Download AnthonyRoleTVIInfants - Texas School for the Blind and Visually

Texas School for the Blind & Visually
Impaired Outreach Programs
www.tsbvi.edu
512-454-8631
Superintendent William Daugherty
Outreach Director Cyral Miller
Texas Focus: Learning From Near to Far
New Teacher Pre-Conference:
The Role of the TVI with Infants and Toddlers
Who Are Visually Impaired
Time: 10:00 AM-4:00 PM
Date: June 9, 2010
Presented by
Tanni Anthony, Ph.D., COMS
Colorado Department of Education
Developed for
Texas School for the Blind & Visually
Impaired Outreach Programs
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Role of the TVI with Infants and Toddlers who are Blind and
Visually Impaired
Tanni L. Anthony, Ph.D.
ROLE OF THE TVI
1. To provide support and guidance to families of children. To
respect family priorities and stated/shared needs.
2. To be a knowledgeable team member on early childhood
development.
3. To be a team leader in the knowledge of the effects of blindness
upon early development. (literature / experience)
4. To be a knowledgeable team member on other disabilities.
ROLE OF THE TVI
Assessment with TVI as a lead
 FVA
 Sensory Assessment
 Learning Media Assessment
Assessment with TVI as a lead or a partner
 Developmental Assessment
Co-developer of IFSP goals and objectives (leader on VI-related goals
and objectives, instruction of and use of accommodations)
INCIDENCE OF EARLY VISION LOSS
 Vision Problems – 1 : 20 preschoolers
 Visual Impairment – 1 : 3,000 children
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HIGH RISK INDICATORS
 Prematurity
 TORCH Infections (40,000 newborns annually)
 FAS / FAE or other prenatal toxins
 Cerebral Palsy
 Syndromes (e.g., Down, Goldenhar)
 Deaf/Hard of Hearing
 Pre and Postnatal Virus
PREVALENCE DATA
 1 in 3,000 children are born each year with a visual impairment
 Causes of blindness / visual impairment depend on where you live
in the world.
 Primary causes of early-onset visual impairment have changed
since the 1960s.
CHILDREN WITH VISUAL IMPAIRMENT
 Are little kids who happen to have a vision loss.
 Have varying degrees of vision loss.
 Have a high incidence of additional challenges.
OVERVIEW BASICS: PEDIATRIC BVI
 Visual impairment is a low incidence disability.
 Visual impairment is largely a disability of “access”
 Children with visual impairments represent a highly heterogeneous
population.
 Visual impairment should be viewed from an “individual differences”
perspective.
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FACTORS TO CONSIDER:
 Age of Onset of Vision Loss
 Type of Vision Loss
 Severity of Vision Loss
 Presence of Other Disabilities
 Family Supports
 Environmental Support / Need for Technology
ROLE OF TEMPERAMENT
 Refers to our basic disposition, which influences our behavior.
 Describes HOW a child reacts, not why.
 Expressions of temperament can be influenced by the environment.
 9 primary qualities define temperament
TEMPERAMENT QUALITIES
1. Quality of Mood
2. Intensity of Reaction
3. Attention Span and Persistence
4. Approach - Withdrawal
5. Activity Level
6. Threshold of Responsiveness
7. Rhythmicity
8. Distractibility
9. Adaptability
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CHILDREN ARE CHILDREN
 Every child is unique.
 We have knowledge of a general developmental path.
Each path is
unique to a child in respect to temperament, family situations, and
individual variations.
 Early onset blindness/visual impairment does not explain all
developmental variations.
TODDLER’S PROPERTY OF LAW
 If I like it, it’s mine.
 If it might be mine, it’s mine.
 If it’s in my hand, it’s mine.
 If I can take it from you, it’s mine.
 If I had it before, it’s mine.
 If I’m making something, all the parts are mine.
 If it’s mine, it must never appear to be yours in any way.
 If it looks like mine, it’s mine.
 If I think it’s mine, it’s mine.
BVI EFFECTS: SENSORY
 Although vision is one of the last senses to develop in utero.
 Visual development occurs quickly within the first year.
 Vision has a key role in the development and refinement of other
senses.
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BVI EFFECTS: SOCIAL EMOTIONAL
 Prolonged hospital stays may interfere with “the natural care giving
process.”
 Early social-communication may be affected due to reduced/absent
eye contact, eye gaze, or reciprocal smiling.
 Infant responses may be missed or misinterpreted.
 Caregiver may be under considerable stress and not as emotionally
available.
 Other factors: temperament, caregiver style, expectations.
 Understanding play rules– role of imitation.
 Mediating “nonverbal” and “visual signals” of play relationships.
 Guiding conversational skills
BVI EFFECTS: COMMUNICATION
 Preverbal behavior tied to eye contact, visual gaze, facial
expression, pointing, etc.
 Early behavior may be misinterpreted.
 Increase use of labels and “self-centered” topics based on modeled
language.
 Challenges of a “visual referent”
 Visual language – here, there
 Pronoun usage
 Typical vs. atypical echolalia
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BVI EFFECTS: COGNITION / LEARNING
Object Permanence
 Sound is not a substitute for sight in the first year of life.
