Wearing pediatric belt canes encourages independent walking in Blind 2-year-old

Toddlers who are blind need effective mobility tools for safe mobility, because safe self-locomotion skills are essential for language development (Rosenbaum, 2005; Adolph et al., 2010; Iverson, 2010). For example, Oudgenoeg-Paz et al. (2016) suggested that exploration via self-locomotion measured at twenty months predicted later spatial language, yet children born with mobility visual impairment or blindness exhibit delays in self-locomotion due to lack of access to independently safe mobility (Ambrose-Zaken, 2021).

Children who are born blind grow up with unsafe self-locomotion and this inhibits their willingness of to freely ambulate and contributes to developmental delays (Ambrose-Zaken, 2021). The goal of independent walking is important, because walking freely is tied to language outcomes. Particularly, walking is important for building vocabulary, the most common measure of language development (Oudgenoeg-Paz et al., 2012, 2015, 2016; West et al., 2017).

Matias’ family reached out to Safe Toddles to obtain a pediatric belt cane (PBC) for him, a nineteen-month-old boy who was blind due to Leber’s Congenital Amaurosis. His family provided a video record of his self-locomotion during play activities before and after receiving the PBC. The purpose of this study was to compare the number of steps per second taken by Matias when playing indoors and outside in three conditions; without a mobility device, with a push toy and wearing his PBC.

Method

Participant Matias was a two-year-old boy who was blind with no light perception. He was typically developing and able to walk, however prior to obtaining the PBC he walked only when he was in contact with objects or people, including pushing a chair or pushing a toy. His language skills were also delayed. He repeated words and sentences out of context and he did not engage in conversation or seek out others for social interaction.

Procedures The researcher employed a single-subject repeated measures design. Sixteen videos of Matias before obtaining a PBC and nine videos of him wearing his PBC were analyzed. The videos selected were those of him playing alone inside and outside his home. Ten videos documented Matias’ typical play activities without a mobility tool (six inside and four outside). Six videos observed him when used a push toy during play time. Nine videos were taken when wearing his PBC during play activities (three inside and six outside).

Measurement Visible steps caught on camera were counted. Steps were defined as purposefully moving his foot forward or backwards, walking up or down stairs, anytime the foot moved to change his location. Steps not counted were those considered stamping in place or to adjust his balance. Steps per second was obtained by dividing the number of total steps taken during the video by the number of seconds of the video.

Matias’ steps per second with and without mobility devices

Discussion

The chart indicates that when he was playing without a mobility tool or with a push toy he took very few steps per second. When he was playing while wearing his PBC the number of steps increased over time. The more he wore his cane, the greater number of steps taken.

Matias walked many more steps per second wearing his PBC than under the condition of playing without a mobility tool and with a push toy. Therefore, two-year-old children who are blind may also benefit from wearing PBCs most of the day. This is because PBCs provide the benefits of safe mobility and consistent tactile path information. When children who are mobility visually impaired or blind wear PBCs they take independent steps with greater frequency than without a mobility tool or when encouraged to use a push toy.

Children who are blind wearing PBCs show improved self-locomotion which provides them with new learning opportunities to interact with objects, their environment, and with caregivers. When children who are blind feel safe enough to increase self-locomotion, it allows them to travel independently throughout their environments, traversing long distances to encounter objects and caregivers and builds opportunities to increase concepts and develop language and social skills.

Conclusion

Tactile path information is a known entity, since 1945 adults who are blind have benefited from using a long cane. Most physically and cognitively able adults learn to use a long cane in less than an hour. Toddlers who are blind are not able to employ a long cane for safety, after several years of instruction, many can only hold the long cane for a few steps. Children need safe mobility all day, every day.

Matias is stationary, repetitive playing while lying on his push toy

Matias is playing appropriately with a push toy while wearing his PBC

References

Adolph, K., Tamis-Lemonda, C., and Karasik, L. (2010). Cinderella indeed – a commentary on iverson’s ‘Developing language in a developing body: the relationship between motor development and language development. J. Child Lang. 37, 269–273. doi: 10.1017/S030500090999047X

Ambrose-Zaken, G.V. (2021, March 25-27). Importance of Safe Mobility to Achieving Developmental Milestones: Part 1. [Conference presentation]. Virtual 2021 Rocky Mountain Early Childhood Conference. United States.

Iverson, J. M., and Braddock, B. A. (2010). Gesture and motor skill in relation to language in children with language impairment. J. Speech Lang. Hear. Res. 54, 72–86. doi: 10.1044/1092-4388(2010/08-0197)

Oudgenoeg-Paz, O., Leseman, P. P., and Volman, M. C. (2015). Exploration as a mediator of the relation between the attainment of motor milestones and the development of spatial cognition and spatial language. Dev. Psychol. 51, 1241–1253. doi: 10.1037/a0039572

Oudgenoeg-Paz, O., Volman, M. C. J. M., and Leseman, P. P. M. (2012). Attainment of sitting and walking predicts development of productive vocabulary between ages 16 and 28 months. Infant Behav. Dev. 35, 733–736. doi: 10.1016/j.infbeh.2012.07.010

Oudgenoeg-Paz, O., Volman, M. J. M., and Leseman, P. P. M. (2016). First steps into language? Examining the specific longitudinal relations between walking, exploration and linguistic skills. Front. Psychol. 7, 1–12. doi: 10.3389/fpsyg.2016.01458

Rosenbaum, D. A. (2005). The Cinderella of psychology: the neglect of motor control in the science of mental life and behavior. Am. Psychol. 60, 308–317. doi: 10.1037/0003-066X.60.4.308

West, K. L., and Iverson, J. M. (2017). Language learning is hands-on: exploring links between infants’ object manipulation and verbal input. Cogn. Dev. 43, 190–200. doi: 10.1016/j.cogdev.2017.05.004

Benefits of Belt Cane for 3-year-old with Optic Nerve Hypoplasia

Children with mobility visual impairment (MVI) are unable to visually avoid obstacles. These children have difficulty achieving gross motor milestones because they lack access to consistent path information. Children with MVI can exhibit unwillingness to walk across open space independently, though they are physically able to bear weight. Instead, they seem to prefer to hold on to an object or person to walk places.

Toddlers with MVI are not able to verbally tell people that they feel unsafe walking independently, instead over time they present with a poor gait, slow pace and/or an unbalanced posture. Other observable posture concerns may include self-created taut extremities such as clenched fists.

Independent walking is essential to learning new concepts. Therefore, it is important to identify methods and tools that reduce these adverse motor behaviors. Ambrose-Zaken (2021a, b) has found that children with MVI age five and younger are unable to use rod canes correctly for safe mobility, resulting in continued unsafe travel outcomes (collisions, falls). Ambrose-Zaken (2021b) has shown that gross motor milestones and other nonverbal signs of MVI lessen and/or resolve when a child with MVI wears a pediatric belt cane most of the day, everyday.

