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Early intervention for children with visual impairments

The magical transformation of the helpless infant into the curious, assertive and capable little three year old, is fascinating to observe. To anyone who has watched an infant in the first three years of life, the important role of vision in leading, motivating and clarifying experiences and interactions will be evident.

So what then, if the infant cannot see?

If a child cannot see, it is important to find other ways to interest him in the world around him and help him make sense of what he is experiencing. Few children are totally blind and most have some visual capacity. Ask your ophthalmologist to help you understand what your child can see. Simple changes to the object (for example, using a larger or a smaller ball, using a reflective ball or one with black and white stripes) or to the environment (for example, placing a contrasting, single coloured sheet behind the ball, focusing a light so that it is on the ball) can help your child see things more clearly. Many children will have refractive errors and will benefit from wearing spectacles. A good eye exam is an important first step in helping your child. A rehabilitation teacher can help you understand how to help your child use and develop his vision. Encourage him to explore objects with all his senses – touching it, banging and shaking it to hear the sounds it makes and even putting it in his mouth to taste and feel it with his tongue and lips – will help him later as he learns to recognize it visually.

Children with visual impairments often do not learn to hold their heads steady, sit, and walk as quickly as other children. Many among them may learn to sit or stand, but not know how to move from one position to the other by themselves. Similarly, children may not learn to reach to a toy, or play with it in ways other than banging it, shaking it, or putting it in their mouths. Many children may show understanding of language, especially commands – take this, touch your nose, clap your hands – but do not use language or use it in a repetitive and meaningless manner. Often, children can become very passive, not moving around, not picking up things they drop or searching for toys. They may play with their own bodies, or simply bang or suck on objects they come across. While they seem to recognize their parents or other adults who care for them, some children may not respond to them with the smiles and affection that mark typical parent-child relationships.

Why does this happen?

Just by keeping their eyes open, an infant starts to make sense of the world – they see where things come from, what they are used for, what sounds like the telephone ringing or someone knocking on the door signify. Very early in life, infants will smile at a familiar face, leading us to spontaneously respond, to reach out and touch and talk to the baby. This response from the child lays the foundation of intimacy and caring between infants and those adults that care for them. Another example of the role of vision in development is evident in how children learn to move in the first place. Usually, an infant is fascinated with things that they can see– a flapping curtain, a toy or a person. At first, they move their entire body, wriggling and kicking in an uncoordinated way as they keep their eyes on the object. Over time, they see their hands, learn that they are part of their own bodies and try to use them to reach out to the object. Soon, they gain strength and after a lot of practice, they get better at reaching the target. As they gain better control over their limbs and as they grow in strength, they will try to move their entire bodies toward things they see in the environment. As they move around and explore things with their hands, they learn many things about the world. Words, matched with expressions and actions begin to take on meaning and they start to imitate gestures and sounds in the beginnings of language. As words and sentences make sense, the child experiments with his first words and sees the power they have in giving him access to the world.

Are these problems inevitable?
Certainly not! Spend half an hour in a new place with your eyes closed and you will experience some of the bewilderment and irritation your child will be feeling. Pay attention to what helped you make sense of what was going on around you; what made you comfortable; how you knew what you had to do. This will be your guide in working with your child. Here are some things I have learnt that help immensely –I am sure you will have more to add to this list as you interact with your child.

? Remember, most children with visual impairments, have some amount of vision – they may see light, reflective objects like mirrors or high contrast patterns like black and white stripes. Understanding what your child can see is important as you can select items they will be able to see easily and arrange the environment in ways to help the child see better.

? Help your child anticipate what is going to happen. Even when they are just a few days only and have not learned the meanings of words, tell them what you are going to do before you do it, but accompany your words with a little touch that will give them a clue about what is to come (like tapping her cheek before you feed her, or holding her shoulders gently before you lift her). This will not only help her anticipate what is going to happen, but over time, will help her make sense of the words you are using. Anticipation allows a child to develop a sense of control over the world. This sense of control will give the child the courage to explore, experiment and actively discover and develop their capacities.

? Imagine never knowing when the last mug of water has been poured over you at bath time! Without anticipation, children become resistant to anything you want them to do or very passive, allowing anything to be done to them, but not trying to learn to do things themselves. Make sure he knows when something is over – tell him and until he is old enough, use some action to signal to him that the activity is done (for example, running your hands over the child’s back while saying soaping is over!”). Predictable routines, clear language and clues through touch help the child feel secure and able to make sense of his world and experiences.

