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Q. Why do some children avoid watching their hands or look at them only briefly?
A. Task analysis is necessary to discover the cause of poor visual monitoring of hands, since there are so many possible reasons. Many children with multiple disabilities have poor grading of neck muscles for head control. They must maintain the head totally erect or it will flop into flexion. Thus, fixation on their hands or objects is usually fleeting. Long-term goals can include improving head control, but short-term intervention must provide environmental adaptations such as head support and appropriate positioning of objects so eyes can watch hands. Some children's eyes, however, are influenced by the flexion/extension components of the Doll's Eye Responses, involuntary reflexes that should be integrated by 3 months. If not, when the neck flexes downward, the eyes remain up or are delayed in moving down with the head. Copying from the chalkboard to a paper on the desk would be more difficult and delayed. The integration of this reflex can be accelerated if the child has plenty of practice with the neck flexion/extension movements in a functional but less stressful context, such as a game of identifying objects in far space and drawing a picture on a paper in near space.

Q. How can we decrease distractibility problems in the classroom?
A. Many children are easily distracted by any visual stimulus, especially moving objects, and are unable to maintain attention. To understand fixation, or visual grasp (the ability to keep the eyes on a target), we need to review its developmental process. The newborn's eyes are usually in constant motion, roving through the immediate environment, with only one eye able to align and immobilize briefly on an object presented in a specific spot. By one month, the infant's first true fixation is a vague stare at the surroundings, and fixation on Mother's face is still brief. By 3 months, the baby can maintain fixation on a stationary target unless distracted by a more compelling moving target. Not until 5 months can a moving target be ignored for an interesting stationary one. I believe visual distractibility is a sign of delayed development. We can help these children by analyzing and inserting all the necessary motor components, and/or by conditioning them to focus on relevant stationary targets during attempts to distract with moving targets. For example, we can ask a child to build the tallest block tower possible, while we try to bother him with a squeezie toy frog hopping in all visual fields.

Q. Should we try to help a child move eyes separately from head for faster reading?
A. It depends. Infants don't begin to move eyes separately from head until 5 or 6 months, when the rotational components of the Doll's Eye Responses are integrated and head control has been perfected. If those and other elements are in the process of development, it may be best to allow the child's visual development to proceed normally, although delayed, because visual motivation stimulates head control. If, however, we are reasonably sure that a child with severe disabilities may never gain sufficient head control, we would provide adaptive equipment and positioning to stabilize the head. The eyes could then move very precisely to operate an augmentative communication system.

Q. What can we do about children with cortical visual impairment (CVI) who seek self-stimulating visual displays, including repetitive hand movements in front of their faces?
A. Normal infants go through developmental stages of attraction to specific stimuli, such as black and white patterns, bright colors, moving targets, targets with internal movement and/or sound properties, diffuse light, focal light, and of course, faces. These patterns are gradually linked to concrete objects that they are able to handle and explore, categorize with cognitive awareness, and label through language. The more mobile the developing child, the more opportunity that child has to seek and receive a variety of visual and tactile input. People with cognitive, visual, and/or mobility impairments still have strong needs for that sensory input followed by motor output. Since their developmental process is interrupted, they get stuck using a few stereotypic patterns to satisfy those needs. Our intervention depends on determination of specific developmental levels and sensory motor needs of each individual. For example, children with very low vision may need manual assistance in exploring the tactile attributes of accessible objects, concurrently with learning their names and functional uses. By offering more choices for gaining meaningful sensory information, we help these children expand their repertoire of socially acceptable behaviors. An appropriate sensory diet could address ways of providing proprioceptive and vestibular input as well as tactile, through selected activities that are age-appropriate and related to occupations of childhood.

Adapted from: Erhardt, R.P. (May 18, 1998). Visual Function Series #1. Visual development: Answers to some common questions. ADVANCE for Occupational Therapists, 14(20), 19-20.

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* Glossary of Vision Terms
* Visual Function

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