A pediatric belt cane is a mobility tool that enables children with MVI to experience safe and reliable tactile path information. A belt cane (wearable toddler cane) is custom fitted to children with MVI who are aged five years and younger. The recommendation is that children with MVI wear their belt cane for the entirety of the day to enable free exploration and confidence in the path that lies ahead. The purpose of this single-subject study is to compare a child with MVI when walking using a rod cane to her walking wearing a pediatric belt cane.

Method
Participant: Audrina, a three-year-old with optic nerve hypoplasia, attended a preschool program in New Mexico. She had been instructed on rod cane technique by an orientation and mobility specialist since she was two years old. She had been wearing the belt cane for several hours the morning prior to the intervention of walking to the playground.

Treatment: Audrina was observed in an outdoor environment, en route to the playground with her peers. Prior to this intervention, she typically rode in a wagon to the park and back. This time she was encouraged to walk to the park. Half of the way, she walked with a rod cane and the second half of the way she wore her pediatric belt cane.

Measurement: A single-subject repeated measures design was used. The number of steps taken in 60 seconds (one minute) during ten consecutive minutes. The baseline data shown on the chart represents the number of steps Audrina took each minute while using a rod cane for five minutes. The next five minutes I counted number of steps, per minute, Audrina took wearing her belt cane (intervention data).

Results

The chart above expresses the time in minutes on the X-axis and the number of steps taken per minute by Audrina on the Y-axis. Steps were counted from 10 consecutive minutes of Audrina’s walk outdoors, five consecutive minutes walking with the rod cane and the first five minutes after switching to wearing her belt cane. The baseline performance suggests that while using a rod cane, Audrina’s steps per minute ranged from between 20-50 steps per minute. During the intervention of wearing the pediatric belt cane, Audrina’s steps per minute increased over time from 62 to 150 steps per minute. The average pace of a three-year-old is 3.1 steps per second or 186 steps a minute.

In the rod cane condition (baseline), Audrina exhibited a slow pace, stopped frequently and received frequent prompting from her teacher to use her rod cane correctly. During the pediatric belt cane intervention, Audrina’s pace steadily increased and the number of teacher prompts decreased. Audrina stopped infrequently while wearing the belt cane. When she stopped, it appeared she wanted to further investigate objects that she was able to independently locate in her environment with her cane frame. Wearing her belt cane, Audrina spoke more frequently than in the rod cane condition. Similarly, she asked questions and expressed her observations about the environment on the path to the playground.

Audrina’s long cane skills lead to unsafe mobility – she is out of step and her cane tip is checking behind her.

Audrina smiles as she picks up the pace to a run wearing her pediatric belt cane.

Discussion

Audrina’s first step after donning the belt cane began with a slight turn to free the base of the frame from an obstacle that she otherwise would have tripped over. The first minute after donning her belt cane, Audrina’s pace was faster than any of the minutes she walked with the rod cane. Audrina also eventually ran when wearing her belt cane, something she did not do with the rod cane.

In addition, she was walking to the park as part of a group. The students in her class were also visually impaired. Although her peers have visual impairments, many were not MVI. Their vision allowed them to move easily about the classroom, school and outside with age-appropriate pace, visually avoiding obstacles.

When walking outdoors with her peers, Audrina was unable to keep pace with her peer group. Therefore, she was absent during the instructional conversations about nature and social mores her teachers held with the group of students who were able to walk faster than she was. While walking with her rod cane, Audrina appeared noticeably quiet, her teachers spent most of their time prompting her to walk faster and correcting her rod cane technique.

Once Audrina arrived at the locations of interest explored by the faster walking students, her teachers did not have the same conversations about those locations with her. Instead, she was reminded to hurry up. Wearing the belt cane Audrina began to speak more. She asked more questions about her surroundings and her teachers responded to her questions with the information she requested. Her teachers appeared to relax, once they observed that she was experiencing consistently safe mobility wearing her belt cane.

Audrina appeared more confident when equipped with a safe and effortless mobility tool that provided her consistent path information. Although the difference in Audrina’s pace is apparent as well as the increase in age-appropriate conversation, we can compare the amount of steps Audrina took per minute to produce data on the benefit of the wearable cane.

It should also be considered that this change in age-appropriate conversation as well as increase in pace happened within minutes on the same day. Safe Toddles’ recommended usage guidelines for the pediatric belt cane are that children with MVI wear their pediatric belt canes the entire day, everyday. This is to ensure safe and effortless path information is always available to the child with MVI. Complete and consistent access to path information gives children with MVI security in knowing that they have the information they need for safe and confident mobility. Wearing belt canes all the time ensures that reliable path information will not be taken away causing them to return to a state of uncertainty and fear about where their next step will land.

References

Ambrose-Zaken, G.V. (2021a, March 25-27). Importance of Safe Mobility to Achieving Developmental Milestones: Part

1. [Conference presentation]. Virtual 2021 Rocky Mountain Early Childhood Conference. United States.

Ambrose-Zaken, G. (2021b). A study of Improving Independent Walking Outcomes in Children Age Five and Younger

who are Blind and Visually Impaired. Journal of Visual Impairment and Blindness (submitted 4.2021).

CVI or MVI? Exploring the path to gross motor delays

We have a new video on our YouTube channel – https://youtu.be/f5XEAXGPLCc

In thirty minutes we see how a three-year-old girl with neurological visual impairment improves in five identified areas of need: Tactile defensiveness, gross motor skills, purposeful exploration, language and cane skills.

Please comment, like and share!

Blind toddlers taught me about the cause of their gross motor delays

The world has a vaccine to alleviate the COVID-19 epidemic and we need your help more than ever in getting the solution for gross motor delays out to cure the tiniest epidemic known to mankind. It has raged for centuries in every part of the globe: Gross motor delays in blind and mobility visually impaired children due to unsafe mobility.

Congenitally blind children’s difficulty achieving developmental milestones has been described by scholars in every recorded century. In the past ten years, research studies on the concept development, physical education, language skills, and social skills of blind children continue to report that the greater the degree of congenital visual impairment, the worse the outcome. There is a direct correlation between severity of visual impairment and poorer developmental outcomes, but not for the reasons some have hypothesized. It is not because being blind makes you “unaware”. Nor does being blind make you “incapable of learning about space”.

All other things being equal, the blind child’s brain is perfectly capable of learning by doing. In fact, one might argue they have succeeded in spite of having to do it in the face of constant and extreme duress. Children who are blind or mobility visually impaired face difficulty when they attempt to explore their world independently, because when they walk without mobility tools they are unable to predict and avoid bodily collisions. Children who experience unavoidable bodily collisions are growing up under duress.

