all four”, walking, and the use of hands are often delayed in otherwise normal children. This is because visual information stimulates infants to copy movements of other children and adults. If an infant’s visual sphere is limited, motor development is likely to be slower than normal. Stimulating play areas and toys as part of an early intervention program aim at helping the child reach his developmental milestones.

Mild and moderate visual impairment do not need to affect the general development of a child during the first years of life. For example, a child with RP may have near normal visual acuity still in school age. Changes in night vision disturb finding clothing and toys in closets and dark corners, playing outside in twilight and walking through areas that are not well lit in early morning and late evening. These losses of functioning are problems that need to be solved in early intervention.

In disorders that progress rapidly during the school years, like Stargardt’s disease, medical assessment of visual situation should be performed in time so that plans for the next school year can be made. Educational assessment and training of new devices should be arranged whenever the old devices do not allow usual development of learning strategies. Sometimes the administrative paper work is so slow that the child receives the new device just before the next term although the device should be trained for weeks before the child is comfortable in its use during the school day.

Development of spatial awareness

A brown box can be modified to an effective training tool for exploring space. Make slits close to the upper edge to give the infant visual structure of the space. The boxes can be decorated with materials found in the household: a silver colored bottom of a chocolate box, a shiny yellow inside of a coffee package; both without washing them to save the smells; a piece of man-made fur and a musical toy on the wall and a few interesting objects hanging from a sturdy rubber band. The decorations on the walls have both visual and tactile contrasts to be studied with hands and feet.


The “little room” was made of cardboard box set up with stimulating materials on the walls and hanging from the top.

The ”little rooms” are of different sizes, very small box for a prematurely born tiny infant and a larger box for an older infant. Boxes for children, who remain at an early developmental level, can be quite large or a corner of a room is used as the space that the child can explore. The infant or child needs to reach to both sides with arms and/or feet to be able to study them using his/her body as the measure stick.


Object permanence and spatial awareness develop in play situations where the infant can effectively use his vision and combine visual information with information from other senses. The closed play area of ”little rooms” has been used since late 60s both for normally sighted infants and toddlers and for infants and toddlers with impaired vision and developmental delays to support development of several concepts. Since the toys and other interesting objects hanging from the rubber band can be found in the same place and explored hundreds of time, they facilitate the development of the concept of object permanence.

The structure of these “little room” boxes differs from the commercially available “little rooms” designed by Lilli Nielsen. Hers are intended for blind children and thus the ceiling can be transparent. In the boxes with non-transparent ceiling the stripes of light on the sides make the space also visually defined. At the same time they increase airflow so that the space does not become unpleasantly hot during a warm day.


The echo area between a metal washing basin and a plastic wastebasket amplifies the vocalizations that the infant makes.

Vocalizations make the child aware of the echo areas and teach auditory orientation. The child gets feedback from his own movements, which activates his motor functions and vocalizations, which in turn gives the child more to listen to. Note that the infant in this picture has absorptive lenses because of photo-phobia.


When an infant has become accustomed to playing on the resonance board he may be left alone to play for short periods of time. During that time, the adult can maintain contact with the child by talking. A big ball hanging in the net can be placed on the infant’s stomach. The infant uses both arms and legs to explore it, thus creating a small space surrounded by his body, the first egocentric space for haptic exploration.

If the adult cannot stay in the same room with the infant, she can take him along to play on a play mat. A playmat for a visually impaired infant is designed so that where there is a visual contrast there is also a tactile contrast. The visuotactile contrasts are acquired by combining dark materials of smooth surfaces with rough materials of light colours. This design decreases the risk that the dark colors would bleed. A play mat can be sown either as a quilted mat or appliquéd. Play mats are often sown with two different surfaces so that they form a good contrast against different floor or training mat surfaces.


A visuotactile playmat has ends that are made clearly different so that they function as orientation marks and help the development of spatial concepts.

This play mat was the first play mat sewn with this kind of design when Dr. Juhani Hyvärinen’s group (Hyvärinen J et al 1978) found in a scientific experiment with monkeys that tactile information permanently inhibits the use of vision if visual input is weak during the first months of life. These infant monkeys had the best thinkable early intervention program with two caregivers and a psychologist. Yet they remained functionally blind with some awareness of large moving shadows.


