One reading training technique is to show the child patient a picture of a cow and ask him what it is. Then ask how he knew it was a cow and discuss the experience of seeing a cow and how he may have learned about cows. After the discussion show him the word "cow" and ask what it is. You will have to know, of course, what words the child does know before doing this. Tie together the fact that the picture of the cow and the word "cow" denote the same thing and it will begin to relate the same information to him. Words are pictures; they represent things and places. They tell things. Talk about the alphabet and its 26 letters and how these letters arranged in a certain way gives a picture.

This is a very basic step with the nonreader or the poor reader; we know that phonics and language skills will later be necessary. It is not a matter of sight reading versus phonics; we do not believe that there is such a thing as one against the other. Optometrists, above all others, know that sight-sound-speechtouch blend as a totality. Children with learning problems have not been able to learn by conventional methods, with tutorial help, or even in special school classes. The same material presented in a different form, a new experience, a new input, will sometimes be the difference between success or failure. An investigation of the most common basic words will show you that, in most instances, these words have to be learned as sight words.

The child advances to a home program with Dolch Flash Cards. We have used these for years with excellent results. The parent-if the child can work with one of the parents-is instructed to use the cards 6 to 12 times each day for very short periods of time: 2 to 10 minutes at most depending upon the case.

The pack is sometimes kept in the office and only a few cards at a time are given to the child, five or six to start out. With the whole deck, the child sometimes gets discouraged just looking at the task he has ahead.

When the child is well on his way to knowning most of the words, the cards are presented to him upside down. This is difficult if the child has a problem in laterality, a situation often found in the neurological learning problem child. It requires considerable spacial orientation. Crossed hand/eye dominance is usually associated with laterality problems.

HAND/EYE COORDINATION TRAINING

Children as old as 10 years of age are often unable to tell their right from their left. Without question, the incidence of crossed hand/eye dominance in learning problems is extremely high. Occasionally, a child is found where the sole outward sign is crossed hand/eye dominance.

Alternating hand/eye coordination training is an effective procedure. There is no need to go into the numerous methods one can use for this training. We still prefer the old alternating illumination teletrainer technique. We hear and read much about keeping training patients away from instrumentation and train instead in a natural environment. But, these childen have been unable to learn in their natural environment. An instrument confines them to the task at hand which is sometimes very necessary for a child not able to concentrate. Many children are very gadget conscious. Parents often tell of the child's curiosity and how he likes to tinker with things; this is another observation by parents which confuse them more with the total problem.

What parents interpret as a quest for knowledge or mechanical aptitude is generally meaningless playing; the child pokes and pulls things apart, and this is it.

Case history alone will often pick out the hyperkinetic child in need of medication. He flits from thing to thing, never stays quiet, never sits still. and can't concentrate long enough on any one thing to be able to complete a task. He is distracted by his surroundings. With an instrument he is excluded from his surroundings; the very workings of the device will often fascinate him sufficiently to stick with it.

Here again we speak with the child. We tell him that without exact fixations upon a target, pointing is impossible and we demonstrate. Hand control of the instrument rather than mechanical operation is most often necessary at first to slow down the procedure for step by step performance.

Keystone Movie Cards and the AN number star cards are the ones we prefer Two different colored pointers are used. The child knows in which hand he has each color. If his right hand holds the red pointer, he has to point with the right hand when he sees the red pointer, etc. The room is not in complete darkness; there is enough light so that he can see the cards in the instrument. We

explain that the light, when it's on, is a signal to the eye which signals the brain which signals the hand. We tell him his vision is at work, not his hands. There are some children that cannot accomplish this task unless reinforced with auditory signals. Each time the light flashes on, we say "point" in a loud voice. After a few trials, we stop and have the patient continue without auditory signals. We often find it necessary to go back to the auditory phase until the youngster slowly begins to perform without the extra sense.

Ocular motility problems are sometimes severe. Even after a child is released from training, ocular motility skills may be subnormal.

BLENDING LATERALITY

In a visual perceptual pilot study of 41 children, we noted that the 11 spastic hemiplegics in the study were all (100 percent) classified as having visual perceptual problems. The majority of the hyperkinetic nonphysically handicapped children were likewise classified as having visual perceptual problems (87 percent).