 Between six and seven months, hearing and holding are two
separate events.
BVI EFFECTS: COGNITION/LEARNING
 Limited perception of environment – need for meaningful input
 Sensitivity to overload
 Decreased incidental learning/risk for fragmented information
 Challenges of generalization
 Movement has ties concept development
(Fraiberg, 1968)
BVI EFFECTS: MOTOR
 Low postural tone base – movement/transitions
 Movement tied to object permanence
 Movement tied to imitation
 Reduced opportunities for repetitive motor play
 Need for movement cues/preparation
REACH (MOVEMENT) – COGNITION.
“Before the blind baby is able to achieve a direct reach on a sound cue
alone, he must be able to solve a conceptual problem. When he hears
the sound of his favorite musical toy “out there,” the sound must
connote a thing which has certain tactile and acoustical properties
which constitute its identify and its wholeness.”
(Fraiberg, 1968, p. 282)
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TYPES OF VISUAL IMPAIRMENT
 Ocular visual impairment
 Cortical visual impairment (CVI)
PARTS OF THE VISUAL SYSTEM
 Eyeball
 Optic Nerve
 Brain
PEDIATRIC VISUAL IMPAIRMENT
Top three reasons for early onset visual impairment: CVI, ROP, ONH
Blindness: 10 - 25%
Light Perception: 25%
Low Vision: 50%
FVA AND CLINICAL EYE EXAMS
Clinical
 Conducted by medical professional
 Determines health of eyes, diagnosis and prognosis, visual field
acuity, refractive error measurement, and surgical or medication
recommendations
Functional
 Conducted by TVI, support and input from caregivers and team
 Results provide visual function information (i.e., how the child uses
his or her vision) and identify child’s strengths and needs
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FUNCTIONAL VISION ASSESSMENT
 Compliments a clinical vision assessment.
 Determines what HELPS visual performance
 Determines what HINDERS visual performance.
 The FVA provides information that will assist in developing
interventions and strategies, such as environmental adaptations
and sensory motivators that will enhance the child’s use of vision
for early learning activities
PHILOSOPHY OF ASSESSMENT
 Parent info & participation are essential, as is a full team approach
guided by a TVI.
 It takes time to complete a FVA.
 The FVA should reflect real life learning and activities.
 It is key to determine the child’s learning style.
 Qualitative and quantitative skills should be noted in a FVA.
BACKGROUND INFORMATION
 Cumulative Folder Review (medical, grade, achievement,
assessment data, services, glasses / low vision devices)
 Parent Interview (family and child medical history, family priorities,
observations, concerns)
 Classroom Teacher Interview (strengths, class performance,
observations / concerns across settings)
 Student Interview (hobbies / interests, likes / dislikes, performance
across settings)
REVIEW MEDICAL RECORDS
The analysis of medical information including
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 birth history,
 presence of other disabilities, and
 visual diagnosis / prognosis / recommendations for medical
treatments such as glasses / surgery
Creates a foundation for subsequent observation and assessment. May
assist with assessment hypotheses.
MEDICATIONS AND SIDE EFFECTS
It is important to be aware prescribed medications.
There may be a variety of contraindications that will affect the child’s
visual attention and performance.
(see accompanying handout)
THE CAREGIVER’S ROLE IN FVA
 Can share details the child’s life, home history, preferences (likes
and dislikes).
 Shares information to help the TVI plan the assessment and to
address family’s specific priorities, needs, and concerns.
It will be helpful to frame your questions to parents. Avoid simple yes /
no questions. Probe for examples that will fuel the assessment
findings.
INFORMAL TOOLS AND PROCEDURES
Informal assessment ideally occurs with observing the learner within the
daily routines in the natural learning environments.
 playing with toys / interacting with daily objects
 sharing a storybook, reading a book
 eating lunch / completing other daily care activities
 moving in familiar and unfamiliar environments
 interacting with siblings and caregivers
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PIECES OF THE FVA PUZZLE
Familiar vs.
Unfamiliar
Settings
Internal Factors
Environmental
Control Factors
Need for
Rapport /
Emotional
Safety
Attending to
Positioning
Need for Wait
Time
Reading Child
Responses
Type of Sensory
Targets
SETTING PREPARATION
 Familiar / Unfamiliar
 Controlled / Real Life (lighting, noise)
 Accessibility of Materials (for you and student)
 Duplicates of Materials
 Opportunities for Movement / System Prep
 Presence and Use of Others
(Langely, 1998)
RAPPORT / PACING / WAIT TIME / CHILD RESPONSES
 Build a connection with the child through his or her interests.
 Be sensitive to pacing and wait time needs.
 Pay attention to subtle and overt responses.
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POSITIONING
 Ensure the child is in a supported posture.
 Hips support = trunk support = head support.
 Focus should be on looking and not maintaining balance.