The pieces of materials along the borders of this first play mat are small because the dark pieces were pieces of good quality satin from an exhibit and were given to the project as a gift. The pieces can be of any size. The satin pieces are smooth; the light pieces are materials with different rough surfaces.

Play mats are useful presents for all infants and young children. When the infant has the opportunity to simultaneously combine information through both channels, visual and tactile information do not compete with each other in the associative brain functions. Visually impaired children should develop very fine tactile discrimination, but the tactile information should not suppress the use of visual information. Fusion of information from these two senses is important to all infants with disabilities as well as all healthy infants.

Visually impaired children’s vision was previously thought to develop to its maximal potential without training. Brain research has shown that vision is a learned function. The development of vision can be supported by training and stimulation through play situations during the preschool and school years. Like the normally sighted infant, the visually impaired infant has to learn to accommodate, to track with his eyes and to achieve convergence.

Certain diagnoses bring to our mind certain type of behaviors of children with that specific diagnosis. It is important to be aware of the large variations in the severity of changes and disability in children with the same diagnosis, for ex. retinoschisis . In some families the changes are severe at birth so the child needs to learn many strategies typical to blind children. Other children with a milder form of retinoschisis function like typically developing children.

Early intervention

Visual impairment, both the anterior, ocular impairments due to disorders of the eyes or the anterior visual pathways and the visual processing disorders due to brain damage should be diagnosed as early as possible. A few of the disorders can be treated (ROP, cataract, muscles adhered to surrounding structures preventing eye movements, glaucoma, retinoblastoma) surgically or medically (glaucoma) or with spectacles (refractive errors, accommodation) but in a great majority of infants with early visual impairment there is no medical or surgical treatment. When there is treatment, after the treatment the infant or child seldom has normal sight. Early intervention can and needs to be started immediately when there is suspicion of visual impairment and continued during the treatments.

Several hospitals have written guidelines on early contact, diagnostic procedures, first information and starting early intervention in different types of diseases and family situations to decrease the stress to the family. It should be a standing rule that only doctors with experience in communicating frightening news should take care of these delicate situations, preferably together with the early intervention worker who can continue the discussion with family and arrange practical things.


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Fraiberg S and Fraiberg L. Insight From the Blind: Comparative Studies of Blind and Sighted Infants, Basic Books, New York, NY 1977.

Hyvärinen J, Hyvärinen L, Färkkilä M, Carlson S and Leinonen L. Modifications of visual functions of the parietal lobe at early age in the monkey. Med Biol 1978, 56:103-109.

Hyvärinen J, Hyvärinen L. Blindness and modification of association cortex by early binocular deprivation in monkeys. Child Care Health Dev, 1979, 5:385-387.

Hyvärinen L, Lindstedt E (eds). Early visual development – normal and abnormal. Acta Ophthalmol (Copenh) Suppl, 1983,157:1-122.

Sonksen PM. Vision and early development.. In Wybar R and Taylor D (Eds) Paediatric Ophthalmology: Current Aspects. Marcel Dekker, New York, NY 1983.

Carlson S, Hyvärinen L. Visual rehabilitation after long lasting early blindness. Acta Ophthalmol (Copenh) 1983, 61:701-713.

Degelin E, Hyvärinen J, Hyvärinen L, Carlson S, Valvo A and Scholler H. Learning to see. Movie, 44 min. Beerse, 1983.

Sonksen PM, Levitt SL, Kitzinger M. Identification of constraints acting on motor development in young visually disabled children and principles of remediation. Child: care, health and development, 1984, 10:273 – 286.

Sonksen P, Stiff B. Show Me What My Friends Can See. John Brown (Printers) Ltd. Nottingham, 1991.

Dik M. Babys und Kleinkinder mit visuellen Funktionsverlust. Robert Weijert, Emmes, Niederlanden, 2006.

http://www.perkins.org/scout/early-childhood/orientation-and-mobility.html 24.11.09

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