Global developmental delays result when mobility visual impairment or blindness prevents children from sustaining the 18-month motor milestone, “walks well, able to avoid collisions.” The more toddlers who are blind or mobility visually impaired attempt to move through space without mobility tools, the more collisions they sustain. Children who are blind or mobility visually impaired who achieve the 18-month gross motor milestone, have been found to regress from 15-month milestone of walking independently with a wide-based gait to the 12-month-milestone, “walks only with assistance (cruising/holding hands)”.

     The simplest explanation for this common motor skill regression is that blind children have learned that the only way they can avoid bodily collisions, is to walk only when help arrives. 

Blind and mobility visually impaired three-year-old children who are only able to walk with assistance are not able to confidently join social groups. No matter how many times a sighted person prevents a blind child from a collision; toddlers can only gain self-confident travel when they can save themselves from collisions. Blind toddlers have difficulty learning because they cannot navigate without direct bodily collisions from a very early age.

Providing children who are blind with belt canes has allowed me to learn the relationship between safety and learning. The pediatric belt cane is effective because it blocks sudden, bodily collisions, and because it provides information about the walking surface, including the location of drop-offs.

Children who are blind and wear belt canes become more social including improved language skills. Their language is filled with meaning and they engage with others, seek out others and seek out places and activities. These children are blind and become more connected to their world. To become a self-confident blind preschooler, they need to wear belt canes.

Below are a series of photos of Charna seeking out a toy she kicked under a chair. Charna has inspired new curriculum topics: For example, how to teach two-year-old girls who are blind to keep up with the family group during a walk in the park when she refuses to ride in the stroller and doesn’t want to hold anybody’s hand (Nov. 4).

Charna’s family uses voice calling (Sept 4). to help her follow them on sidewalks, at the zoo and in parks. Wearing her belt cane at home, Charna is underfoot in the kitchen (Dec. 17) and she knows how to wrangle toys that go under chairs (June 11).

In the park, Charna is confident enough to refuse help from strangers and independently seek out her dad. As soon as she hears him, she puts on a huge smile and moves directly to him with her trusty belt cane leading the way. She doesn’t want to hold dad’s hand; she just wants to walk and talk with him. Now, those are some age-appropriate social skills.

Charna and other children like her who are blind and wear belt canes have taught me that they didn’t do these things before because they felt unsafe. The belt cane allows them to feel safe. Everything you ever learned about gross motor delays in children who are blind has been written from the point of view of teh blind child who wasn’t given equal access to path information.

We have learned that with effective path information, gross motor delays are not an outcome of being blind. If you too want to prevent gross motor delays in blind toddlers, provide them with effective tactile path information. Provide them with safe mobility tool, provide them with a pediatric belt cane.

Charna finds a toy with her belt cane.

She turns towards the toy and pushes it under a chair.

She reaches down to grab it and accidentally pushes it further under the chair.

Charna is determined to get her toy, she uses her leg to locate it.

She reaches out to grab the toy with her hand.

Success! Of course, the fun was in the finding, she only plays with it for a few moments more.

Toddlers taught me all I know about belt canes

I made a lot of assumptions about how blind and mobility visually impaired toddlers would respond to belt canes. This is a list of ten assumptions that have been proven wrong since collecting videos of children wearing belt canes. The blue links take the reader to webpages containing specific example videos demonstrating the point made in that paragraph. I continue to learn about belt canes from the toddlers and preschoolers who are blind and mobility visually impaired wearing them. It won’t be long before I need to add part II of what blind and mobility visually impaired toddlers have taught us all about using belt canes.
1. Hands free – I thought hands free meant building a cane frame that never deviated from the path ahead. A major emphasis of the belt cane design was to make something that was completely hands free. The Safe Toddles’ team thought the belt cane should never drift from the path ahead. The belt cane design does stay ahead of the child on most smooth surfaces when walking alone (not holding a hand). Yet, on rougher surfaces and/or when walking in guide with an adult, the cane frame can drift off to one side, causing the need for either the child or adult to right the cane (put back into forward position).

When asked, parents were the first to allay my fears about this aspect of the belt cane. Charna’s mom and dad frequently responded by saying, “That’s not a problem for us. She doesn’t mind and Charna knows how to fix her cane.” In fact, when Charna, who was blind and two years old, wanted attention, she moved her cane around to her back, knowing her parents will say, “Charna, fix your cane.” and she did. And because they spoke, Charna now knew where her parents were located and went to them. She is so clever.

2. Push back – I worried that it would take time for children to learn to tolerate the intensity of tactile path feedback. Alilah put her first belt cane on when she was 20 months old. Right out of the box, she was filmed walking in the kitchen. We see her O&M specialist block her path with a chair. When the cane base contacted the chair legs, you see her get pushed back from the force of inertia. She remained standing. Several more times when the cane contacted something on the ground, she again withstood the impact. Once, she did fall back and she cried a little. However, mostly Alilah took it all in stride.

In her videos you can watch her gait and her pace improve. She walked much faster and further away from her parents with greater ease than she did in her “before” videos. She used her cane frame contacts to locate objects for further investigation.

3. Stairs- I thought the most important aspect of the belt cane would be that it performed like rod and rectangular canes on stairs. The first question that every O&M specialist asks about the belt cane is, “what about stairs?” We are O&M specialists, so we were the first people to ask that question. As we too want the belt cane to easily negotiate ascending and descending stairs. We have found that descending stairs, the cane works well. The method for ascending stairs wearing the belt cane has varied. However before we get too far ahead of ourselves, it is important to remember the value of knowing exactly where the stairs are. The belt cane tells the wearer exactly where the ascending and descending stairs begin. The problem that we see in children who are blind right now is that they can only guess at where the stairs begin, and can only find the stairs when their foot collides with the riser. Without consistent tactile path information, children under five have no warning before their body touches/falls down the stairs. We need to be reminded that currently, children five and younger without consistent tactile path information demonstrate highly inadequate outcomes of navigating stairs. The benefit of the belt cane is path information. I am sure that given time and opportunity, toddlers will figure out how to navigate stairs, in fact Matias has found that going up the stairs backwards is one way to go. Wyatt and Jack have both demonstrated great competence navigating the step up to wash hands at the classroom sink.

4. Free time – I thought that there was a benefit to being without a cane when you’re blind or mobility visually impaired. Many authors of early intervention articles have contended that blind children benefit walking without canes. However, there is overwhelming evidence that this is not true. When you cannot see where you are going, it is only a matter of time and distance before you collide with obstacles.

     These unavoidable obstacle collisions cause developmental delays in children who are blind or mobility visually impaired.

