tors, the significance of which is too often obscure. The positive aspects often are not prominent, or they are distorted and appear to deviate from the norm. Seeing the negative picture more clearly than the positive one is often the consequence of the physician's limited observations of blind children. Moreover, seeing the child in a doctor's office is quite different from observing him in his own home or in a schoolroom setting. As a result the label of mental deficiency may often be attached to the child who has suffered from sensory, environmental and/or emotional deprivation. The label of psychosis, or childhood schizophrenia may be fixed on the child for the same reasons, or because the child fears environmental contact, seems mute, has not mastered self-care skills, lacks socialization, and makes extreme attempts at affection seeking.

A mistaken diagnostic impression given to the family of a blind child is likely to have untold damaging effects. The parents' attitude toward the child, and conceivably their subsequent relationship, will be shaped according to their own personality makeup and ego strength. Common reaction takes the form of either of two extremes: overprotection or total indifference. The cycle of unfortunate events which usually follows can develop into a complexity of problems involving the entire family.

NEUROLOGICAL EVALUATION

A neurological evaluation is an additional source of medical information to be used in assessing a child's potential.

The neurologist as well as the pediatrician is presented with a unique challenge because there are comparable difficulties in recognizing positive developmental evidence which he may use in making an evaluation. In the congenitally blind child, accurate diagnosis is difficult at best due largely to the utilization of standards which are based on the functioning of children with sight. The ages at which certain developmental levels appear-such as, sitting up, walking, coordinated hand and finger dexterity, and even the beginning of speech, may vary from the norm established for the sighted.

Frequently, skills develop at a different and often "out-of-normal" sequence in an individual blind child; e.g., extended plateaus may exist in manual abilities; speech may develop before taking the first step; walking may occur before creeping, etc.

Sighted children who have central nervous system impairment often exhibit certain characteristic mannerisms. However, these same behavior patterns may be seen in children who are blind, or functioning without vision, who otherwise show no neurological impairment. Moreover, the apparent retardation in physical development is usually interpreted negatively in evaluating the blind children.

In the use of diagnostic instruments such as the electroencephalogram, the neurologist is handicapped not only by the paucity of research but also by the conflicting or inconclusive findings of extant research.

In EEG studies of very young children, Gibbs reported on 51 cases of children blinded from retrolental fibroplasia; Jim and Krause on 15; Parmalee* on 6. Gibbs reported a high percentage abnormalities, whereas the others did not report an unusual number.

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The EEG patterns generally interpreted to be indicative of abnormal brain functioning in sighted children may be seen in the EEG records of blind children who are considered to be functioning normally as reflected in their cumulative case records. Moreover, convulsive seizure type patterns are sometimes seen, according to Lairy," in the EEG records of blind children who are well adjusted and who, reportedly, have no history of seizures. The reverse has also been reported: i.e., that some blind children who do have a history of seizures will have EEG patterns which appear "normal." Thus the capacity of the EEG to clarify the functioning of the blind child is no greater than it is for the sighted child, and is subject to the same contradictions and limitations. For these reasons, investigators of neurological aspects accompanying blindness agree that the EEG should be weighed carefully as a diagnostic instrument, and that it should be regarded as a potentially misleading predictor of central nervous system abnormality in blind children.

The role of excessive oxygen as a cause of damage to the cerebral cortex has not been definitely established. Also to be regarded as questionable causal factors of developmental abnormalities in blind children are birth weight and length of stay in an incubator. In considering factors which may have caused brain damage one must also take into account the fact that there are children who are blind who have been subjected to problems of prematurity and who have made very satisfactory achievement free of any trace of brain damage.

The problem of relating the diagnosis of structural normalities and abnormalities to the over-all functioning has been stated succinctly by Dr. Raymond L. Clemmens." "The subject of minimal brain damage involves considerable controversy as to whether or not this is a diagnosable clinical entity. The dispute is not unexpected, however, for several reasons:

1. The subject matter deals with inherently complex functions which are difficult to measure.

2. The clinical techniques available to assess brain function are relatively crude and, in general, not designed to elicit subtle deviations in higher cerebral performance.