? Guide your child gently when exposing her to new experiences. She will be more willing to try if we do not push her and she feels that her fears are respected. Place your hands under hers so she can hold you while you touch the toy or object that is new to her. Over time, allow her hand to touch the object and then guide her to feel it.

? Remember he cannot see what is happening around him. Talk to him, telling him about the sounds he hears; show him from where things come and where things go. The more complete his experience, the better he will be able to engage with the world.

? Expose your child to things other children her age are doing. Before you teach your child how to do them, blindfold yourself and go through the steps so that you may be better able to anticipate how to guide her best. Guide her from behind so that she will experience your movements as she herself would do them.

INFANCY
Some typical areas of difficulty and some suggestions for intervention

Awareness of people around him and his own body

Reading his signs; developing a relationship
The sighted infant learns early to recognize familiar faces. Although your child may not see you, he will quickly learn to recognize your voice and your touch. As you come near, he will often get very quiet and still. Parents imagine that the child is not interested or responsive, when, in fact, he is so quiet because he is listening to your voice and waiting for your touch. Here are some signs to tell you he is happy you are there:
• When you place his hand on your body, his fingers wiggle as they try to feel you.
• He may smile, move his hands and legs excitedly, or wiggle his fingers a few moments after he hears your voice.

We are used to infants looking wide eyed into our eyes and it will feel strange to have a child who doesn’t do this. Often we respond by talking less and playing less with our baby. This can delay the development of that warm, secure bond between parent and child that influences the attitude with which children take on the world. This early talking with the infant also lays the foundations of language, another area that can be delayed in children with visual impairments.

Some things you can do:
Hold your child in your lap, so that he is facing you. Let him feel your face as you talk or sing to him.
Faces are the best visual stimulus available to a child. If your child has some vision, you can help him see you more easily by making sure light falls on your face; wearing a single coloured top that contrasts with your skin colour and sitting so that there is a light coloured wall behind you (so that your face is in higher contrast). Black hair framing your face will make it easier for your child to focus on it, similarly, eyes outlines in kajal or with darkened eyebrows will help your child find and focus on your eyes.

Preparing for action
Many children arch away when you try to carry them and seem happiest when left alone on the bed. Most of them do this because they are startled, not having realized what was about to happen to them. We tend to respond by getting more abrupt and more forceful when we need to pick them up. Soon they learn that when people come near them, something unpleasant is about to happen. They may tolerate their parents or regular caregivers but do not seem to enjoy most interactions. We, in our turn, begin to dread picking them up and begin to do so only when absolutely necessary.

Some things you can do:
Next time, tell the child what you are going to do, then touch him gently but firmly at his shoulders and only then lift him, change him, feed him or begin any new activity with him. Spend a few seconds talking to him or holding him and singing gently to him until he is calm. Over time, he will understand what is about to happen and be more relaxed.

Discovering his body
At three or four months, a baby who can see, will start to look at his hands, holding them in front of his eyes and watching as he moves his fingers and shakes his hands. He is beginning to discover that they belong to him and that he has control over them. Soon, his awareness extends to his toes and you will often find your child grabbing his feet and even pulling them toward his head. Apart from discovering his own body, the child is also getting good exercise, building his muscles and learning to control his movements better. Babies who cannot see may be passive at this age, and are slow to discover their bodies and understand how they can use it.

Some things you can do:
While you play with your baby, hold his arms and gently guide them toward each other.
Help draw his attention to the different parts of his body – walk your fingers up his arms and legs, blow on his palm and under his feet, pat his tummy and his back.
Changing the baby and bath time are great opportunities to work on this skill.
Most of us massage our babies with oil and this is another great opportunity to draw his attention to the parts of his body. Remember that routine and predictability help your child learn, so follow one order of massage with your child, always signaling with a tap before you start with a body part and firm pressure to indicate that you have finished with it.
Place anklets on his feet and bangles on his hand. Guide his hands to feel and explore them.
Select bright bangles or arm bands in colours that your child sees best– bright colours, reflective objects, stripes. Direct your child’s attention to it by helping him first touch and explore it, and then helping him attend visually to it by bringing it close to his eyes or shining a light on it to attract his visual attention. Bright socks or the same arm bands on his feet should work to get him excitedly exploring his toes as well!

Awareness of her space
Developing touch
When vision is impaired, touch becomes an important way to gather detailed information about things in the environment.

Experiencing movement

Following sounds – gross and fine

Participating in life
Dressing
Eating

-- Namita Jacob

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