Developmental Disabilities

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Vision/Hearing

Prehension and Manipulation in Play Activity of Visually-Impaired Toddlers, 15-30 Month Old

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The purpose of the investigation was to look at the play behavior of toddlers in terms of their manipulation of objects in the second year of life.  The two-pronged thrust of the work was to do a search of literature for prehension and manipulation, under the general heading: Play and Use of Hands,  and to design a series of manipulative tasks the elicit cognitive skills.  I kept journal entries for each day I was there.  Data was collected on six children, but as the term evolved, one child emerged as a major observational focus for the study, Julia.

Fraiberg and Adelson report there are cognitive “defects” in blind babies during the first 18 months of life.  Educators also note that there are vast handling differences between sighted infants and toddlers and those with visual impairments.  The hands are not the eyes of blind baby—they seem to be quite the opposite—non-useful tools that almost seem to interfere with cognitive progress.

Other developmental delays noted in blind children between the ages of  0 and 24 months are such things as auditory-hand localization of sound (appearing as late as 9-10 months), directional reach and attainment by sound (not until 10-11 months), manual entrapment and transfer of objects (6-10 months), grasp in crawl position (10-11 months), ability to find hidden objects (12 months), and exhibition of anxiety at separation of attached person (not until the end of the second year).

A blind toddler drops a squeaky toy from a table top.  The child appears not to search but assume he has dropped the toy into “nothing.”  A blind toddler holds a spoon outward toward his mother.  He waves it, brings it to his mouth, as if he imagines the food to simply be there.  A toddler cruises around the couch, but does not carry small toys with him, yet they are most favorite toys and “hears” them and knows they are there.  In essence, the important research is to examine what role object manipulation has in development of true thinking.  What does the human blind baby have to learn to make a human connection between the darkness of his imagines (colorless, flat, lacking contour?) and the sighted world of objects.  How can we help blind children use their arms and hands and fingers as extensions, as tools of the body?  How will this skill help them to know that they are “causers” of action and events, that they are instruments of act and experience?  How can we apply the “good fit” or “problem of the match” criteria to manual tasks of blind toddlers so they can use mobility in the second year, and prehension, to develop exploratory habits and skill?

When these facts are examined within a broad-range of developmental norms, it is striking how important developmental gaps are to the blind child, not in infancy, but during the second year of life.  It becomes a major concern of educators to determine exactly how to help the blind child construct an image of handling object and to maintain a sense of “intentionally” in overall behavior.  The major goal of toddlerhood seems to be to match the blind toddlers social adaptation to the environment, to her mental image-making “work” to overtake sensory deficits caused by visual loss.

Understanding object concepts, constructs of reality (Piaget), and manipulation through the tactile and auditory receptors is the real work of a blind toddler.  It is part of a process of intellect, of mentality, and it is, I think, the antecedent of forming other types of human connections, such as attachment and social experience.

INDIVIDUAL INVESTIGATION IN SPECIAL EDUCATION

SEPTEMBER 13:  I met with parents and staff to outline the work I proposed to do: namely, to create a series of manual tasks which would be done each week in a certain sequence, in order to study individual manipulative and cognitive learning styles.  The play-learning sessions would be 15 minutes in length and would match with the overall goals and objectives set by the staff and parents for the education of the young toddlers.  I gave parents copies of the data sheets I proposed to use, and held a demonstration session to show the use of the materials.  The play materials are all home-made or home available.

I observed the children in the study, staff, and teaching aides in the classroom.  During the initial weeks I will directly interact with children, demonstrate the prehension tasks.  As familiarity increases, I will withdraw and let the parent-teacher take over the directed play interaction.

