"The characteristics of visually impaired children with multiple disabilities"
by Miss Shirley Tso,
Low Vision Training Subject Convenor
Ebenezer New Hope School, May 1997



A. Overall Characteristics
B. Characteristics in learning and cognition
C. Characteristics in motor, movement and posture
D. Emotional and behavioral characteristics
E. Characteristics in social behaviors
F. Characteristics in visual function
G. Characteristics in language development
H. References

VI: visually impaired
MHVI: multihandicapped visually impaired

A. Overall characteristics:

1. Visual impairment would obstruct the child's development in various areas, i.e. cognitive, language, motor and social development.

2. The following would affect the personal development of a MHVI child: the onset, cause, category and extent of the visual impairment as well as other impairments.

3. A child who has lost his/her vision before the age of 5 can be categorized as having a congenital visual impairment, since the visual images that he/she has preserved are so few which cannot assist his/her learning. The visual impairment in most visually impaired children is congenital in origin.

4. Approximately 1/3 to 1/2 of visually impaired children have more than one handicap conditions. The 1990 statistics in UK stated that out of 12000 VI children, there were 6000 who were MHVI. Besides visual impairment, MHVI children may have other handicaps in:
@@@@@-motor functioning
@@@@@-mental functioning
@@@@@-auditory functioning
@@@@@-emotional and behavioral functioning
or exhibit learning difficulties.

5. Each of their handicap conditions differs in nature, combination and extent. Consequently, their development, learning mode and needs would also differ. Moreover, no two visually impaired children would have identical visual conditions. The only common condition is they both have visual impairment.

6. If we can understand how the child's visual functioning has affected his/her development, we can understand his/her unique educational needs and subsequently design appropriate training methods, no matter what the child's age is.

7. The child needs special visual training, no matter what extent or nature are his/her other handicaps. But the parents or educators may not be aware of such need, especially if the child's other handicap conditions may seem to impose a greater impairment than his/her visual handicap. As a result, the child may lose the opportunity of early intervention in his/her vision development.

8. Early intervention in their vision development is very important to MHVI children. The lost cannot be compensated by later efforts, since the functional development of the child's eyes would be completed around the age of 8.

9. Since vision is of significant importance to the learning process, VI or MHVI children would all exhibit various learning difficulties to certain extent. However, some of the learning difficulties are not directly caused by their visual impairment. This would be explained later in this article.

10. Visual impairment would also affect the accurate assessment of the child's ability.

11. Although many MHVI children's emotional and/or behavioral problems are major obstacles to their learning, they can still develop their potentials in various aspects.

12. If a VI child still has residual vision, limited functional vision can still assist in his/her learning.

13. When a child learns through other senses, he/she still needs to collect information via the visual channel, since vision can provide some data which cannot be effectively collected from other senses, e.g. color and spatial relationship of objects. Moreover, early learning is mainly via imitation, in particular, imitation via visual observation. Children with normal vision can naturally learn through unintentional observation and imitation. VI children face limitations in this process.



B. Characteristics in learning and cognition:

1.Difficulty in concept formation: VI children have difficulty in understanding complex, abstract concepts, e.g. color, spatial distance, spatial relationship, etc.

2. Visual impairment itself would not affect the child's cognitive processing of sensory information. One of the limitations is that the child lacks in contact with the environment, which affects his/her ability in getting the maximum input of sensory information.

3. If the formation of the basic concept of objects was affected, formation of other concepts would also be affected, e.g. object permanence, cause-effect relationship, spatial relationship and object classification.

4. VI children have difficulty in understanding the environment comprehensively, although other senses could help to a certain extent, the loss of vision could not be completely compensated by auditory and tactual senses because of the following reasons:

a. Hearing and touch cannot provide the same kind of stimulation and information as vision. Without vision, some concepts can never be fully understood and grasped, e.g. clouds, the height of high-rise buildings, etc.
b. The information collected from hearing and touch is mainly received one after another; the information from vision is presented simultaneously.
c. Vision assists the child in understanding all of the object and its parts, as well as the relationship among the parts and the part-whole relationship, whereas touch and hearing requires the child to investigate each part and then integrate the images in the mind to form a complete picture. The latter is much less effective in concept formation and might easily create incomplete or incorrect concepts.