Here again, considerable talking with the child is necessary. We discuss his relationship with the room in which we are working and his position in relation to the screen. We talk about direction. This is not as simple as it sounds, not with this type of child. When we reach the point that one place within the form can be fairly well localized, we go on to two places, and, finally, to three. All responses are oral.

The Keystone View Co. has a form upon which only the crosses and circles in the form have to be reproduced. Oral responses have been more effective for us. Flash the form; the child has to get the mental image; he then gives the oral response as "cross-top-right," "circle-bottom-left."

Each time the form is presented the child has to reorientate his space in relation to himself. The cause of the laterality problem is not known; what we see in the child's performance is the outward signs and results of the difficulty. These are revealed as poor writing primarily and associated reading problems.

THE DIGIT SPAN

Problems in laterality are also picked up in digit span. The child may always write from right to left or reverse the order of numbers. Digit span will manifest perseveration, the inability to change from one task or performance to another.

Perseveration of digit span will look something like this: Numbers flashed 24-68-98-64-70; numbers recorded 24-64-94-94-74 (in this example the digit 4 is perseverated). Imagine the difficulty when this chald perseverates while read

ing.

If the child's limit is two-digit span, we flash two digit numbers in rapid succession so that as the child orally responds to one number he is perceiving another. If 68-94-20 are flashed in succession, the child perceives the 94 as he recalls the 68 and recalls the 94 as he perceives the 20. Input and output must be well coordinated for performance at this level.

We use the same procedure using words and eventually phrases when the child is able to get to this level of reading. Some investigators of brain-injured children have reported that these children have poor association ideas and ability. We have not found this to be true many times. In word-flash recognition training, we have observed the following: With flashed words "grass," "sheep," "party," "mother," and the child responded "green," "lamb," "birthday," "father."

OPTOMETRY'S ROLE

The variations and problems are multiple in working with the nonachiever. Emotional situations are many. A mentally retarded child with very limited intellect does not realize his inabilities. Supply his basic needs, proper medical care, and love him and he'll love back.

The nonachiever with normal intellect, however, is well aware of his inabilities and learns about these quickly when he gets to school. Acting-out behavior and emotional problems soon work into the total problem.

If the hyperkinetic syndrome is present then medication is as necessary as any treatment or training; usually, without it, other treatment is of no value. It is almost a standard rule that if a child presents one problem or abnormality, look for others.

Optometry can play an important part in this total field, but this requires constant investigation, study and education of the practitioner, which in turn will earn respect from allied fields. We must continue to work with others who may not be completely aware of optometry's usefulness in the complex field of mental retardation and general nonachievement.

THE PHILOSOPHY OF DEVELOPMENTAL VISION

(By Jerome Rosner, O.D.1)

The purpose of this paper is to supply the reader with a general background survey of the works pertinent to the field of developmental vision. It is not our intent to treat the subject fully; this is too vast a project. Rather, we shall attempt to present the essence of the philosophy and sources of reference with the hope that some may be enticed into further investigation.

THE TERM, DEVELOPMENTAL VISION

The term "vision" does not imply "visual acuity," which is but a part of the total process we term "vision." Vision, in this paper, then, refers to that ability of the organism (individual) to receive a light stimulus, integrate that stimulus with other sensory stimuli that are concurrently being received and, with previous experiences, interpret the stimulus and be capable of responding to it (intellectually, physically, and/or emotionally) in a satisfactory manner.

The term "developmental" obviously infers that a growth pattern or learning sequence can be noted. Such is the case. The newborn infant is incapable of utilizing his visual mechanism in any but the least efficient manner. He arrives, in most instances, with the equipment more or less intact. His task then is to proceed through innumerable experiences that enable him to develop an adequately functioning visual system-one that will provide him with the ability to respond to the constant demands of his environment and culture.

It must be acknowledged that a finished product-a completely developed organization—is never achieved. Rather, new adaptations and reorganizations are constantly occurring as long as there is life.

PIAGET'S CONTRIBUTIONS

Origin of the subject of developmental vision extends in the literature back to the 19th century. Seguin's contribution, "Idiocy and Its Treatment by the Physiological Method," can be read with interest today, albeit its publication date of 1846. Also, the works of Maria Montessori, the famous physician and educator of 60 years ago, are still pertinent.

