• By: Galton Vasconcelos, MD; Luciene C. Fernandes, MD
    Low Vision

    Introduction

    The International Classification of Functioning, Disabilities, and Health, Children and Youth Version, and Management of Low Vision in Children (World Health Organization) established that visual functioning of infants and young children can be stated in 4 main areas of daily life function:1,2

    • Orientation and mobility (O&M)
    • Communication
    • Activities of daily living (ADL)
    • Sustained near-vision tasks

    The effect on these 4 main areas varies depending on the type and degree of impairment and additional impairments. The effect is also influenced by the social environment and culture the child lives in.2

    Parents and relatives who live with and relate to a low-vision child might fear for the child's safety, depriving them of elementary experiences necessary for physical survival and psycho-emotional and social maturity, both of which can increase dependence, increasing the damage caused by the visual disabilities themselves.

    Orientation and mobility (O&M) training can help develop the child's orientation in space as well as movement and safety in travelling.

    O&M instruction is not only crucial to the multihandicapped child, but can also be very helpful to the mild or moderately vision-impaired child as well. (See Delayed Visual Development: Development of Vision and Visual Delays.)

    Severely affected O&M causes further serious limits on a visually impaired child. By walking independently, a child with low vision will have more opportunities to achieve their social integration and become independent individuals.

    Definition

    Orientation

    Orientation means an awareness of position in space.3 It refers to the ability of a child to realize his surroundings, establishing body, space, and time relations with his environment through the senses of hearing, touch, smell, and residual vision.

    Mobility

    Mobility means the capability of moving through the environment safely, efficiently, and independently.3 It refers to the ability of child to move and to react to various stimuli. This is often achieved through a teaching-learning process that involves the use of several features including a sighted guide, a long cane or a support cane, a protective arm, trailing, a guide dog, and an electronic aid.

    There are no reliable current statistics on the use of canes or guide dogs in the United States, especially in children. However, Guiding Eyes for the Blind estimates that "there are approximately 10,000 guide dog teams currently working in the United States and about 2% of all people who are visually impaired work with guide dogs."4

    O&M is usually available on an itinerant basis in the community or in a school for the blind.

    O&M Training

    Basic Guidelines

    • Considering its complexity, O&M training must be stepwise and geared toward helping the low-vision child eventually move and navigate independently.
    • O&M training is much more than simply teaching the technique on how to use the cane. Both the psychosocial and cognitive aspects relevant to teaching a person with disabilities must be considered, especially for them to get around with autonomy in locomotion and self-confidence.
    • An O&M training program must be geared toward the difficulties of each low-vision child individually.
    • A child who is born with low vision or who becomes visually impaired very early in life might have problems related to the development of concepts linked to position, location, direction, and distance.
    • At the minimum, each child should be given as many practical and meaningful experiences related to the context of their particular life, and this should be started in early intervention programs.
    • Evaluating basic visual functions for each child is very useful. The ophthalmologist should always try to find ways to improve contrast, color differentiation, and appropriate illumination of the environment.
    • Procedures and skills should also be transferred to the family members, who in turn will reinforce continuation of learning these skills at home. (See Delayed Visual Development: Development of Vision and Visual Delays.)

    O&M Programs

    O&M programs should be structured individually for each patient. Although individualized, it should be exercised in small groups, with the participation of other professionals and family.

    Objective

    The objective is to provide conditions for a child with visual impairment to develop their abilities to navigate and move independently.

    O&M training should cover activities that allow the child to explore their maximum potential. Some technical considerations are listed below:

    • Basic movement: locomotive, manipulative
    • Perceptual skills: visual discrimination, auditory, tactile, olfactory, and coordination ability
    • Physical capacity: cardiovascular and muscular strengths, flexibility, and agility
    • Nonverbal communication: Common postural problems are tilting the head forward or downward, avoidance of extension of the arms, dragging of feet and arms, and loss of balance. The longer the duration of immobility after the diagnosis of low vision, the more pronounced difficulties might be found.

    The program is divided into 2 parts: indoors and outdoors.3,5

    Part 1: Indoors

    • Training in the use of residual vision and nonvisual senses
    • Interpretation of clues, establishment of benchmarks, relationship with space and time through the remaining senses
    • Skills to be developed: techniques using a sighted guide, self-protection, and long-cane techniques

    Part 2: Outdoors

    After achieving adequate indoor abilities, the child can move to outdoor experiences such as mobility in areas with intense pedestrian traffic, familiarization with vehicles, public transit, elevators, supermarkets, shopping malls, and other specific environments. Follow-up is essential. The mobility instructor must accompany the child to give reorientation, avoid accidents, and discuss difficulties with the patient and family.

    The sooner the O&M training begins, the easier it will be for the child to build an organized self-image, body awareness, and independence in daily life.

    References

    1. World Health Organization. International Classification of Functioning, Disability and Health: Children and Youth Version. ICF-CY. WHO Press. 2007.
    2. World Health Organization. Program for the Prevention of Blindness: Management of low vision in children. Report of a WHO Consultation. Bangkok: 1992.
    3. WHO/PBL/93.37.
    4. Faye EE. Clinical Low Vision. 2a.Ed. Boston/Toronto: Little, Brown, and Company. 1984. 415433.
    5. Guiding Eyes for the Blind. General Information. 2014.
    6. Hyvarinen L, Jacob N. What and How Does this Child See? Assessment of Visual Functioning for Development and Learning. Helsinki, Finland: Vistest Ltd. 2011. 174.