Developmental Disabilities

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Vision/Hearing

Techniques for Infants and Toddlers with Visual Impairment - Developmental Hurdles

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Developmental Hurdles

DeBose (1979) identifies 62 curricular concerns for the development of young children with visual impairment. Space does not permit a discussion of each, but some of the principal developmental hurdles for infants and toddlers should be addressed.

Sensory stimulation. Observing the infant without a visual disability easily demonstrates the role vision plans in early development, attachment, play, imitation, and motor skills are only a few of the areas that are explicitly, related to vision. From the second day of life, infants make eye contact and follow moving objects (Brazelton, 1973). Vision both provides and demonstrates attention, and forms the as is for all future learning. Barrage (1983) suggests that vision integrates all other sensory modalities. For this reason, the loss or distortion of vision necessitates that interventionalists carefully guide the visually impaired child so lost sensory information is received in some way.

For infants with visual impairment, the primary mode of obtaining information is limited, unreliable, or missing altogether, so the child must utilize other means to obtain the sensory information that forms concepts. Unfortunately, it is not known how infants do this and there is some evidence that infants with visual impairment experience delays in intersensory coordination (Ferrell, 1984a; 1984b). Consequently, even with intact input from the other senses, there is no guarantee that the information has meaning for the child.

Vision verifies information received through the other modalities for sighted infants. In other words, when the sighted infant hears the sound made by a favorite toy, the child turns to look at it, and then smiles in recognition. The blind infant, however, may hear the sound, may even turn toward, it, but requires touch to verify its recognition. The visually impaired child’s response is neither immediate nor assured. There is always delay, even assuming that tactile recognition occurs at the same age as visual recognition.

Sensory input that is at times absent, and at other times unbalanced, has a cumulative effect on how the visually impaired child interprets the world. This effect begins in infancy and the child may not catch up until adolescence (Stephens & Grube, 1982; Stephens & Simpkins, 1974).

Imitation. Visual imitation plays a critical role in early learning (Miller, 1983) and is involved in almost every aspect of the child’s development. The infant with visual impairment is unable to observe others in motor activities, in food preparation, in conversations, or in play. It is not uncommon for children with severe visual limitations or blindness to need improvement in some social area because most social skills are learned through visual imitation (Raver & Drash, 1988). Parallel and imitative play are very important to the child’s social-communicative development. Without these experiences, peer-to-peer play and later social skills may be limited in adolescence (Scholl, 1986).

Motor development. Adelson and Fraiberg (1974) provide an extensive account of motor development in blind infants, which Fraiberg (1977) summarizes. Motor delays tend to be difficulties in locomotion, rather than overall motor development. Visually impaired children tend to acquire gross motor postural milestones within the same range as sighted children. However, items requiring self-initiated mobility and locomotion have a greater chance of presenting delays.

Fraiberg and her colleagues postulate that locomotion delays are attributable to the delay in reaching to sound, which for infants in their study did not occur until late in the first year. Fraiberg believes that reaching is a significant event in the life of an infant, and that sighed infants who reached at 4 or 5 months of age were actually demonstrating their understanding of objects outside the self. Infants with good vision practice this awareness and develop their knowledge of objects for approximately 5 months before crawling. Blind infants, on the other hand, who are unable physiologically to reach to sound until 9 or 10 months, seem to then need the 5-month practice period before they can crawl.

The theory seems plausible, particularly because alter studies seem to support the locomotor delay. However, this hypothesis does not take into account later studies of auditory development which show that reaching to sound can occur earlier than previously thought. The real hurdle may be related to intersensory coordination and the delayed cognitive development of object permanence.

It may also be that locomotor delays are related to inadequate experiences while basic postural skills are acquired. For example, many blind children walk with an unusual gait – feet externally rotated, stiff-legged, center of gravity lowered, almost waddling. It could be that this gait, which is characterized by weight shift without hip and trunk rotation occurs because the infants’ early experiences did not incorporate hip and trunk rotation into daily routines. Sighted infants first practice hip and trunk rotation in the sitting position, by turning to retrieve an object that is picked up by their peripheral vision. This rotation, reach, and retrieve action is the foundation for moving from sitting to crawling.