For the sake of organization in this presentation, however, we shall commence with the work of Jean Piaget and Arnold Gesell. Although they belong to different disciplines, there is an amazing correlation between their work as it pertains to the subject. Their contributions form the foundation of all that follows, their insights were phenomenal, notwithstanding the obvious fact that their accomplishments were based upon those that preceded them.

Piaget's contribution can be traced mainly to four sources: (1) Piaget's "The Origins of Intelligence in Children" (1936); (2) Piaget's "The Construction of Reality in the Child" (1937); (3) Piaget's "The Psychology of Intelligences" (1947); and (4) Hans Aebli's "The Development of Intelligence in the Child" (1950), the last a summary of the works of J. Piaget published between 1936-48. Piaget states that "perception is influenced by motor activity from the outset, just as the latter is by the former." Distinguishing the two as separate activities (i.e., sensory stimuli and motor responses) is fallacious; and hence, he prefers to refer to a "sensory-motor" phenomenon. Piaget divides the development of sensory-motor intelligence into six stages that commence during the first 18 months of a child's life.

PIAGET'S SIX STAGES OF DEVELOPMENT

Stage I-"Exercise of the reflexes" (1st month): At birth, the child possesses a series of reflexes from which all behavior derives a continuous process of dif

1 Member, Advisory Council for Mentally Disturbed Children, United Mental Health Service, Allegheny County, Pa.

ferentiation and integration (e.g., sucking, grasping, etc.)." "Behavior," states Piaget, is "a life process that tends to maintain a state of equilibrium between the subject and environment."

Stage II "First acquired adaptations and primary circular reactions" (2d to 4th months): This implies "the formation of new patterns of behavior as a result of experience" and can be summarized as one wherein the activity patterns "consist in researches which derive from reflex activity and which still lack any intentionality, but lead to new results of which only the discovery is fortuitious, their conversation being due to an adapted mechanism of combined assimilation and accommodation" (i.e., an interaction of environment and organism).

Stage III "Secondary circular reactions and procedures aimed at maintaining interesting spectacles" (4th to 5th months): This level "begins with the coordination of vision and prehension; new behavior appears which represents a transition between simple habit and intelligence."

Stage IV-"Coordination of secondary patterns and their application to new situations" (5th to 12th months): Briefly stated, "the fourth stage is characterized by the beginning of coordination of the activities between the various sensory schemata * * * there are no inventions or discoveries of new means, but simply applications of known means to unforeseen circumstances. During this stage, feedback circuits commence to become efficient; constancy of form and size develop. The child now recognizes a square even though its position is such that in perspective it looks like a rhomboid."

Stage V-"Tertiary circular reactions and discovery of new means by active experimentation" (1 to 2 years): During the previous stage, the child produced the same result repeatedly. During the fifth stage "he experiments to see how he can vary this result so that repeated tries will be interesting and sufficiently different to avoid satiation."

He

Stage VI "Invention of new means by mental combination" (2 to 8 years): This stage "commences with the appearance of interiorized actions which, on the one hand, are at the basis of symbolic function, which, in turn, makes possible the acquisition of symbolic systems, such as language *** by relation to his body-schema he can perceive movement which cannot be directly seen. develops a mental space structure and spatial representations of perspective." Piaget concludes that the sixth stage "marks the completion of the development of sensory-motor intelligence." In his argument with Gestalt theory, he states that "it is impossible not to see in the behavior of an infant at this sixth stage the end result of all the development characterizing the previous five levels."

It will serve no purpose to go further into Piaget's work at this point. Our intent in restating (in extremely condensed fashion) the early development of the child, as described by Piaget, was to illustrate the importance this researcher places upon the ever elaborating sensory-motor coordinative processes that occur during the first 2 years of life. From his study, we can readily observe the child structuring space of ever increasing complexity and concurrently, developing an adequate self-awareness. Conceptual development is, of course, dependent upon this foundation.

CONTRIBUTIONS OF GESELL

Two important works are credited to Arnold Gesell and his staff. These are "Infant Development" (the embryology of human behavior) and "Vision-Its Development in Infant and Child."