VISUAL TARGET CHARACTERISTICS
 Illuminating
 Reflective (has “movement” features)
 Colored
 Patterned / Complexity Features
 Novel vs. Familiar
 Accompanied, as needed, by touch, vibration, and/or sound
FVA MATERIALS
 Daily objects
 Favorite Objects
 School Objects
 Penlights / Caps
 Illuminating Toys
 Mylar
 Reflective Objects
 Wind Up Toys
 Slinky
 Finger Puppets
 Small Objects
 Doubles of Objects
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 Containers
 Black / white covers
 Occluder
VISUAL PRESENTATION PARAMETERS
Present within the “individual working space” of the child.
 attention to focal distance
 attention to visual field needs
 use “movement agitation” as needed to elicit the child’s visual
attention
 provide time for visual latency
FVA COMPONENTS: FIRST GLANCE
 Appearance of Eyes / Structural Integrity
 Corrective Lenses (should not be worn during FVA)
External Ocular Status
 Appearance of the eyes can possibly indicate the presence of a
visual impairment and quality of functional vision
 External structures such as the globe, eyelids, pupils, iris, and
cornea should be observed for symmetry, size, and shape
 Observation of unusual redness, tearing, eye matter, and/or
nystagmus.
Erin, 2000; Langley, 1998
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APPEARANCE OF EYES
 Ocular V. I.: often have nystagmus, may have visible damage to
eye.
 CVI: no nystagmus, no visible damage to eye
The appearance of the eyes provide clues as to visual functioning.
EYE APPEARANCE
Findings
Recommendations
 Self-conscience about
 Self-advocacy about eye
 May be isolated or teased by
 Peer support groups or
appearance
peers.
 May have physical
discomfort or pain
condition.
opportunities with peers with
visual impairments
 Counseling
 Treatment options
VISUAL REFLEXES
Visual reflexes are involuntary motor responses of the visual system.
 Defensive Blink: A defensive blink can be elicited to a large visual
target that is rapidly presented in the infant’s central visual field. It
is a learned reflex.
 By five months, the infant has a defensive blink to oncoming
objects of various sizes in both the central and peripheral fields
(Nelson et al, 1984).
RECEPTION /PERCEPTION OF VISUAL STIMULI
 Light Perception
 Light Projection
 Shadow and Form Perception
 Hand Motion
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PUPILLARY RESPONSE
A visual reflex = confirms pupillary pathway function.
 Penlight / Occluder
 Room Lighting
 Outdoor Lighting
 Changes in Lighting
VISUAL RESPONSE TO LIGHT
 Detects environmental lighting sources such as windows or doors.
 Orients or points to penlight, capped penlights, cellophane with
penlight, lightbox, lamps, overhead lights, environmental light
sources, etc.
 Knows when lights are on or off in a room.
LIGHT-RELATED VISUAL BEHAVIORS
 Eye Pressing (internal stimulation)
 Photophobia
 Stares at lights
 Blinks / squints / tears to light
 Flicks fingers / objects against light
 Head bowing to avoid too much light
 Needs more light
 Needs less light
 Poor light / dark adaptation
 Poor night vision
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ILLUMINATION NEEDS (LANGELY, 1998)
Low Lighting
Bright Lighting
Variable Lighting
Achromatopsia
Aphakia
Amblopia
Albinism
High Myopia
Hyperopia
Corneal Opacities
Macular Degeneration
Macular Pathology
Glaucoma
Optic Atrophy
Uveitis
Colobomas
Retinal Detachment
Aniridia
Retinitis Pigmentosa
Posterior Cataracts
Retinopathy of
Prematurity
Cone Dystrophies
Cataracts
Iritis
VISUAL RESPONSE TO LIGHT
Findings
Recommendations
 Nonresponsive to light
- end
of FVA.
 Responsive to different
locations, strengths, and
types of lights.
 Use of light as a learning
and literacy tool.
 Use of light for orientation
purposes.
 Need for more or less
illumination / different types
of illumination.
 More light/dark adaptation
time.
 Attention to glare sources.
 Need for light-absorption
lenses, hat brims, etc.
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COLOR VISION
 CV deficiencies within the typical population and are especially Xlinked with males.
 The first true means to evaluate the child’s ability to discriminate
color is at 29 to 33 months when matching of primary colors.
 Occur with certain types of ocular visual impairments.
 Check for color preferences. Color vision remains intact with CVI
and may be an area of visual strength.
COLOR / CONTRAST DISCRIMINATION
Findings
Recommendations
 Difficulty with tasks involving
 Black markers for outlining /
 Difficulty discerning door
 Map / graph adaptations
 Increase or decrease in
color discrimination.
frames, stairs, etc.
 Difficulty with clothing
matching.
grading
lighting
 Labels on crayons, clothes
 Traffic light interpretation
EYE PREFERENCE
 Anisometropia
 Nystagmus Equity
 Monocular Items
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ALIGNMENT AND OCULAR MOTILITY
 The corneal light reflection assessment or Hirschberg corneal light
reflection test is used to indicate the presence of strabismus, an
imbalance of the extraocular muscles.
 During the light reflection assessment, notice how the child moves
his or her eyes and head. These observations can help to
determine which eye has more functional vision and the cause of
the misalignment. (Langely, 1998)
Figure 1 Chart showing examples and definitions for Heterotropia
or Strabismus.
EYE TEAMING = BINOCULARITY
Depth Perception
Figure – Ground Perception
 Ability to perceive depth requires visual teamwork.