5. However, we must note that:
a. Not all VI children would suffer delay in concept formation, in particular, children with mild vision loss or those who suffered vision loss later in their childhood.
b. Low vision children may have difficulty in concept formation, but the use of residual vision can help them in concept formation, even if they have some vision within a short period of time.
c. Early intervention/ training at an early age is thus very important.



C. Characteristics in motor, movement and posture:

1. The development in mobility and motor of VI and MHVI children is generally below normal standard because of the following reasons:
a. The lack of visual stimulation.
b. They cannot learn through visual imitation effectively.
c. Environmental causes, e.g. over-protection by parents, the lack of opportunities in motor activities.

2. Many VI and MHVI children exhibit low muscle tone. This is not because they are suffering from cerebral palsy. Instead, they lack enough visual input to elicit movement and their bodies lack enough motor movements. Some children have high muscle tone and don't know how to relax, which result in abnormal postures.

3. The above situations would result in the following problems: bad sitting and standing postures, difficulties in motor co-ordination, poor gaits (e.g. head bowing, tip-toeing, knees bending while walking), etc. They intend to maintain a wide base of support and turn the whole body instead of the trunk only. As the modes of activity are less in VI children, early intervention is very important in order to correct undesirable trends. The development of proprioceptive senses (joint senses) can also help the VI children in maintaining correct posture and movement.

4. Problem in co-ordination of both hands, delay in fine motor skills development, e.g. difficulties in bending the joints of their fingers.

5. Action is slower. The VI child takes more time to complete an activity. Kinesthetic and tactual input is needed to reduce the effect from the loss of vision.

6. Spatial discrimination is slower; the VI child would easily lose the sense of direction. The child doesn't know where he/she is and the awareness of his/her body position in relation to the surroundings is lower.

7. The child would lack self-confidence in walking and have difficulty in starting his/her motion. His/her movement would be slower. Some VI children used to walk with their hands stretching out, while others, particularly MHVI children might not reach out to search their way. They are particularly afraid to descend on slopes and would walk more slowly.

8. The children would find it difficult to search for objects, especially objects dropped.

9. The children might easily bump into objects or overturn objects.

10. Those with low vision would walk cautiously, as they cannot see clearly, especially when they are ascending or descending staircases, or in dim environment due to the poorer contrast.



D. Emotional and behavioral characteristics:

1. The MHVI children would lack interest in and response to the environment. They would lack the motivation to explore the environment as they lack the visual stimulation to motivate them.

2. They usually lack responses to other types of instructions apart from verbal instructions.

3. They are more prone to self-stimulation, e.g. rocking their body, head shaking, hand flapping, eye-poking, even self-injurious behaviors. Some people think that the VI children have such behaviors because they have autistic features. However, these undesirable behaviors are because of the lack of stimulation and limitations in learning opportunities.

4. Some MHVI children are very sensitive or over-sensitive to others' touch or body contact, they dislike or resist such contacts, e.g. hugging.

5. Some are particularly sensitive to loud or special sounds, e.g. those created by alarms, firecrackers and balloons that burst. They would feel frightened or throw into temper tantrums.

6. Some are over-sensitive to special tastes or special textures, e.g. moist and sticky texture. They would resist in touching/tasting objects/food with such special sensation.

7. Most of them enjoy auditory stimulation, especially musical and noise-making toys, or tapping the table with their hands or another object. Most of them enjoy listening to music,particularly fast and happy tunes.



E. Characteristics in social behaviors:

1. The social development of VI children is usually slower than their sighted peers, since social learning depends much on visual imitation.

2. When children suffer considerable loss of vision, they cannot effectively interact with their family members, children of their age, and people in their surroundings. They would thus be easily misunderstood or constrained, so that they are isolated, aroused negative attitudes, and cannot involve in social contacts.

3. As VI babies or children lack eye contact or smiles, their parents might find it difficult to understand their responses. The child might seem uninterested or passive.

4. VI children suffer limitations in the exploration and participation in the social environment. They thus rely more on the help of others to explain the social or play situation to them.

5. The play behaviors of young VI children were found to be in lack of imagination and expansion. Their social exchanges may also seem brief.

6. VI children lack eye contact, varieties in facial expressions and body languages, so that others might find it more difficult to understand their feelings.

7. VI children have difficulty in maintaining the same type of interests as their peers with normal vision. They might be more self-centered in their contacts with others. What they express might also be confined to experiences at home. As their social and play experiences are more limited, their communications with sighted peers are also affected. The VI children are thus more easily being neglected by children with normal vision.