In the latter, we find such statements as "the development of human vision must be pictured as a growing complex of structured functions which change with the advancing morphogenesis of the action system." Vision must be thought of "as an act which is mediated by eye and brain, but which emanates from a growing action system.* * * Vision is a complex sensory-motor response to a light stimulus mediated by the eyes, but involving the entire action system." Gesell presents, from studies conducted at Yale Clinic of Child Development, the visual developmental stages, as they occur in prenatal and postnatal lifeup to the age of 10. He coins the phrase "developmental optics" and states that it "is concerned with the ontogenesis and the organization of visual functions in ther dynamic relations to the total action system."

As did Piaget, Gesell places emphasis upon the importance of the motor basis of visual perception. He states that "the growth of the visual functions must be interpreted in terms of a basic motor maturation" *** the patterns of

visual behavior are configured by pervasive muscular determiners-not only by the oculomotor activators, but by the total postural mechanism and orientation."

GESELL'S THREE COMPONENTS OF VISION

Built upon a motor base, Gesell delineates the three functional components of vision. These are interdependent fields, developing conjointly but not uniformly. He terms them: (1) skeletal-"the visual system seeks and holds the image"; (2) visceral-"the visual system discriminates and defines an image"; and (3) cortical "the visual system unifies and interprets the image."

"By image" says Gesell, "is meant any effective optical stimulus or optical cue. The visual reaction thereto results in ascending degrees and modes of attention, identification, localization, apperception, and mental synthesis."

Gesell attempts to describe the visual development of the growing child by "observing the child's patterns of ocular and postural behavior in their manifold interaction." The first 18 months of life are divided into 6 quarter-year periods, with the first month being treated separately. It is striking to note the similarity in the observations to Piaget's work-although the different approach.

This study, of course, is more concerned with the visual apparatus, per se, than was Piaget. Gesell offers us, in this work, a means of observing and evaluating the stages of development as presented by Piaget. Therein lies one of its great values to optometry. A test sequence was standardized for the age groups from 21 months to 5 years and a more complex sequence for those from ages 5 to 10. The results of the study were organized, and it was noted that the development of this total process termed "vision" could be observed and compared at its various levels.

Maldevelopment, and its effect upon the spatial organization of vision, was also studied and found significant. Mentioned briefly, but of extreme importance, is the concept that therapy (such as training) could be effective in aiding proper visual development. The magnitude and importance of this study is not, even today, fully appreciated. In the interest of brevity, we have omitted many of the important facets of this work.

THE STRAUSS-KEPHART CONCEPT

In the past decade, there has emerged the concept of utilizing the philosophy as presented by Gesell and Piaget in the treatment of improperly developed visual abilities.

The work of Strauss, Lehtinen, and Kephart on the "Psychopathology and Education of the Brain Injured Child" must be mentioned. Volume I of this series was published in 1947. It stressed the Gestalt concept of perception. The authors suggested motor activity for the child, but basically as a means of inhibiting distractability.

Volume II, published in 1955 with N. C. Kephart as coauthor, reflects a new concept: "When we speak of the embryological development of the organism we must continually bear in mind that we are speaking of the development of this organism as a whole. We may single out certain parts and trace their specific development for the purpose of making our analysis easier. We must not forget in this process, however, that we have artificially abstracted this part from its whole. In the development of any organism, the parts subserve the whole and we cannot correctly think of the parts except in their relationship to the whole. "When we trace the development of a part, as the nervous system, we must not allow ourselves to consider that what we observe of its development exists alone. Rather, we must at all times remember that this particular development which we are observing has only the purpose of contributing toward the whole, and its development will be modified and altered to serve the demands of the whole of which it is a part. *** What is true of the skeletal and muscular development of the organism is likewise true of its nervous and mental development.

"There is an intimate interrelationship of parts by which changes in one are reflected in changes in all the others. Not only are the parts themselves smaller wholes in which elements combine, but the total organism is an organization of organizations. At every point the characteristics of the whole determine the characteristics of the parts as the parts in turn contribute to the development of the whole. It is this whole and the relationships of parts thereto which determines the course of development. This fact is at one and the same time a disadvantage and an advantage in our attempts to deal with an impaired organism.