The more children who can’t see the path ahead walk freely, the greater number of body collisions they experience. Blind and mobility visually impaired children have no way of veering away from these collisions or slowing down to reduce the impact. Therefore, children learn that walking causes pain and that causes them to avoid walking alone. Instead, they smartly ask to hold onto a hand, touch a wall, cruise furniture, but they do not want to walk across open space on their own. It isn’t the walking with assistance that causes delays, it is walking with fear.

There is no benefit to walking in the pitch dark and there is no benefit to walking while blind without consistent tactile path information (like lights for blind kids). When children wear their belt canes, they gain confidence in themselves. They walk across open space, they let go of the wall and they let go of the hands of adults. They become hands free, because they don’t need to walk with assistance anymore. Children who are blind or mobility visually impaired walk more, better and faster wearing their belt canes. The more they wear it the greater their self-confidence.

Just remember: lights on, cane on.

5. Cane sticks – I thought that canes getting stuck under furniture would cause children to reject the belt cane. The belt cane is a set of one belt with two cane frames. The two frames were created for children in order to reduce the amount of cane sticking. The daily cane is the correct length for children who are blind and mobility visually impaired to obtain two steps of warning. The tight spaces frame is ninety percent of the length and the cane tip is turned inward to reduce catching. However, the rectangular cane frames catch on chair legs and get stuck, and this is all a part of learning. Children who are blind don’t know that canes getting stuck are a different experience from sighted people, because when you are three-years-old you think everybody is the same. Canes get stuck and that’s a fact of life, and the more you wear your cane the better you get at getting unstuck. More experience adds up to better skills. There is a difference. A child who is blind and walks and experiences direct bodily collisions, has no way to “get better” at walking with collisions, except to stop walking. A child who wears her cane all the time develops confidence. A child with confidence whose cane gets stuck, can improve in her ability to get unstuck because her confidence in herself drives her to master this problem by finding an independent solution. One thing they don’t do is ask to take off the belt cane. They just work to free themselves.

6. Catchall – I thought the cane would need to be designed to locate all the objects all the time. After two months of wearing her cane, there is a moment when Charna’s cane glides over/misses little toys on the floor, and she steps on them. Charna reaches down and investigates what she stepped on and then continues on her way. This is not the first time her cane has allowed Charna to step on something. The difference is that the number of times Charna runs into walls, cabinets, chairs and people has been reduced by ninety-five percent. Thus, the five percent of the time the cane isn’t there is within acceptable limits. We can all tolerate little accidents that occur infrequently. Next time her cane signals little bumps, she will have learned to turn away, or to step carefully. She has already learned to pick up on many of the signals her cane provides, because she is walking and learning. This is very different from children who walk without any warning, they are walking with fear. You can’t learn anything when you’re walking with fear, all you can think about is how to protect yourself. You are motivated to find safety, not to learn. The belt cane removes fear and improves learning.

7. At arm’s length- I thought that the cane frame would need to collapse so that the child could get closer to objects. One noticeable difference between the belt cane and the rod and rectangular canes is that the belt cane frame does not retract. Although Charna can achieve cane retraction because of her size, her belt slips above her waist as she moves towards a bin when wearing her tight spaces cane frame, this is not a typical outcome when wearing the belt cane.

Our search continues for a magical cane frame material that can remain strong and straight during forward propulsion and yet, when enough pressure is exerted retracts to allow the user to step closer to explore objects blocking their path. The magic part is the expectation that the material will be able to spring back to straight, strong and extended into the path when freed from the blockage. We will keep looking for that material or design feature, but in the meantime, the children have shown us that they are able to figure out multiple strategies for getting closer to objects they find. Like Matias, who when playing with a water toy one summer, put his cane frame behind him. His cane is still there, ready to be returned in front when he is ready to move again.

8. Take on/off independently – We thought it would be important for children to learn how to take their belt canes on and off themselves. At first, the first belt cane was a bungee belt, and children stepped into the belt like a pair of pants. We thought that this would be a routine that would be easily mastered by very young children. The magnet belt is a much better design. It is much less cumbersome to put on the child, as there is no need for the child to step into or out of the cane frame. The belt is closed using a mushroom head fastener that requires an adult’s strength and dexterity to pinch close and pull open.

It turns out, that some highly capable three and four-year-old boys and girls do learn how to detach their belt canes. They don't discard them, they push them. They get to decide if they want to keep them attached or detached. So, while we intended to make the canes like car seats, we made them so well that kids can take them off, and still want to use them. This is helping them with the transition to the AMD and later the rod cane.

9. Mobility instruction – I thought the child would have to be taught how to employ the belt cane. The Audrina Series, documents a three-year-old girl wearing her belt cane and compares her wearing the belt cane to when she is using her rod cane. In the video series, we see clearly that she is not able to work her rod cane to achieve one step, one swipe. No matter how much she is prompted to do so by her teachers and O&M specialist. Yet, with no instruction at all, she is moves about freely and with greater speed and self-confidence with the belt cane.

When Audrina wears her belt cane, she becomes much more of a three-year-old (meaning less compliant). She begins to discuss, some might say argue, orientation and route planning. Her language is more interesting, and she begins to run and explore and have fun. The benefit of the belt cane is that now O&M lessons can be about concept development as the cane arc is built in and the children learn to confidently explore their world. Belt cane O&M lessons are more fun because it can focus on concept development, route travel, locating fund destinations, learning the rules of the road -just more learning period about important concepts can happen when you don’t have to worry about safe mobility.

10. I didn’t know blind children would run without prompting – The first child who was mobility visually impaired to run wearing the belt cane was Jojo and he was the first child with mobility visual impairment to wear the first ever 3D printed bungee belt cane in September 2017. Since then, almost every three- and four-year-old who wears the belt cane, runs. If they are physically able to run, they run.

     Blind and mobility visually impaired children do want to run; they want to let go of the wall and they want nothing more than to feel safe and confident and to be independent.

Anybody who says the blind child prefers a sedentary lifestyle is asking that child who is blind or mobility visually impaired to walk/run without consistent tactile path information. When they have no path information, they are the smartest person in the room, as they know better than anyone else that running without path information is dangerous. Running with path information is fun (watch part five of the Audrina series).

Comparing visual and tactile path preview

What happens when a driver takes her eyes off the road? When she looks up she might jerk her head back and quickly turn the steering wheel to correct for a veer and avoid a collision. By contrast, when a driver keeps her eyes on the road she can smoothly navigate a turn so that the passenger barely notices. The advantage of vision is distant path preview allows you to make subtle path changes to avoid objects and follow the clear path.
Sudden visual path information is a lot like typical tactile path information, the jerk is physical and shocking to the system. Sighted people experience sudden visual path information much less often than belt cane users experience the push back from tactile path information. Tactile path information looks very jerky, because it is.