The children are Charise, 18 month child born with severe cataracts; she has almost no vision bilaterally, wears glasses which allow some focal vision centrally, uses a head tilt protruding tongue, and sloped postural stance toward right.  Dante, 19 months, congenital blindness, birth trauma, parents are also blind.  April, 17 months, etiology unknown, behavioral differences, visual difficulties, some autistic tendencies noted by battery of neurological tests since birth.  Veronica (Ronnie), 18 months, has a left hemisphere-right side brain damage according to reports, and loss of vision in both eyes, but is high-functioning and communicative; Julia, 2 years 6 months, severely affected left CP, with no useful vision due to underdeveloped optic nerves, and severe behavioral difficulties.  Julia screams and shrieks from onset of time with program to end of session (Mother is wife of a teacher, very eager to see progress and change, wants to get her ready for a day-care experience so she can go back to work).  Jamie, 15 months, congenital blindness due to prematurity; mother has low vision, as well.

September 20:  I prepared the environment for the play-learning sessions.  I will work in the living room area of the apartment, which is the setting for the program.  The use of an apartment-style-home-atmosphere has been one of the most exciting aspects of the project.  The staff has been able to dramatically cut down the duration-of-adjustment-rate for children and parents.  All staff agree that an instructional program for visually-delayed children is less threatening when conducted in home-like atmosphere.  Optimal potentiality and “ease of “ access to learning materials are heavily integrated into this concept.  I had an observer present – the day care teacher where Julia will be going during the day in addition to Sight Center program.  We started the session with floor activities, then progressed to sitting at a small table, then to lap-sitting with mother and caregiver.

Charise: Says “chair, block, red, blue;” uses whole hand grasp, pokes, inserts fingers, pronates wrist, pushes, pulls, uses whole forearm for support, handles 2 hands together, claps, raises hands up, lower with alternating bilateral nice smooth motions; uses voluntary release, some avoidance to tactile extremes; resistant to obstacles, things out of reach, doesn’t bother to deploy hands to obtain; plays in the container-contained mode, covers, uncovers, objects are significant when large, red and shiny; when out of range.  Largely unconcerned about separating from mother.

Julia: Screaming throughout session: “I crying,” I kick,” “Sleepin,” “going,” “ I drink” – large open screams, whole body involved and rigid; mother waits.  I say she’s furious and she dislikes being interfered with.  Mother nods, and allows our work to continue, but finally says “Julia dry it up right now.”  Julia started to stop, gasping, and I quickly gave her a soft fleece floor polishing pad and said, “Good, you stopped crying.”  She commenced screaming.  I talked as she screamed.  “Pick up the ring” (She did); “Put the toy in my hand.” (She did.) I described what was happening.

Mother and I set some rules: a) the activities were “work” which Julia had to do at school, and b) we would continue to “work” and positively encourage her when she stopped any screaming.  Her hand function consisted of palmar pronated pushing away, no voluntary grasp, whole hand activity, or purposeful reach noted.  No handling except when we finished, and her mother gave her “drink”, she took the glass in two hands, straight to open lips, gulped, tongue depressed, liquid spurted out, she gagged, started to swallow, and succeeded in getting the juice down.

Dante:No language, sounds and gestures, much reaching out and up for sources of light and sound and some objects; does whatever his mother directs him to do but tilts so much to listen, I question hearing at normal sound range.  Mother is totally blind, and cues him with a repertoire of “focus” questions:  “Do you have the ball? Is it in your hands?  Are you sitting?  Can you give me the bells?” Handles objects with quick entrapping motions, almost as if he’s afraid it will be taken away—typical of partially sighted – he uses a great deal of tilt toward the left to “catch” any light or specks which constitute probable his visual repertoire (or any sound cues, if his hearing is poor?).  His floor activity is scattered, disorganized, and aimless—high activity level.

His preference for handling objects is nil; his motivation is self-induced and appropriate for his level of overall functioning – 1 year.  He plays peek-a-boo, and row-row, if lead through the exercise with a lot of praise and fuss.  Reacts well to up-down concepts; does not appear interested in container-contained, push-pull; separation from mother was no cause for concern at any time.