Eye teaming
should be measured in efficiency and quality.
 Acuity influences binocularity.
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CORNEAL LIGHT REFLEX TEST
Look at where the light is reflected in each eye.
Figure 2 Picture of young child’s eyes with light reflected in the
pupils.
MUSCLES CONTROLLING EYES
 Six muscles attached to each eye
 Innervated by nerves – controlled by frontal lobe
 Allow eyes to move up/down and left/right
OCULAR MOTOR BEHAVIORS
 FIXATION (null point/ head tilt)
 CONVERGENCE
 DIVERGENCE
 TRACING
 TRACKING
 SHIFT OF GAZE
 SCANNING
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EYE TEAMING PROBLEMS
 Can occur within the typical population – esotropia, exotropia,
 Occurs with Mobius syndrome, oculomotor apraxia.
 Occur with many ocular visual impairments.
 Co-occur with CVI due to cerebral palsy.
OCULOMOTOR SKILLS
Findings
Recommendations
 Visual fatigue with sustained
eye movement tasks
(scanning communication
board)
 Poor quality eye teaming
skills
 Associated head
movements with eye
teaming
 Grading of visual movement
tasks.
 Teaching of eye / head
movement
 Attention to communication
systems and/or reading
tasks that benefit from
smooth saccadic
movements
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VISUAL FIELDS
Figure 3 Drawing of human visual system showing range of the
normal visual field.
 180 degrees total filed from side to side
 90 degrees temporally
 60 degrees nasally
 120 degrees upper and lower fields (vertically)
 50 degrees upper
 70 degrees lower
(Jose, 1985)
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VISUAL FIELD LOSS
 Can occur with ocular visual impairment. Higher risk populations =
neurological and/or retinal damage. (e.g., cerebral palsy, head
trauma, coloboma, Retinitis Pigmentosa, ROP)
 Can occur with CVI and/or other neurological damage (cerebral
palsy). In addition, the child with CVI may have visual field
preferences.
Figure 4 two images of visual field loss, one showing “islands of
vision” and the other showing hemianopsia.
Figure 5 examples of peripheral field loss, central field loss, and
scattered field loss or scotomas.
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PERIPHERAL FIELDS
Upper Left
Upper Central
Upper Right
Central Left
Central
Central Right
Lower Left
Lower Central
Lower Right
Establish the student’s gaze on an object straight ahead. Then
introduce a second item in other areas of the visual field and note the
student’s response.
VISUAL FIELD LOSS BEHAVIORS
 Turns head to scan when still or moving
 Misses objects outside of central field
 Fails to notice objects/people on side(s)
 Bumps into objects on one or both sides
 Startles when approached from side
 Eccentric viewing (central loss)
 “Overlooking”
 CVI and close viewing / head turn when reaching
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VISUAL FIELD LOSS
Findings
Recommendations
 Preference / neglect of an
area of visual field.
 Changes in field specific to a
progressive visual loss.
 Presentation strategies.
 Communication system
accommodations.
 Seating / positioning
accommodations.
 Scanning / hearing turning
strategy training.
 Safety glasses/PE cautions.
 O&M strategies specific to
field loss.
VISUAL ACUITY LOSS OCCURS
 With typical refractive errors (this may be on top of Ocular VI and
CVI)
 With the vast majority of cases of ocular impairment (damage to
cornea, lens, pupil, lens, retina, optic nerve).
* check out nystagmus for cues
Figure 6 examples of normal and blurry vision.
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OBSERVE NEAR VISION
 Describe how the student explores new materials (visually,
tactually, auditorily, or a combination).
 Does student maintain eye contact/visual attention with activities?
With people?
 What are examples of recognition / identification of near objects
OBJECT ID AT NEAR RANGE
Object
Size
Distance
IDed
Cup
5 X 3, red
Yes / No
Shoe
7 X 3, brown
Yes / No
Pencil
5 X .25, yellow
Yes / No
Spoon
4 X .5, silver
Yes / No
Behaviors
PICTURE ID AT NEAR RANGE
Picture
Size
Distance
IDed
Colored photos
of objects
Yes / No
Colored photos
of family
Yes / No
Colored drawings
of objects
Yes / No
Black and white
drawings of
objects
Yes / No
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Behaviors
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NEAR ACUITY DISCRIMINATION
Findings
Recommendations
 Difficulty with near acuity
discrimination tasks (object,
picture, money etc. ID)
 Social stigma of close
viewing
 Visual fatigue with sustained
near acuity tasks.
 Low vision evaluation.
 Use of magnification tools /
enlarged materials.
 Increased contrast.
 Teach critical features of
pictures.
 Dual literacy modes and/or
braille as single mode.
 Visual and/or ractile
adaptations.
CONSIDERATIONS
OPTICAL DEVICES
Use of prescribed optical devices such as magnifiers and monoculars
may help children with low vision gain visual access to their world.
Optical device training may
 improve self-image,
 facilitate independence,
 facilitate learning, and
 heighten motivation and curiosity
to explore.