However, visually impaired infants, because they never see objects in the periphery, may never practice hip and trunk rotation in sitting. For this reason, it is essential that visually impaired children have experiences that closely match those their sighted peers spontaneously seek. Interventionists must assist families in establishing varied and continual pre-locomotion experiences (e.g. trunk and hip rotation in reaching, sitting, standing,) so that later locomotion skills will be based on adequate early, motor preparation.

In addition, if atypical posture such as head droop, rounding of the lower back, and atypical motor patterns develop, the services of a developmental therapist may be warranted. If these behaviors are not corrected in early childhood, they can negatively affect how people perceive the child’s competence and social desirability  (Raver, 1987a, 1990). The reader is referred to other sources for specific information for normalizing atypical motor and social patterns (e.g., Raver,  1984, Raver & Dwyer, 1986, Raver, 1987b).

Intersensory coordination. The ability to use all the sensory modalities simultaneously is critical in early development. Equally important is cross-modal transfer, the ability to take information obtained through one sensory modality and apply it to another. Most early intervention strategies assume that intersensory coordination and cross-modal transfer occurs, without evaluating whether it does. If, however, observation indicates that cross-modal transfer is not occurring, then coactive movements are needed. Coactive movements occur when the interventionalist aids the child through a movement such as crawling, spoon feeding, or completing a puzzle.

Another typical early intervention strategy is the multisensory approach in which the interventionist attempts to provide as much simultaneous sensory stimulation as possible for the child. This may assist or compensate for difficulties the child experiences in integrating sensory input. Activities or routines are presented systematically through the remaining four senses of smell, taste, hearing, and touch. (Any vision the child has is also used.) For example, during  diapering, the infant is encouraged to smell the difference between fresh cloth and disposable diapers, taste and feel their differences and commonalities, and attend to their different sounds. Parents’ comments would guide this type of exploration. It can never be assumed that incidental learning and intersensory coordination spontaneously occur in infants and toddlers with visual impairments.

However, for some visually impaired infants, the multisensory approach leads to  sensory bombardment that prompts the child to tune out, instead of integrating the information. Unfortunately, there are few guidelines for deciding which approach, and how much input, is optimal for a child. Generally, if the child appears to withdraw from an activity, it may indicate that input is excessive. Recent research failed to find evidence of cross-modal transfer in 24 children between the ages of 6 and 24 months on a test of tactual-to-visual transfer, even though the infants had all demonstrated.  Although evidence from interventionists suggests that intersensory coordination is a problem area for many visually impaired children, more information is clearly needed.

Object permanence. Object permanence is the knowledge that an object or person exists when the object or person is not in sensory contact with the individual. For the infant this usually means that a toy played with yesterday is searched for tomorrow. The infant with good visual abilities is able to make this connection easier than the infant with visual impairment because of the immediate feedback and verification provided by vision. Substituting sound or tactual qualities for objects may not provide sufficient information.

Parents of infants with visual impairments must constantly create situations in which play with and explanation of objects is arranged, rewarded, and expected in an effort to compensate for the anticipated delay in this area. Mobiles, playpens, wrist rattles, and toys with short strings aid in keeping toys nearby and retrieving them when they are pushed out of reach.

Fine motor skills. It is often assumed that tactual development is more highly developed in infants with visual impairment precisely because they are so dependent on it. But this is not the case (Cutsforth, 1951). Fine motor development does not occur in isolation but is interrelated with all aspects of development. Many infants with visual impairment do not receive sufficient opportunities in the prone position and, consequently, miss the experience of weight bearing on the hands and subsequent refinement of grasping. If the child’s grasp and object relations do not become refined, self-feeding does not occur (Kitzinger, 1980). If the muscles in the mouth are not exercised through the introduction of new textures, speech does not occur.