3. In an era in which the importance of environmental stresses in the causation of abnormal activity has been emphasized strongly, it has become somewhat unfashionable to diagnose organic cerebral pathology in the absence of specific neurological signs."

Thus it is reasonable to expect that this same problem becomes even more complex when the neurologist attempts to assess the potential for functioning in children who have a sensory deficit.

PSYCHOLOGICAL APPRAISAL

In psychologically appraising the blind child with no other physical impairment, it is possible for the trained examiner to use standardized tests and procedures and produce relatively dependable

results. While difficulties exist which are not present in evaluating a sighted child, it is still possible to get a fairly accurate psychological appraisal of the child. (See Appendix for a listing of psychological instruments.)

The process of appraisal of the blind child becomes complicated when additional deviations are present. Not only do the few standardized tests cease to be guides, but also the norms of child development become less useful. The child then becomes a truly unique case and a psychological appraisal of him becomes as challenging as is the medical one. If cues are ignored or symptoms misinterpreted, the risk of misguiding the child's future becomes great. No clinical facilities seem to be immune from errors in diagnosis or in interpretation of the behavior of the young blind child.

The psychological examination cannot give a full picture; it has its limitations too. It may result in only an impression. One cannot be too specific in recommendations because of the insufficiency of the psychological instruments.

In some instances a diagnosis becomes tempered with phrases such as "autistic-like," "psychotic-like," or "pseudo-deficient" by professional persons who recognize a difference between a blind child and a sighted one with similar symptomology. The interpretation of behavior thus becomes an especially pertinent responsibility for those who work with multiply impaired blind children.

The behavior of these children may be interpreted more meaningfully by recognition and analysis of stages in the child's individual development and functioning than by comparison to norms, particularly those derived from a sighted population. The significance of a pattern of actions is thus most correctly determined by analysis of both a cross sectional and a longitudinal view of the total child. (The cross sectional aspects would include information from medical, social and psychological areas while the longitudinal would include, in addition, aspects of the individual's life history.)

Two cases are presented for their pertinence to the foregoing discussion.

THE CASE OF DEBBY

Debby at the age of four years ten months, was referred to the residential school for evaluation of her development. She was a totally blind child, apparently retarded, accompanied on the visit by her mother and maternal grandmother. She had been born after a six months' gestation and at birth weighed two pounds four ounces. After a period of seven weeks in an incubator retrolental fibroplasia developed. Debby's mother, 24 years old at the time of the school evaluation, was separated from her husband, age 29, and was planning a divorce.

Debby was observed in the psychologist's office as well as in a number of situations in the residential school. The mother was interviewed for further information which might have bearing on the psychological aspects of Debby's development.

In the initial part of the visit, Debby cried, rolled on the floor, beat her head with her fists, and would not respond to the quieting attempts of her mother or the staff. The grandmother was eventually able to settle her down by taking her on her lap and by giving her a bottle. In the several situations in which Debby was observed, she displayed almost no behavior which would come up to that expected of a fouryear-old blind child. One exception was her skill in moving about. She was able to travel around the unfamiliar rooms and halls of the building without fear, exhibiting a keen awareness of objects. However, her traveling appeared aimless; she made no attempt to investigate her surroundings. In one of the kindergarten classrooms for example, she showed no interest or awareness in the many toys, the walk-in playhouse or in any other equipment. Attempts to direct her attention toward apparatus met with no success. After a short period of apparent meandering, Debby stretched out on the rug and made indistinguishable sounds.

Debby accompanied the examiner willingly when he took her to his office. Her first display of affection came when she cuddled up on the examiner's lap for a short time. She then resumed her aimless wandering about the office and rejected the examiner's efforts to continue a relationship. She also rejected attempts to direct her toward constructive endeavors of any kind. Responsiveness to toys and test materials was virtually nil. She threw the toys about the room and