in the context of a warm developing relationship with some adult whom the child likes and trusts (often a nursery school teacher) and as a part of a generally improved trend in the child's total situation. Focusing on the "treatment" of the speech problem in isolation is unrealistic because speech is merely one symptom of a general problem involving the child and his reaction to his environment. In addition concentration on speech as such intensifies the problem because it increases pressures on the child which he handles only by further withdrawal. Less extreme than the lack of speech development is the problem found in the child who prolongs his period of repetitive speech and where the meaningful use of words as a means of communication is delayed. Such cases can be understood in terms of the child's total development and experience. Many of the same factors are found in cases of children with extremely delayed speech and language. These factors are usually in a less severe form, or the child's situation possesses favorable and compensating experiences not characteristic of those where speech is extremely delayed. Does this mean that the parent can disregard the importance of auditory stimulation? Quite the contrary. But the development of speech can take place only within a larger framework in which the needs of the child are recognized and understood, and where the parent is aided to see it in perspective. Often the suggestion is made that the child be talked to less rather than more. Radio and television stimulation should also be used in moderation. Their indiscriminate use is often associated with the indiscriminate use of speech to stimulate the child. Under these circumstances, the child becomes accustomed to a constant bombardment of sound which has no meaning, even though it may apparently "keep him happy" or "out of mischief." The continuing barrage of sound may also become something on which the blind child is overly dependent for satisfaction. On the other hand, the child who has an opportunity for good over-all development with plenty of firsthand experiences in relation to his own widening curiosity, will use speech effectively and appropriately in the course of the learning process. His use of speech will be in direct relationship to the ability of the adult to guide and understand his reaching out for new experience. In this area nursery school teachers have taught us much about the art of listening and meeting the child on his own level of experience. Skill is required to make sure that the child is neither pushed faster than he is ready to go because of the adult's anxiety, nor that his interest is shut off because the adult does not recognize that the child's questions have real import that should be grasped and responded to appropriately. BEHAVIOR MANNERISMS Often the behavior of the blind child is confusing, disturbing, or even unpleasant to the adult. The child may use unconventional sensory mechanisms, such as, use of the mouth to explore objects. Such sensory pathways may be of primary importance to the child but may not be understood as such by adults. What seem to be regressive activities, and random muscular movements, often sources of adult concern, may in themselves contribute positively to the development of the child who must function without vision. Other behavorial mannerisms lack this developmental potential and, when prolonged, usually indicate that all is not well with the child. Such behavior is often labelled a "blindism," an unfortunate term which implies that blindness is the primary cause of the mannerism and that the mannerism is an inevitable accompaniment of blindness. Eye rubbing, rocking, head banging or shaking, or other extremes in motor activity fall into this category as, of course, does excessive thumb sucking. The same mannerisms may be found in emotionally disturbed sighted children as, for example, those who are portrayed in the Roudinesco and Spitz documentary films. To a lesser degree the mannerisms may be seen in the nursery school child who momentarily feels unequal to the task which he thinks is expected of him. To attribute these activities primarily to blindness is to misunderstand their significance as well as to make the reaching of any sound theory of treatment more difficult. Other problems which appear can also be related to the child's over-all experience. These problems are usually present in several areas of the child's development, rather than particularly acute in any one. Thus attempts to inappropriately restrict or control the child in any area of his behavior may result in reactions such as temper tantrums. Similarly, the withdrawal and refusal to respond, so dramatically illustrated in many cases of delayed speech development, may appear in other aspects of the child's behavior. Significantly, the most acute problems have tended to appear in the areas of motor development and speech. These are acute because they represent areas in which all parents take justifiable pride. Parents feel themselves under the pressure to teach the child and to demonstrate his capacity because slow development in these areas is usually interpreted by society as inadequacy. Problems of a different nature appear when adults fail to recognize the child's readiness for new experiences, or fail to provide appropriate opportunities for development at crucial times. One or both of these unfavorable factors may exist in situations in which there are developmental problems. Treatment of the problem depends upon understanding its basis, a basis that may only indirectly be related to blindness. IV. Appraisal and Evaluation Each blind child studied by a competent professional examiner is a living laboratory. Positive factors in the child's makeup may be too easily overlooked or misinterpreted if behavior symptoms are weighed by standards based on the sighted world. The child's overt behavior may seem unique and incomprehensible, too often defying analysis by general principles of child development. This may hold true in any professional discipline with responsibility for evaluation of the blind child: medical, psychological, social service and educational. When such a child is observed, there is question about the significance of behavior which by known standards appears symptomatic of serious emotional disturbance. Yet in the blind child it is most important to know which factors may be accurately attributed to blindness per se, and which are directly related to emotional disturbance. A sensitive analysis of the emotional disturbance present in the child is the basic task of the professional person who appraises behavior as this analysis will in turn have a profound effect upon the future of the blind child. Following are some descriptions of behavior which are not directly related to blindness: • The child whose response to the extended arms of an adult deviates to extremes-from screams when the most gentle effort at contact is made, to an excessive need for affection. • The child who is most content to sit on the floor, rocking and making indiscriminate sounds. • The child who makes his simplest needs known by shrieks, kicks and wringing of hands. • The child who appears to derive satisfaction from inflicting pain on himself—such as, by banging his already bruised head on the floor, or possibly scratching an already raw spot on his arm. • The child who does not cry or does not laugh. • The child who does not speak. • The child who speaks only in a language without meaning to others. • The child who spends his affection on what appears to others as an insignificant inanimate object. • The child who has no concept of day or night-or of time. • The child who has strong tastes for particular foods. • The child who rejects solid foods. • The child who does not use pronouns "I" or "me" in referring to himself as a person. • The child who does not use his hands for touching and grasping. • The child who does not reach out into the world around him. None of the foregoing descriptions of behavior is attributable to blindness per se. MEDICAL EVALUATION The pediatrician is generally the first person involved in making an evaluation of the development of a congenitally blind child, preceded or accompanied by the ophthalmologist's diagnosis of blindness. Responsibility then rests heavily on the pediatrician for analysis of the child's total development and behavior during early months of life and for prognosis. (It is, of course, assumed that with visually impaired children, early and continuing attention will be given to comprehensive and appropriate audiometric testing.) The pediatrician is often confronted by a child who does not fit any pattern of growth he has seen. Developmental norms are based on the sighted population. Every blind child presents individual and perplexing problems to the pediatrician. Yet the doctor must make a statement to the family relating to the child's physical condition. Evidence is based on observable fac |