Blind kids can’t “keep their eyes on the road” to make smooth course corrections. Thus, walking towards a wall, the belt cane is working when it suddenly stops the blind child in her tracks. She never sees the wall coming, because she is blind.
It is important not to judge the jerkiness of tactile path preview by the standard of visual path preview. Instead, every time you see a young blind child’s cane suddenly stop them from colliding with a wall, understand that is a great outcome. It is a body collision avoided. When the cane frame takes the hit, the child gains confidence in the same way we sighted people learn to appreciate our eyes and quick reflexes.
The video I have put together shows a two year old girl who is blind. In the first scene, she is stopped from hitting the cabinet in her kitchen, she then makes a course correction and goes on to locate her mom using her words.

Next we see her stopped because a rise in the sidewalk, she uses her cane to learn that there is an iron gate blocking her way and turns to locate a clear path. Next we see her step more cautiously because her cane frame stopped her at a sidewalk rise. At the park, she finds a pole and purposefully clangs it with her cane frame on both sides, and then turns to ask her dad, “What is this?”
Finally, we see her cane stop her from hitting a sign post on the sidewalk with her body, and then she uses her cane frame to again clang the sign post, this time she reaches out with her hand to explore the sign post further.
The benefits of tactile path information is sometimes hard to understand in the eyes of those who can see, because it appears jerky and cumbersome. Yet, each time blind toddlers feel that jerk is a win for them. From the point of view of a blind toddler, tactile path preview is a kinder way to explore the world. Much better than body slamming walls, sign posts and kitchen cabinets.
Remember: Every time the cane clangs, a blind toddler is saved from a body bruise.
Pediatric belt canes are best when worn most of the day – more belt cane clangs and less body bangs encourage self-confidence, independent exploration and expansive learning.

Pediatric Devices are Made to Fit Children’s Abilities

The first known, dedicated wheelchair was invented in 1595 for Phillip II of Spain. By 1956, motorized wheelchairs were being mass produced. Now there are pediatric motorized wheelchairs made so that children who are three years old can operate them independently. Wheelchairs are essential for people who cannot walk. Wheelchairs replace the function of the legs with wheels. They are bulky, they do not traverse stairs, so modern architecture has been changed, by law (see the Americans with Disabilities Act (ADA)), to accommodate wheelchair users.

Three-year-old boy operates his electric wheelchair.

The first electric hearing aid was created in 1898. It used a carbon transmitter, so that the hearing aid could be portable. Hearing aids assist the function of the ears, by amplifying sound by taking a weak signal and using electric current to make it a strong signal. Overtime hearing aids have improved to include infant hearing aids. The earlier the child receives hearing aids, the better. It is possible to be fitted with hearing aids within the first weeks or months after birth. Although hearing loss happens in the ears, the real effect is in the brain. It is the brain that makes sense of sound. The brain regions involved in hearing need to be stimulated to develop hearing responses.

Babies as young as seven-weeks have shown benefit from hearing aids.

The first long cane was invented in 1945. It was made for World War II veterans with mobility visual impairment and blindness (MVI/B) who stormed into their commanding officer’s office to ask for better solution to moving about blind. They refused to believe that walking around crashing into walls was the best the US army could do for them.

They were right. Long canes replace the safety function of eyes by substituting tactile feedback. The US Army’s solution was to re-purpose aluminum tubing, add a chair glide for a tip and a golf grip for a handle. The white cane reflexive tape completed the look. The US Army created the first ever mobility tool almost any blind adult could employ within minutes after introduction.

The cane is rod-shaped. In order to get effective, tactile path information using the rod-shaped cane; the user holds it in the hand and sweeps it back and forth, one step, one swipe. While most adults can learn to swing a cane in a rhythmic fashion very easily, these canes are very challenging for children, older adults, and anyone with hand or wrist injuries including arthritis.

It typically takes less than an hour for an otherwise healthy adult to learn to sweep a long cane correctly for safe mobility. For those who are unable to rhythmically sweep a long cane for safe mobility after an hour of instruction, there is another solution, a rectangular-shaped cane. Rectangular canes are better known as an adaptive mobility devices (AMDs). The rectangular cane is an all white rectangle with black grips. The shape offers a built-in cane arc, in other words, the user simply pushes the shape ahead, no sweeping necessary. There is very little instruction needed to immediately effect safe mobility by most users.

The purpose of these canes is to provide effective information about whether the path ahead is clear or blocked by an obstacle (change in floor surface, drop-off, or object). Having this essential information enables the blind user to experience safe mobility. This tactile path information is essential to someone who cannot otherwise move about safely, due to their visual impairment.

The problem for children aged five and younger is both canes are hand-held, they require the user to intentionally use the cane correctly all the time they are walking and running. Toddlers, preschoolers and those with intellectual and motor disabilities experience great difficulty intentionally employing these canes with every step they take. When you are B/MVI, you need safe mobility all day every day, so the answer is to create other white cane options, one especially for toddlers, for example.

Pediatric belt canes have been created for infants, toddlers and preschool learners. Children this young cannot sweep the rod cane back and forth with each step and they also tend to let go of anything in their hands after a few steps. The belt cane was designed with this in mind. The children wear their canes to obtain the path information needed for safe mobility.

Babies and toddlers with MVI/B need safe mobility the same amount (or more) as adults. Some have misinterpreted toddlers with MVI/B inability to use rod and rectangular canes to mean that they don’t need tactile path information. Yet, if this were true, the incidence of independent walking delays would not be so ubiquitous.

The faulty logic of those who propose only the adult rod-cane is necessary for blind babies goes something like this, if babies who are blind needed path information they would keep holding the cane. This faulty reasoning has also led to an instructional algorithm that suggests toddlers who simply hold the cane for a few steps a few times a day will one day become effective cane users, yet the true result is that they grow up without safe mobility, they experience horrific motor delays (slow pace, poor gait, fear of moving independently).

The rod cane is only able to protect the user when used correctly.

These faulty assumptions about blind babies are causing harm, because babies are not responsible for themselves; they do not dress themselves, they do not change their diapers and they do not strap themselves into their car seats.

Young children depend on adults to keep them safe.

Blind babies are simply babies and they need adults to provide them with equipment made for babies that can help keep them safe. Pediatric belt canes employ the rectangular shape, the belt makes it easier for the blind child to keep the shape correctly positioned for optimum path information.

The belt cane is a developmentally appropriate mobility tool for toddlers with MVI/B, when worn, blind toddlers receive the benefit of tactile path preview because the base of the cane frame maintains contact with the floor two steps ahead of the intended path. Toddlers with MVI/B cannot forget their belt canes because the top of the frame is connected by magnets to a belt that is worn about their waists

Twenty-month old boy who is blind wears his belt cane in a mall.

The pediatric belt cane is a mobility tool that enables babies with MVI/B to safely experience the freedom to explore independently. Like a wheelchair, some people find Safe Toddles’ pediatric belt canes to be bulky and tricky to use when going upstairs. But also like a wheelchair, to the user, the advantage of wearing their belt canes outweighs any minor inconvenience.