Wilkinson, 2000
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CCTV AND BOOKS
JC Greeley – September 2003
Early Intervention-VI Infants/Toddlers listserv posting
The most fun "nature" activity we have had with the CCTV was putting
one of those ugly horned tomato worms on the screen using a bright
fluorescent color and watching it undulate towards our faces with its
mouth open. Perfect story prop for the Very, Very, Very Hungry
Caterpillar.
DISTANCE VISION
 Distant vision is the discrimination of objects, pictures, and print at
10 feet or greater.
 Functional distant discrimination can be assessed by: (1) locating
common objects on varying surfaces at distances greater than 10
feet; (2) locating a wall clock and describing the positions of the
hands; (3) imitating body movements and identifying facial
expressions; and (4) recognizing pictures, numbers, letters and
single words written on a whiteboard.
DISTANCE VISUAL ACUITY CARDS
 For 2.5 years and older (if able)
 Remember to double the denominator if you screen from 10 feet.
DISTANCE VISION
 Identifies distance objects / people inside
 Identifies distance objects/ people outside
 Thrusts head forward to see
 Locates requested distance object
 Avoids objects while moving
 Walks with confidence
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DISTANCE VISUAL ACUITY
Findings
Recommendations
 Difficulty with distance acuity
discrimination tasks.
Boundaries of distance
vision – what is doable and
what is not.
 Visual fatigue with sustained
distance acuity tasks.
 Low vision evaluation.
 Use of magnification tools
for distance (monoculars,
CCTV).
 Teach critical features of
distance objects.
 Description of environment.
 O&M training.
VISUAL INTERPRETATION
 This is the hallmark feature of CVI.
 Factors:
 visual latency
 difficulties with visual complexity
VISUAL INTERPRETATION DIFFICULTIES
 Children at risk include those with neurological damage (prenatal,
perinatal, or postnatal).
 Interpretation problems are different than visual perceptual
problems.
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VISUAL INTERPRETATION
Findings
Recommendations
 Visual latency challenges
 Visual complexity challenges
 Wait time
 Use of familiarity
 Use of color preferences
 Decrease of visual clutter
 Use of auditory / tactile
strategies
VISUAL BEHAVIORS
Light
Field
Close Viewing
Acuity
Oculomotor
X
Head Postures / Tilt
X
Unique Eye Positions
X
X
X
Eye Pressing
Sort of
Eye Blinking
X
Eye Squinting
X
Cessation of Mvmt.
X
X
X
VISUAL MOTOR COORDINATION
 Gross Motor Tasks
 Fine Motor Tasks
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COLOR
 Color may impact how children use vision.
 Red and yellow may be preferred colors for children with CVI.
 Color preferences can promote the use and further development of
functional vision.
CONTRAST
 Contrast describes the child’s sensitivity or ability to detect
difference of brightness.
 TVIs and caregivers can modify the background when a child is
having difficulty completing a task.
LIGHTING
During the FVA, TVIs should consider
 the child’s visual diagnosis and implications
for determining lighting
needs; the lighting conditions in each environment, e.g., artificial or
natural; and
 the child’s sensitivity to light indoors and outdoors and the need to
provide protection from glare and/or ultraviolet rays.
SPACE & DISTANCE
Space is the three-dimensional field in which individuals function in
everyday life.
Distance is the amount of space between the child and an object or
activity.
Space and distance considerations:
 child’s physical position
 physical arrangement of environment
 presentation of activities and objects at child’s eye level
 visual landmarks within the environment
Erin et al., 2002; Topor & Erin, 2000; Webster, 2001
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TIME
 Children with visual impairments and multiple disabilities need
more time to
 detect,
 recognize, and
 act upon an object or person in their environment.
Brennan, Peck, & Lolli, 1992
REPORT WRITING
 Personalized (who is the child first)
 Factual
 Acronyms / Jargon Explained
 “Can do” Descriptive with Examples
 Inclusive of Other Perspectives
 Respectful of Student Sensory Strategies
 Findings linked to Recommendations
Sara has a lower field loss that restricts her view of instructional
materials that are placed below her chin.
A slant board will assist in bringing her learning materials into view
without the continual fatigue of tilting her head downward.
Sara often closes her eyes and/or turns her head when new visual
information is presented.
It will be important to present one item at a time to reduce visual clutter.
Pay attention to reducing auditory distractions when new visual targets
are introduced.