Classification. Abstract thinking, reasoning, and generalization are used in the cognitive process of classification. Because of the lack of opportunity to observe objects by size, shape, or color infants who are visually impaired may experience a delay in the first stage of classification: grouping by physical attributes. Gerhardt (1982) found that blind infants between the ages of 14 and 18 months learn to control objects by devising a strategy involving the simultaneous use of two objects, one in each hand. This study reported classification of objects based on their similarities paralleled the development of sighted children, with a slight developmental lag.

Language development. Visually impaired infants have been described as demonstrating fewer positive vocalizations, making fewer social initiations to the mother, evidencing more negative affect (such as crying and whining), and spending more time ignoring the mothers than sighted infants of the same age (Rogers & Puchalski, 1984; Rowland, 1984). Although language development of blind children generally parallels sighted children’s (Bigelow, 1987; Parsons, 1985), deviations and common delays have been identified, such as limited use of object names and requests, heavy reliance on routine phrases and people’s names, limited reference to objects and events out of touch, and delayed development of personal pronouns (Urwin, 1984), as well as deviations in some pragmatic aspects of language (Anderson, Dunlea, & Kekelis, 1984).

Attachment. Als, Tronick, and Brazelton (1980) and Fruberg (1977) have devoted considerable attention to attachment in infants with visual impairment, focus on the different responses and signal behavior that demonstrate. Infants with visual impairment have a sophisticated repertoire of attachment behaviors that are different from infants with intact vision (Rogers & Puchalski, 1986). Sighted children rely on eye contact for feedback and social engagement. Visually impaired infants, on the other hand, respond with facial expressions, body movements, and autonomic and not easily observable behaviors (e.g. heartbeat, breathing patterns) to communicate.

What is not frequently understood is that infants with visual impairment, because they must rely on their hearing, are unusually quiet – which causes them to be seen as passive. Sudden movements without preparatory cues may frighten the infant, eliciting a startle reflex and extension of body parts. Adults who are unaware of the infant’s interaction style may interpret this as emotional rejection when, in fact, it is more likely a response to the adult’s insensitive approach. Consequently, it is important for adults to prepare the child before touching, moving, or interacting with the child. Comments such as “Hello, Billy, I am gong to give you a hug,” signal the child that a change is going to occur. Family members often need to be trained to recognize the unique attachment behaviors and signals of infants with visual impairments. In this way, families can more effectively reward and increase their child’s social involvement and reciprocity.

Additionally, visually impaired infants tend to suffer prolonged periods of separation anxiety that seem to be due, in part, to their necessarily greater dependence on caretakers. As infants grow older, visual impairment places other limitations on social interactions. Anyone who was reared by the crook of their mother’s eyebrow knows the importance of nonverbal communication and appreciates the amount of information visually impaired infants miss.

The inability to observe the signals of others places them at a disadvantage not only in interpreting and generalizing from the actions of others, but also in monitoring their own behavior. Blind children are often described as manifesting lags in social maturity and as initiating fewer social contacts than their sighted peers (Markovits & Strayer, 1982).

Most people learn social rules from others, such as when it is permissible to scratch, or eat with the fingers. These rules are learned directly through verbal admonishments or indirectly through stares or disapproving facial expressions. The visually handicapped child cannot read the indirect signals, nor can the child change the behavior unless someone tells the child about it. If these behaviors are not changed, relationships with peers and adults will suffer (Ferrell, 1986; Raver, in press; 1987a).

Incidental learning. In normal development, infants acquire new skills almost naturally, with little intervention. However, for the infant with visual impairment, learning can never be left to chance. A good example of this is the skill of dropping objects into containers and then dumping them. No one has to teach an infant without disabilities how to do this. Non-handicapped children observe the people around them doing this every day as they throw away trash, put money in a purse, take change out of a pocket, pour milk, and take a cookie out of the cookie jar. When an adult introduces a toy that requires the skills of in and out (such as a plastic milk bottle and clothespins), little instruction is needed because the sighted infant has already had a good deal of vicarious experience with these concepts.