The belt cane stays two steps ahead of the wearer and provides consistent tactile path information. Babies and toddlers with MVI/B learn to depend on their belt canes. The pediatric cane allows them to build confidence in themselves as they explore independently without direct bodily collisions.

Although vision loss happens in the eyes, the real effect is in the brain.

The brain must be stimulated to develop, but bodily collisions are the wrong type of stimulation. The brain does not learn well when it is worried about the next bodily collision. The belt cane allows the brain to anticipate obstacles and to make sense of sensory information that arrives in a less jarring manner. When babies move about wearing their belt canes they learn about space and time. They are also allowed to decide what they reach out to touch and explore with their hands, and what they rather bang with their cane frame.

Babies with MVI/B are able to make sense of tactile path information in a way sighted children would not be able to do and do not need to do. Pediatric belt canes are devices that help blind babies to achieve what they’re capable of achieving using the abilities they have.

Independent walking is fundamental to learning. The onset of independent walking triggers immediate, significant acceleration in language growth; a pattern that is stable and is evidenced across cultures. Infants’ walking experience significantly predicts both receptive and expressive language growth with walking infants having significantly larger vocabularies than their age‐matched peers who are not yet walking.

It is unfair to expect blind toddlers to wait until they are able to use rod canes for safe mobility, like car seats and drawer locks; safety devices need to be made for them. That’s what the Safe Toddles’ pediatric belt cane has succeeded in doing.

Tear-less collisions are a troublesome sign

There is a need to fear the lack of tears in response to collisions in preschool learners who are blind. The reason Safe Toddles is advocating for children who are mobility visually impaired or blind to wear their pediatric belt canes is because they are too little to use long canes for safety. Babies, toddlers and preschoolers are also too little to know that their experiences are not the norm.

Children grow up believing they are the center of their universe and the universe is the same for everyone. Children five and younger are also dependent upon the adults to protect them from harm.

Three-year-old girl who is blind collides with wall.

The unfortunate outcome of growing up mobility visually impaired and blind is unavoidable collisions. Toddlers and preschoolers who cannot see the path ahead are destined to collide with obstacles. Families and providers of early education for learners who are blind have all experienced the occasion of observing a blind toddler walking freely, there is only one toy in the middle of an otherwise clear carpet and somehow the blind child misses all that empty carpet to tumble over that one, unseen toy. What happens next? A chorus of “I’m sorry” or “watch out”.

One of my worst experiences might actually be when a two-year-old girl who is blind was happily walking and chirping and suddenly hit her forehead hard against the corner of a door frame. She was lost in her own joyous world, her happy state transformed into an unhappy state with loud crying, protesting the pain she felt from that unexpected crash in the safety of her living room. Her father rushed over to soothe her, “I’m sorry, you’ll be OK, I’m so sorry”.

Fast forward to when she is four- or five-year-old-preschooler. Now we notice the absence of her tears in response to collisions. The reason Safe Toddles is advocating for children who are mobility visually impaired or blind to wear their belt canes is because they are too little to use long canes for safety and they need safe mobility solutions that prevent these collisions.

Babies, toddlers and preschoolers are too little to know that their experiences are not the norm. All children grow up believing they are the center of their universe and their universe is the same for everyone. Children five and younger are also dependent upon the adults to protect them from harm.

Three-year-old girl who is blind collides with wall.

Yet, once blind toddlers become three-year olds who are blind and have experienced a year of unseen collisions, now when they crash into the wall with they remain silent. They don’t cry, because they have learned this is normal. It’s normal to trip, crash and experience unavoidable collisions.

Children who are mobility visually impaired and blind are growing up with no way to comprehend that unexpected collisions are not common among sighted peers. Thus, a two year old child who is blind and cries because of the pain she experienced from colliding without warning (colliding, because her visual impairment prevented her from being able to slow down, put up her hands, or flinch in the face of oncoming collisions); becomes that three year old who simply understands that life is painful, unexpected collisions, and one doesn’t cry about normal, common experiences for which there is no solution.

Instead, these three-year-olds who are blind and mobility visually impaired stop crying and the also stop moving. They stop moving because the only way to avoid collisions is to avoid walking, avoid letting go of the couch or a parent’s hand.

There is a solution. The pediatric belt cane changes the lives of toddlers and preschool learners who are mobility visually impaired and blind by providing them with a way to detect obstacles in their paths and prevent these harmful body collisions.

The belt cane allows them to experience the confidence of moving with information about the path ahead. When the cane collides with obstacles, it is not their body or their foreheads that take the hit, its the cane.

When the belt cane collides, then the child who is blind has the information needed to know that his path is blocked and needs to find a clear path. The belt cane takes the brunt of the collision, the toddler who is blind or mobility visually impaired takes the information from the belt cane and learns to process it and grows in confidence with every knowledgeable step.

The pediatric belt cane is confidence to go.

Can crying be positive?

When I was a doctoral student at Vanderbilt University, Peabody College. I was there to study orientation and mobility (O&M) under the esteemed Professor Everett Hill. Professor Hill was a pioneer in preschool O&M. Among his many achievements is the only measure of concepts standardized with children (aged six to ten) who were visually impaired called “The Hill Performance Test of Selected Positional Concepts.”

In the ninties, we were just beginning to study how to include O&M into early education programs for children with mobility visual impairment and blindness (MVI/B). It was there that I met a boy named Mike.

Two-year-old boy who is blind with his push toy

Mike was three years old and blind. He was attending the on-campus Susan Gray School which has the distinction of being the first nationally recognized inclusive preschool where typically developing children learned alongside children with disabilities in an educational setting.

During my first observation, I watched Mike transition from classroom to playground for recess. The classroom door opened onto the playground; from there he walked by himself. He trailed the outside brick wall to an alcove that had floor to ceiling glass windows. Where he stood all recess.

Mike’s chosen activity was to put his face on the glass with his hands up around his ears tapping the glass as he stuck his tongue out and licked it. He remained there, undisturbed, until the end of recess when he was collected and brought back to class.

Mike was quiet, passive and in his own world. I asked if I could volunteer to provide early education O&M supports for him. His teachers agreed. They told me that they had little experience with children who were blind. They also said, “he was a good little boy, as he rarely cried”.

My goal was to teach him how to play like the other children. This being the mid-90s, I had no understanding that he needed to have tactile path information. I understood only that he lacked concepts and his current recess activities were not providing him with real-life activities that would result in useful concept and language development (Lowenfeld, Abel, & Hatlen, 1969).

The excerpt paragraph from the book “Blind Children Learn to Read” does not mention any consequence to their advice, blind children should be encouraged to move towards sounds and objects (without any mobility tools to prevent harmful collisions).