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Medications That Influence Visual Functioning
By Dr. Stuart Teplin and Dr. Josh Alexander
MEDICATIONS FOR ATTENTION DEFICIT HYPERACTIVITY
DISORDER
Medication
Name
Pemoline
Brand
Name
Cylert
Side Effects
 nystagmus (rapid rhythmic repetitious
involuntary eye movements)
 oculogyric crisis (eyes may converge,
deviateupward and laterally, or
deviate downward)
MEDICATIONS FOR SPASTICITY AND MOVEMENT DISORDERS
Medication
Name
Brand
Name
Trihexyphenidyl Artane
hydrocholoride
Side Effects
 dilation of the pupil
 blurred vision
 angle-closure glaucoma (with
long-term
 treatment)
Dantrolene
sodium
Dantrium
 visual disturbance
 diplopia (double vision)
 excessive tearing
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Medication
Name
Brand
Name
Side Effects
Baclofen
Lioresal
 abnormal vision
 abnormal accommodation
 diplopia
Carbidopa/levo
dopa
Sinemet
 oculogyric crises
 diplopia
 blurred vision
 dilated pupils
 blepharospasm (involuntary forcible
closure of the eyelids)
Diazepam
Valium
 blurred vision
Tizanidine
Zanaflex
 amblyopia
 blurred vision
MEDICATIONS FOR SEIZURE MANAGEMENT
Medication
Name
Brand
Name
Side Effects
Felbamate
Felbatol
 diplopia
 abnormal vision
Tiagabine
Gabitril
 nystagmus
 strabismus (eye deviation)
 amblyopia
Levetiracetam
Keppra
 diplopia
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Medication
Name
Brand
Name
Side Effects
Vigabatrin
Sabril
 loss of vision
Ethosuxamide
Zarontin
 myopia (nearsightedness)
Zonisamide
Zonegran
 diplopia
 amblyopia
 visual field defect
 glaucoma
 photophobia (light sensitivity)
 iritis (inflammation of the iris)
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MEDICATIONS FOR ALLERGIES
Medication
Name
Cetirizine
Brand
Name
Zyrtec
Side Effects
 ptosis (eye lid droop)
 syncope (vision may fade)
 tremor
 twitching
 vertigo
 visual field defect
 blindness
 conjunctivitis
 eye pain
 glaucoma
 loss of accommodation
 ocular hemorrhage
 xerophthalmia (dry eyes)
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MEDICATIONS FOR DROOLING
Medication
Name
Brand
Name
Trihexyphenidyl Artane
Side Effects
 ptosis
 syncope
 tremor
 twitching
 vertigo (dizziness)
 visual field defect
 blindness
 conjunctivitis (infection of conjunctiva)
 eye pain
 glaucoma
 loss of accommodation
 ocular hemorrhage (internal eye
bleed)
 xerophthalmia
Glycopyrrolate
Scopolamine
Robinul
 blurred vision
 dilatation of the pupil
 cycloplegia
mydriasis (dilation of the pupils)
cycloplegia
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MEDICATIONS FOR NEUROGENIC BLADDER
Medication
Name
Oxybutynin
Brand
Name
Ditropan
Side Effects
 amblyopia
 cycloplegia (paralysis of ciliary
muscles)
 decreased lacrimation (tears)
 mydriasis
 blurred vision
MEDICATIONS FOR GASTROESOPHAGEAL REFLUX DISEASE
Medication
Name
Ranitidine
Brand
Name
Zantac
Side Effects
 blurred vision
REFERENCE
Mosby, Inc. (2003). Mosby’s drug consult. Retrieved May 2, 2003, from
http://home.mdconsult.com/das/drug/view/28204821
This handout is from the Visual Conditions and Functional Vision:
Issues for Early Intervention Module. Session 4: Functional Vision
Assessment and Developmentally Appropriate Learning Media
Assessment. Web link: http://www.fpg.unc.edu/~edin/index.htm
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Approximate Functional Visual Acuity for Different Sizes of
Objects and Distances
DISTANCE FROM THE CHILD
Size
of
the
2
feet
4
feet
6
feet
8
feet
20
feet
object
¼ inch
20/200
20/100
20/67
20/50
20/20
½ inch
20/400
20/200
20/133
20/100
20/40
¾ inch
20/600
20/300
20/200
20/150
20/60
1 inch
20/800
20/400
20/267
20/200
20/80
Topor, I. (2004). Approximate functional visual acuity for different sizes
of objects and distances. Chapel Hill, NC: Early Intervention Training
Center for Infants and Toddlers with Visual Impairments, FPG Child
Development Institute, UNC-CH.
This handout is from the Visual Conditions and Functional Vision:
Issues for Early Intervention Module. Session 4: Functional Vision
Assessment and Developmentally Appropriate Learning
Media Assessment.
Web link - http://www.fpg.unc.edu/~edin/index.htm
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Recommendations to Enhance Vision and Vision Efficiency
within the Physical Environment
When considering environmental adaptations for children with visual
impairments, think about changes that will allow them to be more
independent. For example, if there are no natural obstacles in the way,
children will never learn to go around an obstacle. On the other hand, if
there are so many things in the way that children cannot move
independently, they will most likely be restricted in their movement and
interaction with the environment. When adapting or changing the
physical environment, consider:
 changes that increase children's independence—do what makes
sense versus creating an artificial environment;
 changes that will benefit all children;
 making adaptations natural versus artificial;
 whether or not children can negotiate the physical environment with
 familiarization versus changing the environment; and
 fading adaptations to assure that children can negotiate the real
world.
ADAPTATION
Lighting
HOW TO UTLIZE THE ADAPTATION
 Information about how the child's visual condition
affects lighting needs. More is not necessarily better;
child may be light sensitive or see better in dim
lighting. Dimmer switches can help control lighting.
 Where should the lighting be positioned? Usually it is
better for light to come from behind the child.
 Some children need higher intensity lighting for detail
vision. Task lighting can sometimes be helpful.