8. The social development of VI children is also deeply affected by others' expectations. If other people expect their performances to be hindered by their visual impairment, then such limitation would become a part of the children's self image. On the contrary, the children would take a more positive attitude towards their own social ability and their social skills and growth would be enhanced.

9. Many parents would provide fewer outings for their children or reduce their contacts with the world because of their children's visual impairment. They might even constrain the children's movement and activities at home, fearing of possible and hidden dangers. This made the VI children's life experiences limited and not as varied as their sighted peers, which in turn made them lack in self-confidence and social skills.

10. Some VI children, especially MHVI children, exhibit social behaviors which seem inappropriate, e.g. touching people with their hands, holding on to others' hands, talking or sitting too closely together. This is because of the lack of visual data and the tendency to use touch to substitute for visual contact.



F. Characteristics in visual function (for VI children with low vision):

Their characteristics are varied according to different degrees of visual loss, different types of visual loss and different causes of visual impairment. However, they may exhibit the following behaviors:

1. They like to view objects closely.

2. They like to position themselves near to the light source, e.g. window, lamp, or bright objects.

3. They find it difficult to judge the distances of objects relative to their body accurately. They lack in depth perception.

4. They tend to rely on tactual senses. They won't use their residual vision spontaneously, and they won't rely on visual senses alone.

5. Other characteristics: e.g. color vision problems, squint, visual field defect, accommodation problem, nystagmus and poor visual acuity, depending on the cause and effect of the visual impairment.



G. Characteristics in language development:

1.The language development of VI children is basically not much different from children with normal vision. Their early vocabulary is similar to their sighted peers. However, the vocabulary that they use is not as abundant in meaning and detail in descriptions as their sighted peers. The difference is caused by the limitations in early social experiences and the lack of visual cues and stimulation.

2. VI children seem more difficult to understand that words are abstract symbols. They are slower in drawing the conclusions to the meanings of vocabularies.

3. Due to the lack of experience, the content of VI children's speech is more limited. They have more difficulty in expressing themselves.

4. Due to the lack of visual information, many MHVI children have more difficulty in understanding "you", "me", "they", "his/her" or using such pronouns.

5. Besides the effects of concept formation and lack of experiences on their language development,
"It has been found that too heavy a reliance on verbal descriptions by others as a means of developing concepts about the environment and the world may result in verbalism or verbal unreality (Burlingham, 1965; Harley, 1963). Verbalism refers to the use of concepts for which the child who is visually impaired has no firsthand experience. For example, a child who is blind may talk about the white, billowy clouds and yet have no real understanding of the words white, billowy, or cloud. When teaching a blind child, it is important for the educator to be aware of verbalisms and to verify through demonstration that the child truly understands the meaning of what he is saying."(Sacks, Rosen, Gaylord-Ross, 1990)

6. Young VI children tend to repeat others' expressions (echolalia), even phrases in advertisements. This might be because of the intention to carry on a dialogue or because of a lack of understanding.

7. VI children tend to ask more questions or repeat the same question. They may not really understand others' answers. Their topics are more concentrated on their own interests or actions rather than on others' needs.

8. Because of the lack of visual cues (the positioning of the tongue, for example), some VI children, especially MHVI children, have difficulty in grasping the articulation of some syllables, e.g. /s/, 'ch', 'th', /l/, /n/, which result in articulation problems.

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H. References:

1. First Steps. A handbook for teaching young children who are visually impaired.
Los Angeles, California: Blind Children's Center, 1993.

2. Starting Points. Instructional practices for young children whose multiple disabilities include visual impairment. Los Angeles, California: Blind Children's Center, 1995.

3. Pagliano P. (1994) Students with a vision impairment, in A. Ashman & J. Elkins (eds), Educating children with special needs (2nd edn), Australia: Prentice-Hall, 345-383.

4. Sacks, S.Z., Rosen, S. & Gaylord-Ross, R.J. (1990) Visual impairments, in N.G.Haring & L. McCormick (eds), Exceptional children and youth (5th edn), Ohio: Merrill, 405-445.

5. New Directions: Towards a better future for multihandicapped visually impaired children and young people. London: Royal National Institute for the Blind, 1990.

6. Gibson, J. & Cronin, P. (1990) Designing programs for children with multiple disabilities and severe vision impairment: A step by step approach. Australia: Royal Victorian Institute for the Blind Children's Services Education Centre.