The infant with visual impairment cannot profit from vicarious experiences. Consequently, interventionists and families cannot afford to make assumptions about the child’ prior experience. Instead, those around the child must take the time to demonstrate and explain, as much as possible, all that is occurring around the child. The child needs to be directly engaged to develop adequate experience with concepts. Experiences must be direct, concrete, and meaningful to the child to expand concept development.

Part to whole. Most infants learn from global to specific that is, they observe the totality of an object before they examine the small parts. Infants with visual impairment, however, must learn in the opposite direction. They have to examine the parts and then somehow fit them into a whole concept. This style of learning is clumsy, slow, and easily leads to misinterpretation or the formation of faulty concepts.

The difficulties this learning style imposes are illustrated by the way infants obtain information and concepts about the family pet. The infant with good visual abilities sees a whole cat, simultaneously. When the cat meows, the child sees the mouth open, when it licks or scratches the child’s hand, the child sees its tongue or its paw and how these parts fit into the concept of cat. In contrast, the infant with visual impairment obtains information about the cat in random pieces. The child can feel only one part of the cat at any time and does not know how all the parts fit together. The child may hear a meow, but does not know where the sound comes from; the tongue and the paw come out of nowhere, and the soft fur may brush against the skin at any time without warning. Giving the infant with visual impairment a stuffed toy and labeling it as a cat adds further confusion to the child’s effort to understand the concept of cat. The stuffed toy feels and acts nothing like the real cat. All infants form concepts gradually, utilizing all sensory input; infants with visual impairment do so with disjointed information. Of course, the visually impaired child eventually learns the concept of cat, but the concept is based on the child’s unique sensory experiences, and the resulting concept may or may not resemble the concept of cat held by sighted individuals.

Concrete experiences. As children mature, it is possible to introduce toys or models to illustrate concepts. However, it is important to recognize that visual limitations affect toddlers’ abilities to symbolize (to have an object stand for the real object or person), simply because they cannot see it. This is why concrete materials and the child’s own body and body movements are preferred for instructional purposes. Concrete materials and direct experiences increase the likelihood of forming both accurate and adequate concepts, because they are genuine and not merely objects that someone with sight, who has already formed the concept, thinks represents reality.

There are many objects that do not lend themselves to concrete experiences: the sun, birds, bumblebees, tigers. Nonetheless, each of these also has sensory qualities such as warmth and brightness, chirping and wing fluttering, buzzing, and roaring. During the first years of life, it is important to focus on concrete, direct experiences that have meaning to the infant, rather than abstract experiences that may have meaning only to sighted adults.

In summary, visual impairment has the potential to affect all aspects of development. Even with early intervention, some of the influences of the loss or reduction of vision, such as delays in locomotive movements, may be difficult to completely compensate for because auditory development does not provide the same advantages as visual development (Adelson & Fraiberg, 1976). Further, the acquisition of visual-perceptual skills and spatial relationships concepts such as body image, body awareness, and space awareness are often not well developed due to visual impairment  (Palazesi, 1986). Interventionists must be careful to not be misled. A child can verbally describe a concept and still fail to integrate it intellectually or apply it in life. A critical role of interventionists is to assist visually impaired children in their efforts to integrate developmental domains.

In 1989, Dr. Turben received funding that enabled the Cleveland Sight Center to initiate the first large-scale, family-centered Children's Services Program in Cleveland, Ohio. Dr. Turben worked for Lake County Early Intervention Collaborative Group in 1988-89 as the consultant who prepared the County Needs Assessment and assisted the collaborative in the preparation of the 1988-89 Lake County Early Intervention Collaborative Plan, which launched family collaboratives as a network of families with children who had disabilities.
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