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ADAPTATION
HOW TO UTLIZE THE ADAPTATION
 Check for glare on television and computer monitors,
blackboards, and laminated pictures. Alter the
position of lights to control glare.
Size and
distance
 Increase the magnification of objects by bringing them
Positioning of
materials
 Position materials within the visual range of the child.
Time
 The speed of objects as they pass through the visual
closer or by increasing the size. Allow children to
bring materials as close as they need to and allow
them to be close to you, materials, or activities such
as circle time.
If the children need to hold materials close to see,
place the materials on a slant board, wedge, or higher
surface so that the child does not have to hold his
head down to see. If children use special seating
equipment, position materials in the visual field.
field affects children's ability to see. A rolling ball may
move too fast for the child to fixate and follow; a
balloon of the same size moving slowly may be easier
for the child to follow.
Brown, C. (2003). Recommendations to enhance vision and vision
efficiency within the physical environment. Chapel Hill, NC: Early
Intervention Training Center for Infants and Toddlers with Visual
Impairments, FPG Child Development Institute, UNC-CH.
This handout is from the Visual Conditions and Functional Vision:
Issues for Early Intervention Module. Session 5: Using Assessment
Results in Intervention.
Web link: http://www.fpg.unc.edu/~edin/index.htm
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The Blind Child in the Regular Preschool Program
By Ruby Ryles, Ph.D.
Blind children, if given a chance, can play and learn right alongside their
sighted peers. An open mind, a positive attitude, and a little creativity
are usually all it takes to integrate blind students into regular preschool
programs.
To help you understand how you, too can be successful integrating a
blind preschool into a regular program here are some answers to
common concerns expressed by preschool teachers and administrators.
Remember that this is only an overview of common concerns. The
National Organization of Parents of Blind Children (NOPBC) can help
you with additional literature. We can also refer you to other local and
national resources.
A BLIND CHILD IN OUR PRESCHOOL PROGRAM? BUT...I DON’T
HAVE ANY SPECIALIZED TRAINING.
None is needed. All successful preschool teachers possess knowledge
of general child development and instructional techniques appropriate
for this age. The blind child can learn the same concepts that are taught
the other children.
The only difference is the method of learning. The blind child must make
more extensive use of the other senses. They also need parents and
teachers who will “bring the world to them” through lots of hands-onexperiences.
For example, pre-reading skills should parallel those of the sighted
child. Concepts such as big and little, same and different, prepositions
(over, under, in, out, behind), shapes, number concepts, and scores of
others are easily taught with concrete objects as an alternative to
pictures on paper. Raised line drawings are also useful and provide one
form of readiness for tactile reading.
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BUT...HOW WILL HE GET AROUND?
Parents are used to helping their children get accustomed to new
places and will guide you in this respect. Usually, one or two visits to the
classroom when the other children are not present will be sufficient to
orient the child. Children will use many cues to find their way around.
The sound of the wall clock or heat register may be a landmark. They
quickly learn that the story time area is carpeted and that the dress-up
area is next to the windows where they can feel the sun or hear the rain.
In moving outside the classroom a child may sometimes use the
teacher or another child as a guide. More and more blind preschoolers
are using white canes for independent travel. If the child in your school
used one, ask the parents about how and when it should be used,
where the child should store it when not in use, and what to do if the
child misuses the cane.
BUT...WE HAVE SO MANY ROWDY CHILDREN - SHE’LL GET HURT.
All child get bumps and bruises. Learning to cope with groups of people
is a natural and vital part of learning to live in our society. Protecting a
child from the boisterous, rowdy play of other four-year-olds denies her
a crucial stage in her development. Encourage the blind child to join in
the running, wrestling, and rowdiness of her classmates. If she has
been overprotected, she may need some extra encouragement and
demonstrations of how to play in this manner. Skinned knees and tears
from bumps last a few moments. The negative effects of sheltering last
a lifetime.
BUT...HE ISN’T REALLY BLIND; HE CAN SEE SOME.
Blindness does not mean that the child is totally without usable vision.
The majority of blind children have varying amounts of residual vision,
which can be quite helpful. “Legal blindness” is a term you may hear. It
simply means that a child has 10% or less of normal vision. Teachers
need to know that many factors affect what, and how much, a child may
see at any particular time. Type of eye condition, fatigue, lighting,
excitement, etc. all affect a partially sighted child’s vision.
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However, the child with partial vision is often placed in an unenviable
position. She may be expected to perform tasks visually, even though
her vision may not be the most efficient means to accomplish the
particular task. Partially sighted children should be encouraged to
become skilled in using their tactile, auditory, and even olfactory senses
as well as vision. They should, for example, learn to read Braille.
Talk to the parents whenever your have questions. The National
Organization of Parents of Blind Children (NOPBC) can also help with
information and resources.
Blind children sometimes suffer from the “I’m Special” syndrome.
Because their education does require some adaptations, they often
come to expect and demand unnecessary “accommodations.” One little
boy with partial vision was always allowed to sit next to the teacher
during story time so he could see the pictures. Soon he expected to be
next to the teacher in every activity. This caused resentment among the
other children. After a consultation with the parents, it was decided that
the boy could examine the pictures in the book before or after the story
time and take his turn next to the teacher like everyone else.