Ronnie: Age-level speech patterns, vocabulary and expressiveness, 2-3 word sentences; compliant, independent, tip-toe walking most of the time.  Showed quick release, hand and arm motions smooth and bilateral and reciprocal—organized if somewhat restrictive movements of the fingers and pads.  Great interest in insertion tasks, knocking down activities, holding, cradling, rocking, singing to doll and fuzzies; whole pattern of negative, oppositional behaviors which seem to confuse the mother more than annoy her – she appears startled at the wide range of normal responses which the child makes, as if she expects her to be very delayed because of her loss of vision.

Staff concerns: snack time needs restructuring because the teacher aide is blind and “over-protects”.  She does not use localization questions.  She manipulates and does everything she can for the children.  She grabs food out of children’s hands, roughly redirecting them by the arm and hand; she grabs and pulls.  I gave her some ideas about offering objects at the midline and doing absolutely nothing for the children that they could do for themselves.  She says she knows exactly what each child is doing even if she can’t see them.  I explained she thinks she knows, but must let the children control their own responses to a set situation.

Music time is in the hands of a blind music therapist who is new to children’s services, having been in a program for rehabilitated adults for 7 years! Whoops!  I worked with her on toddler songs and games, but there is little chance this person is appropriate for this setting.  I made audio tapes for her to practice and we will video tape her session next week.  She has no idea what a toddler child is like, so I had her do tactile “scanning” of two children, and she was very uncomfortable doing that.  The children loved doing it back to her.

September 27:  I brought the Portage Project material for parents to take out on loan.  I reviewed tape with the music therapist, but she did not learn the songs, she was more concerned with the rationale and reasons I gave for each type of song and games to be done in group.  This process is not conducive to child-centered learning.  The room overall is too adult focused  with the inclusion of blind staff, parents, speech therapist, volunteers, etc.  We will have a staff-parent meeting next week to work on this problem.

Julia: Said: “Let sit”  “I kicking” “ I sleeping” “ I slee---“ Screamed continuously throughout morning – it has now occurred to her that we are going to continue to make demands upon her while she is at school; mother left for parent group and we ignored crying, “catching” her when she paused, and proceeded to observe hand function.  There was no purposeful entrapment, no whole hand, lateral pincher grasp; much palm-down, pronated pushing with the heel of the hand, occasional flickering of fingers in slightly separated state—nails and pads of fingers cold and clammy, upper arms and trunk and face warm and sweaty and flushed.

I caught her “not crying” several times when she paused to get a breath and the crying intensity diminished each time – 10 trials, 10 times used “ good we can play now that you’re not crying…” – finished the sequence with huge screaming and crying patterns.  Told her to “KEEP your MOUTH closed” (Loudly) She stopped abruptly and I said: “Open your mouth (loudly).”  And gave her a drink, which she took happily.  “I kick,” she said.  Quickly I started the music tape and she remained in a non-crying mode for 5 minutes.  Working on wind-up sounds toys, I talked to parents and staff about Julia: appropriate ignoring and the fact that Julia is continually reinforced for not being cooperative or learning.  She clapped and rocked and exhibited several self-stimulating acts, but did not cry again until we changed activity.

Dante and Veronica:  We will pair these two for the session, in order to look at comparative hand function with one highly verbal and one non-verbal to see if any communicative cues can be observed in the non-speaking child (Dante).  Good passing and receiving actions with them together—used ball and pie tin and cars and tape on a mirror which is supposed to be a road for fingers to walk on… Dante did not use any words but increased the gestural nodding and leaning and pointing and sticking out his chin, which he does a lot, as if to use the face and chin as a third hand (also to hear?).  Floor games involving hand contact were poorly executed and did not motivate the children; table tasks which involve insertion, transferring from container to container occupied them most seriously.  The verbal toddler gave directions and bossed the non-verbal, Dante.