No mention of a mobility tool, blind kids just move toward sounds and objects

These well-known leaders in the field expected blind children to move about without mobility tools towards sounds and objects, and they never once reexamined their recommendations or worried about the safety implications of this recommendation. The failure of preschool learners to thrive has been the outcome of these strategies. And blind children to this day, 2020 are still being pushed to run and explore freely though they cannot see what dangers lie ahead.

This strategy of walking independently absent path information has failed a century of blind preschoolers, as we see in how my implementing this strategy with Mike, that it encouraged compliance and interaction, but it failed because it did not address the root cause of his failure to thrive. Mike was a blind preschoolers. He couldn’t see where he was going and he needed tactile path information that’s why he stopped walking and exploring.

But it was the 1990s, so like everybody else, I spent a great deal of time and energy trying to implement this unproven theory to teach Mike simply to move freely, so he could learn, never asking why Mike didn’t want to move.

The first thing I attempted to teach him was to climb on the little structure that had a slide. As soon as I took him away from the glass wall, he began to cry. He wailed as I helped to guide his body to climb up the structure. Tears streamed down and the volume of crying was so loud that several teachers came over to check whether I should stop what I was doing.

His crying was very upsetting to them. Well, tears streaming and amid loud cries he slid down the slide. As we continued to work and repeat the activity, the volume of his protests got softer. The next day, he wailed again, but for a shorter amount time. He stopped crying mid-slide and began to engage in the sliding activity.

The next day, he didn’t cry, and he competently climbed the structure and slid down with very little help. Once he was routinely able to play on the playground structure without tears, of course, that meant we needed a new activity.

I wanted to show him how to ride the tricycle. The new activity resulted in a return to great volume of tears and crying. He was again so loud the teachers once again came over to see if we should stop or go back to sliding.

Once again, after several days of the new activity his protests stopped, and he began to peddle the trike on his own. What happened? Well, I changed the activity again, this time, he cried, but he wasn’t as loud or as insistent that we stop. He was getting used to learning new things.

We began to have a recess without tears replaced by doing many activities, some sliding, some riding, see sawing and sand play. He was not independent, he did not seek out the equipment on his own. In class, on his own, he began to push a chair ahead of himself so he could walk with fewer collisions. His teachers reported he was becoming more a part of the group activities.

For Mike, crying had been his only way to control his world, when he cried people left him alone. Therefore, for Mike, crying was a positive sign because it signaled that he was being asked to learn something new. Once he learned the new thing, he stopped crying and had a new skill that gave him pleasure and a feeling of worth. For children with MVI/B who are quiet, passive and in their own world, crying can be a positive sign.

Now looking back I wish the tears had been from providing him with his first pediatric belt cane. The activities he was objecting to were beneficial, but I had not solved his most pressing problem, how to safely move independently about his environment.

Children who are blind who cry when they are provided with pediatric belt canes is a sign that we are challenging them, change is hard. When we stop challenging them, we do risk them going into their own world. Like Matias in the photos. Before belt cane he was infantile in play and social interactions. With his belt cane he began to explore and learn about his world in an age-appropriate manner.

Matias before and with his pediatric belt cane

When introducing the pediatric belt cane is met with tears, it is important to understand often crying can be a control behavior. The steps you can take to make a smoother transition would be to a) check that there is nothing hurting them, b) have confidence that the pediatric belt cane is going to reduce the number of harmful incidents by allowing the cane frame to take the brunt of all collisions; and c) have confidence that toddlers/preschoolers want to learn new things, and they don’t know that crying is preventing them from the fun of learning.

So, have courage in your conviction that pediatric belt canes are the solution blind toddlers and preschoolers need to begin walking independently, plug your ears, and introduce toddlers and preschoolers with MVI/B to this new mobility tool.

You can help them learn new things by distracting them from their tears of protests. You can teach them to communicate in new ways- such as with laughter and words.

Reference

Lowenfeld, B., Abel, G., & Hatlen, P. (1969). Blind children learn to read. Thomas.

To Seek a Solution, First One Must Identify a Problem

Once again, orientation and mobility Facebook group members asked for proof … “Show us your data” was the request. Prove that children who are mobility visually impaired or blind (MVI/B) need better mobility tool options (e.g., wearable belt canes).

Which is tough to hear because I thought it was obvious. There are two pictures of the same girl in this blog post, on the Safe Toddles website are her videos that demonstrate the difference wearing a pediatric belt cane made for Alilah.

Before the belt cane – she didn’t walk unless prompted, urged and cajoled by her parents and O&M specialist. When she walked it was with an unsteady, unbalanced gait and she was very quiet. The second photo is Alilah in the mall- her videos confirm. She walks away from her mother, her mother has to find ways to stop her from running away from her. She has to teach her the rules every child must learn about stranger danger- because she will now wonder off. She is also much more talkative.

That’s important developmentally- blind children need to wander off and their parents need to teach them the rules of staying near. Independent walking is the fast track to achieving developmental milestones.

Alilah no longer not fits the poor motor outcomes found in so many research studies that describe children like her – those born mobility visually impaired and blind (MVI/B). She has optic nerve hypoplasia, and a small window of vision.

One year old girl, MVI due to optic nerve hypoplasia, walks without a mobility tool

There is more than a century of research that has identified global developmental delays in children born with MVI/B who grow up with early education, but without access to consistent tactile path information from an effective mobility tools (Celeste, 2002; Hatton, Bailey, Burchinal, & Ferrell, 1997; Hatton, Ivy and Boyer, 2013).

The research on motor skill delays found in children like Alilah (before belt cane) is extensive (Brambring, 2006; Celano, Hartmann, Dubois, Drews-Botsch, 2015; Celeste, 2002; Gazzellini, et. al., 2016; Hallemans, Ortibus, Truijen, Meire, 2011; Hatton, et. al., 2013; Wyver and Livesey, 2003; Tsai, Meng, Wu, Jang, & Su, 2013).

Children born with MVI/B who do not wear belt canes are less likely to achieve motor milestones on time (Bakke, Cavalcante, Oliveira, Sarinho, & Cattuzzo, 2019). Wyver and Livesey concluded that “findings are generally consistent despite the studies being conducted in a wide range of settings, in a variety of countries … there is strong evidence of an adverse impact of visual disability on motor development” (2003, p. 25).

A review of the bulleted list of common gross motor milestone definitions at five ages (Sharma, 2011); finds that toddlers’ eighteen-month-motor milestones included the expectation that they will have developed their visual/motor coordination enough to walk and avoid obstacles independently. By twenty-four months of age, children were expected to be able to run and avoid obstacles, independently (Sharma, 2011).