BUT...WHAT ABOUT MOVIES, FIELD TRIPS, PICTURE BOOK, ETC.?
Adults accompany the class on field trips should provide descriptions of
“untouchables.” Short description of pictures in storybooks are
enjoyable for all the children. When needed, an adult may verbally
describe movies or other performance quietly to the child.
Painting and coloring helps children develop fine motor skills and are a
part of preschool experience, so the blind student should participate,
too.
Some blind children may resist activities which require them to put their
hands into unfamiliar substances (i.e. clay, finger-paints, paper mache,
rice/beans/sand tables, etc.). Usually a loving, firm, “we’ll do it together”
approach will help your blind student get over this problem.
With a little imagination on your part, your blind student will easily gain
as much as his sighted friends from your standard preschool curriculum.
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BUT...WE DO NOT HAVE ANY MATERIALS OR EQUIPMENT FOR A
BLIND CHILD.
A blind youngster in your classroom requires little outside the standard
preschool materials and equipment. Often well-meaning attempts to
create specialized materials result in meaningless activities. For
example, plastic models of animals are often confusing and
meaningless to a blind child. As often as possible, use the real item to
teach concepts. Without concrete teaching, a blind child may posses
the vocabulary but lack the concept.
One preschool blind child seemed to know all about birds and their
habits until one visited his class. As his turn came to pet the bird, he
surprised exclamation of “It can walk, too!” startled his teacher.
Discussions of birds had left him with an incomplete concept. He
examined the bird’s legs and talons, felt it take a step and gained an
understanding on which more complete concepts could be built.
BUT...I DON’T KNOW BRAILLE.
You don’t need to. The blind child will be taught Braille by a specially
trained teacher of the blind and visually impaired. However, you should
find ways to expose your blind preschooler to Braille, just as you expose
your sighted students to print. Twin Vision books (regular print
children’s books with Braille pages added) can be borrowed for use in
the classroom with all the children. Inexpensive Braille labels can be
added to print labels in the classroom. For information about how to
obtain Twin Vision books and other Braille materials for blind
preschoolers please contact the NOPBC.
BUT...WE CAN’T PROVIDE AN AIDE.
Young children learn to solve problems by doing for themselves. An
important part of the child’s life is knowing when to do it himself and
when to ask for help. The additional assistance we too often give a blind
child teaches dependency. This robs the child of confidence and the
opportunity for problem solving.
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Yes, he will need additional hands-on-directions for many things. But
this doesn’t need to be a problem. For example, finger plays and
motions to songs, dances, and exercises are normally learned by
watching the teacher demonstrate. Such activities are easily
demonstrated by putting the blind child’s body through the motions, so
everyone learns them together.
Sometimes a child may have had so few opportunities for experiences
that more individual attention is required for a time. If so, work to find
creative solutions. Talk with the parents. Check into other resources.
See what can be worked out.
BUT...I DON’T HAVE THE HEART TO DISCIPLINE HIM.
Then prepare yourself for the worst. As with my undisciplined child,
tantrums, abnormal mannerisms, poor socialization’s, inattention, and
delays in learning will quickly follow. Like any other child, a blind child
needs firm but loving discipline so he can learn how to get along in this
world.
BUT...HOW WILL THE OTHER CHILDREN REACT TO HIM?
Most preschoolers are curious, but not cruel. They have not yet learned
the negative attitudes about blindness, which are prevalent in our
society. The children will mostly take their cues from you. If you treat the
blind child differently, then the other children will too. If you expect him
to perform and participate just like the other children then the children
will treat him likewise.
From Future Reflections Volume 18, Number 1
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Qualities of a Good Preschool Program for
All Children
By Tanni L. Anthony and JC Greeley, VIISA Course,
January 2005
Figure 7 Clip art image of a young boy playing a drum.
 A developmentally appropriate curriculum
 A skilled and caring teacher
 A predictable routine
 Hands-on learning opportunities
 Literacy materials
 Opportunities to be with playmates / peers.
 Expectations of age appropriate and independent behavior
 A safe learning and movement environment
Qualities of a Good Preschool Program for a
Child with Visual Impairment
Figure 8 Clip art image of a young boy looking at a
bug through a magnifying glass.
 Personnel certified in visual impairment
 Classroom and related service personnel trained to support a child
with visual impairment
 Attention to environmental adaptations (for sensory learning).
 Specialized learning / literacy equipment Specialized O&M tools
 Increased attention to concept development
 Increased attention to spatial organization.
 Ongoing / constant accessibility to classroom information.
 Deliberate facilitation of social skills.
 Environment that conducive to learning for life.
 Clear beginnings and endings to activities
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Texas School for the Blind & Visually Impaired
Outreach Programs
1100 West 45th Street
Austin, Texas 78756
512-454-8631
www.tsbvi.edu
Figure 9 TSBVI Outreach Programs logo
Figure 10 OSEP logo
This project is supported by the U.S. Department of Education, Office of
Special Education Programs (OSEP). Opinions expressed herein are
those of the authors and do not necessarily represent the position of the
U.S. Department of Education.

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