April:  Fades in and out of attending and manipulating; fascinated with multi-colored objects, so I directed her not through commands but through presentation of a series of rainbows I drew on paper; mother was very impressed with what she began to do; she stacked 2 cubes to get the colors; she played row-row, she clapped and nodded to rhythm of  my voice, she touched several adversive stimuli which she has previously refused.  She has a great deal of trouble with approach-contact-differentiation of digits—thumb in place-pick up sequence; she still does an enormous amount of finger-flicking and loose-dropping of fingers form the wrist, with the hands sort of dangling out in front of her in a listless, non-functioning position.  Mother and I talked about postural adjustment, 2-hand contact, getting the hands out in front, down, and ready to prehend, tactile-teaching sessions at home to get her used to new and novel as well as old and familiar stimuli and the importance of overcoming the adversive-response tendency which inhibits manual and cognitive manipulation.  I tried a visual acuity test on her which showed me nothing and interfered with her improved reaction to sitting and playing with her hands.

The materials I am using are already having a positive effect, as I leave them there and the parents can work with them Wednesday and Thursday as well.  The parents like the logical progression from one task to another, and we have put together kits for them to have at home.

There is a good deal of change in the parents even after only 2 weeks; they are letting the children do more on their own and interfering with the pattern of play less and less.  The blind staff members continue to present problems.  They attend to and reinforce the crying (Julia) and the jumping up from table (Dante) and the quick change of activities which Ronnie and April make.  They talk at the children (ceaselessly), with the loud inflections and changes in pitch.  They are literally preventing the children from self-regulation and inter-child communication.  There is too much anticipatory cueing from blind teacher to “normal” child’s play.  No chance to fix mistakes themselves.  Much too much over-correction.

October 4Administered fine motor tests to Dante, Veronica, and Jamie.  No significant lapses in fine motor development, but interesting to give the test while trying to describe it to Dante’s blind parents.  Dante’s immature radial palmar grasp and immature bimanual function in screwing, unscrewing, zipper, shoes, pouring, etc.  seems absolutely the result from lack of experience, rather than delays due to the vision loss.  Using a dominant hand in a skilled role, such as drawing, produces similar findings in small children.  After 5 minutes of teaching the task, each child drew a line, put a third object between two other objects.  Isn’t it amazing to think how much of the brain’s function and potentiality comes out in the finger’s, hands, and coordination of eyes, hands, and mouth?  Blind children certainly operate at a disadvantage, but the brain manages to get the mental image out, one way or another.

Had parents watch a session with April to see the various hand positions, manipulations, and prehension stages that occur during the infant-toddler development period.

April:  pinches and uses cortical opposition in both hands at once

            holds two small toys in one hand

            takes pants, shoes, socks off

            uses househole gadget appropriately

            fits objects inside of each other, stacks, unstacks

            aligns two cubes in a row

            points to parts of a body, pictures in a book

            turns pages of a book, several at once

            strokes crayon, imitatively, in air

            eats with spoon, spills

            builds tower of 3 blocks, knocks down

            scribbles on paper

            uses cup, puts cup down, places cup purposefully

            threads and strings large objects

            holds objects with one hand, laterally

            empties and fills containers using both hands

            begins to dress self, fusses with zippers, buttons, laces

            screws and unscrews

            holds pencil in fist

            uses finger tips to hold small pieces, pellets

            makes strokes to imitate a straight line

            draws circles and boxes and squares

            paints with some design, color

            does simple inset puzzles, form boards

            pushes and pulls objects using a neat palmar or mature grasp

I demonstrated, using pantomime, progressive stages of hand function:

            grasp reflex

            crude prehensile grasp

            thumb opposition

            grasp reflex waning

            voluntary grasp

            voluntary palmar grasp

            radial palmar grasp

            inferior pincher grasp

            cortical opposition in voluntary release of objects

            object permanence in holding on and letting go

            neat pincer grasp using pads of digits

            mature grasp

I discussed sensory-visual developmental stages:

            random movements, doll eyes unilateral to bilateral

            midline regard

            following, tracking and acuity levels, horizontal and vertical

            attending to visual stimuli, searches

            look at own hands, faces, shaky reaches

            grasping and reaching

            hand-mouth activity

            complete manipulation

This study of play and the use of the hands in 15-30 month-olds points out the need for more research in the second year of life.  There is something strange about the imitative styles of blind children that suggest a similar style to the parent in the absence of “seeing” that style.  Hand positions and mannerisms occur in Julia’s

           

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