Www.tsbvi.edu



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Texas School for the Blind & Visually Impaired Outreach Programs

tsbvi.edu

512-454-8631

Superintendent William Daugherty

Outreach Director Cyral Miller

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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

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

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.

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

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.

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

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)

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

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

▪ 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

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.

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

▪ 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

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

▪ Self-conscience about appearance

▪ May be isolated or teased by peers.

▪ May have physical discomfort or pain

Recommendations

▪ Self-advocacy about eye condition.

▪ Peer support groups or 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

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

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

▪ Nonresponsive to light - end of FVA.

▪ Responsive to different locations, strengths, and types of lights.

Recommendations

▪ 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.

Color Vision

▪ CV deficiencies within the typical population and are especially X-linked 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

▪ Difficulty with tasks involving color discrimination.

▪ Difficulty discerning door frames, stairs, etc.

▪ Difficulty with clothing matching.

Recommendations

▪ Black markers for outlining / grading

▪ Map / graph adaptations

▪ Increase or decrease in lighting

▪ Labels on crayons, clothes

▪ Traffic light interpretation

Eye Preference

▪ Anisometropia

▪ Nystagmus Equity

▪ Monocular Items

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)

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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.

Corneal Light Reflex Test

Look at where the light is reflected in each eye.

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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

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

▪ Visual fatigue with sustained eye movement tasks (scanning communication board)

▪ Poor quality eye teaming skills

▪ Associated head movements with eye teaming

Recommendations

▪ Grading of visual movement tasks.

▪ Teaching of eye / head movement

▪ Attention to communication systems and/or reading tasks that benefit from smooth saccadic movements

Visual Fields

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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)

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.

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Figure 4 two images of visual field loss, one showing “islands of vision” and the other showing hemianopsia.

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Figure 5 examples of peripheral field loss, central field loss, and scattered field loss or scotomas.

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

Visual Field Loss

Findings

▪ Preference / neglect of an area of visual field.

▪ Changes in field specific to a progressive visual loss.

Recommendations

▪ 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

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Figure 6 examples of normal and blurry vision.

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 |Behaviors |

|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 | |

Picture ID at Near Range

|Picture |Size |Distance |IDed |Behaviors |

|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 | |

Near Acuity Discrimination

Findings

▪ Difficulty with near acuity discrimination tasks (object, picture, money etc. ID)

▪ Social stigma of close viewing

▪ Visual fatigue with sustained near acuity tasks.

Recommendations

▪ 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

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

Distance Visual Acuity

Findings

▪ Difficulty with distance acuity discrimination tasks. Boundaries of distance vision – what is doable and what is not.

▪ Visual fatigue with sustained distance acuity tasks.

Recommendations

▪ 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.

Visual interpretation

Findings

▪ Visual latency challenges

▪ Visual complexity challenges

Recommendations

▪ Wait time

▪ Use of familiarity

▪ Use of color preferences

▪ Decrease of visual clutter

▪ Use of auditory / tactile strategies

Visual Behaviors

| |Light |Field |Acuity |Oculomotor |

|Close Viewing | | |X | |

|Head Postures / Tilt |X |X |X | |

|Unique Eye Positions | | |X | |

|Eye Pressing |Sort of | | | |

|Eye Blinking |X | | |X |

|Eye Squinting |X | |X | |

|Cessation of Mvmt. |X | | | |

Visual Motor Coordination

▪ Gross Motor Tasks

▪ Fine Motor Tasks

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

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.

Medications That Influence Visual Functioning

By Dr. Stuart Teplin and Dr. Josh Alexander

Medications for Attention Deficit Hyperactivity Disorder

|Medication Name |Brand Name |Side Effects |

|Pemoline |Cylert |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 |Side Effects |

|Trihexyphenidyl hydrocholoride |Artane |dilation of the pupil |

| | |blurred vision |

| | |angle‐closure glaucoma (with long‐term |

| | |treatment) |

|Dantrolene sodium |Dantrium |visual disturbance |

| | |diplopia (double vision) |

| | |excessive tearing |

|Baclofen |Lioresal |abnormal vision |

| | |abnormal accommodation |

| | |diplopia |

|Carbidopa/levodopa |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 |

|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) |

Medications For Allergies

|Medication Name |Brand Name |Side Effects |

|Cetirizine |Zyrtec |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) |

Medications For Drooling

|Medication Name |Brand Name |Side Effects |

|Trihexyphenidyl |Artane |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 |Robinul |blurred vision |

| | |dilatation of the pupil |

| | |cycloplegia |

|Scopolamine | |mydriasis (dilation of the pupils) |

| | |cycloplegia |

Medications for Neurogenic Bladder

|Medication Name |Brand Name |Side Effects |

|Oxybutynin |Ditropan |amblyopia |

| | |cycloplegia (paralysis of ciliary muscles) |

| | |decreased lacrimation (tears) |

| | |mydriasis |

| | |blurred vision |

Medications For Gastroesophageal Reflux Disease

|Medication Name |Brand Name |Side Effects |

|Ranitidine |Zantac |blurred vision |

Reference

Mosby, Inc. (2003). Mosby’s drug consult. Retrieved May 2, 2003, from



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:

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 ‐

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 |HOW TO UTLIZE THE ADAPTATION |

|Lighting |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. |

| |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 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. |

|Positioning of materials |Position materials within the visual range of the child. 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. |

|Time |The speed of objects as they pass through the visual 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:

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-on-experiences.

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.

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.

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.

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.

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

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

Texas School for the Blind & Visually Impaired

Outreach Programs

1100 West 45th Street

Austin, Texas 78756

512-454-8631

tsbvi.edu

[pic]

Figure 9 TSBVI Outreach Programs logo

[pic]

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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