• Nine months — crawling, standing
• Twelve months – cruising, walks with assistance
• Fifteen months — Walks alone feet wide, hands up, often falls, bumps into furniture
• Eighteen months — walks well with arms down, runs carefully but cannot avoid obstacles
• Twenty-four months — runs avoiding obstacles.

Children with MVI/B who grow up without wearing pediatric belt canes demonstrate gross motor milestone delays (Brambring, 2006). The cause of these gross motor milestone delays is their inability to develop visual motor skills needed for ‘obstacle avoidance’ and their lack of tactile information to learn tactile/motor skills for obstacle avoidance (Pigeon, Li, Moreau, Pradel, and Marin-Lamellet, 2019).

People whose MVI/B robs them of visual path information benefit from mobility tools that provide tactile path information. Obstacle detection is the first step needed to develop motor planning strategies used to interact effectively with obstacles, such as obstacle avoidance.

The pediatric belt cane is a developmentally appropriate mobility tool toddlers with MVI/B wear. The rectangular shape of the cane offers a reliable cane arc and enables very young children with MVI/B to experience consistent and reliable tactile path information.

The cane frame maintains contact with the floor, two steps ahead of the child. Toddlers with MVI/B cannot forget their belt canes because the top of the frame is connected by magnets to a belt that is worn about their waists (Ambrose-Zaken, FallahRad, Bernstein, Wall Emerson, & Bikson, 2019).

Alilah found the planter, first with her cane, then she reached out to explore it with her hand.

Families and professionals who order pediatric belt canes for children with MVI/B do so because the children with MVI/B in their care were experiencing unavoidable collisions and the older they became the less they walked independently. By age three, they simply avoided all independent walking.

Adults were actively encouraging the children with MVI/B to continue walking independently, yet they no longer would- they were not interested in colliding with furniture, walls, and tripping over toys without warning. Before requesting belt canes, the adults tried getting these children to hold long canes and push toys. Yet, these children with MVI/B were reported to simply not be able to swing the cane most didn’t even hold the cane for very long.

Families and professionals identified the problem, toddlers with MVI/B were not able to walk safely because they could not see well enough to avoid obstacles. They needed to wear a pediatric belt cane a developmentally appropriate white cane for toddlers with MVI/B.

Toddlers need belt canes because they are unable to keep themselves safe using hand-held white canes. In the hands of a toddler, long canes are easily cast aside or entirely forgotten.

Adults are getting pediatric belt canes for children with MVI/B because these children are afraid to move. It is almost too late! We should be providing these children with effective wearable canes BEFORE they grow afraid and insecure about walking independently.

Wearable belt canes solve the problem of obstacle detection and allow toddlers to gain self-confidence. Proof in the form of family-shared videos is on our website www.safetoddles.org. In our articles, Ambrose-Zaken, G. V., FallahRad, M., Bernstein, H., Wall Emerson, R., & Bikson, M. (2019) and Ambrose, G. V., McAllister, J. & FallahRad, M (2020).

Toddlers with MVI/B want to run. Once they have reliable tactile path information- they do run, they do cross open space, they gain confidence, expand their language and concepts- they enjoy and learn from the information that wearing pediatric belt canes provide them.

References

Ambrose-Zaken, G. V., FallahRad, M., Bernstein, H., Wall Emerson, R., & Bikson, M. (2019). Wearable Cane and App System for Improving Mobility in Toddlers/Pre-schoolers With Visual Impairment. Frontiers in Education, 4. doi.org/10.3389/feduc.2019.00044

Ambrose, G. V., McAllister, J. & FallahRad, M (2020). Would A New Term Improve Gross Motor Outcomes? A Study of Children with Visual Impairment and Blindness, Journal of Visual Impairment & Blindness.

Bakke, H. A., Cavalcante, W. A., Oliveira, I. S. de, Sarinho, S. W., & Cattuzzo, M. T. (2019). Assessment of Motor Skills in Children with Visual Impairment: A Systematic and Integrative Review. Clinical Medicine Insights: Pediatrics. https://doi.org/10.1177/1179556519838287.

Brambring, M. (2006). Divergent Development of Gross Motor Skills in Children Who Are Blind or Sighted. Journal of Visual Impairment & Blindness, 100(10), 620-634.

Celano, M., Hartmann, E.E., Dubois, L.G., Drews-Botsch, C. (2015). Motor skills of children with unilateral visual impairment in the infant aphakia treatment study. Developmental Medicine & Child Neurology, 154-159. doi: 10.1111/dmcn.12832.

Celeste, M. (2002). A survey of motor development for infants and young children with visual impairments. Journal of Visual Impairment & Blindness, 96(3), 169-174.

Ferrell, K. A., Shaw, A. R., & Deitz, S. J. (1998). Project PRISM: A longitudinal study of developmental patterns of children who are visually impaired(unpublished manuscript). Retrieved from http://www.unco.edu/ncssd/research/PRISM/default.html

Gazzellini, S., Lispi, M.L.,·Castelli, E.,· Trombetti, A., Carniel1, S., Vasco1, G., Napolitano, A.,· Petrarca, M. (2016). The impact of vision on the dynamic characteristics of the gait: Strategies in children with blindness. Experimental Brain Research, 234, 2619–2627. DOI 10.1007/s00221-016-4666-9

Hallemans, A., Ortibus, E., Truijen, S., Meire, F. (2011). Development of independent locomotion in children with a severe visual impairment. Research in Developmental Disabilities, 32, 2069–2074.

Hatton, D. D., Bailey, D. B., Burchinal, M. R., & Ferrell, K. A. (1997). Developmental growth curves of preschool children with visual impairments. Child Development, 68, 788–806.

Hatton, D.D., Ivy, S.E, Boyer, C. (2013). Severe visual impairments in infants and toddlers in the United States. Journal of Visual Impairment & Blindness, 107(5): 325-336.

Pigeon, C., Li, T., Moreau, F., Pradel, G., & Marin-Lamellet, C. (2019). Cognitive load of walking in people who are blind: Subjective and objective measures for assessment. Gait & Posture, 67, 43–49. https://doi-org.proxy.wexler.hunter.cuny.edu/10.1016/j.gaitpost.2018.09.018

Sharma, A. (2011). Developmental examination: birth to 5 years. Archives of Disease in Childhood – Education and Practice. doi: 10.1136/adc.2009.175901

Tsai, L.-T., Meng, L.-F., Wu, W.-C., Jang, Y., & Su, Y.-C. (2013). Effects of visual rehabilitation on a child with severe visual impairment. American Journal of Occupational Therapy, 67, 437–447. http://dx.doi.org/10.5014/ajot.2013.007054

Wyver, S. R., & Livesey, D. J. (2003). Kinaesthetic sensitivity and motor skills of school- aged children with a congenital visual impairment. British Journal of Visual Impairment, 21(1), 25–31. https://doi.org/10.1177/026461960302100106