consist of a smooth and generally solid colored board to which cutout plastic parts adhere. These parts can be attached to the board over and over again without glue or paste. The subject matter ranges from simple geometric forms to a complete circus. One of the most valuable is a sophisticated plastic manikin to "dress" by affixing parts of clothing to the doll. The youngster actually designs the costume from various parts of soft plastic clothing. Through this type of game the child learns hand-eye coordination, figure-ground relationships, contour, and the ability to manipulate parts into wholes perceptually.

ROTATIONS CAN BECOME A DELIGHT

The mental defective may experience great difficulty in performing such a simple task as monocular rotations. When the attention span and frustration tolerance is low, as it is in most of these youngsters, and when the hyperactivity and distractability color the performance, the optometrist's ingenuity might well bridge the gap between failure and success.

Simple monocular rotations can become a delight instead of a chore if the rotating disk has a picture of a treasure chest or a ship as the fixation target. The occluder can be a black patch tied over the child's eye transforming him into a one-eyed pirate. The illusion can become complete by putting a black pirate's hat with skull and crossbones on the youngster's head and placing in his hand a cardboard or rubber sword with which he is asked to follow the fixation target.

The retardate, much more than the normal child, needs affection and security. Praise his performance during training. A detachable toy as a fixation target will make a much appreciated reward after the training session, enhancing the child's sense of achievement. While the child is learning ocular motility skills, he should be made gradually aware of his surroundings and not become completely attuned to the fixation target. Ideally, the child who is being trained to perform smooth and skillful ocular movements should also be made conscious of the room and its contents in the background as the training progresses. While he is concentrating on the task at hand, he should also be cognizant of his surroundings. This should be done as a secondary perceptual act, but once the child has begun to move in training, he should never be allowed to become so fixed on the target that he is oblivious of the perceptual world around him.

PATIENCE AND UNDERSTANDING

In many cases an intensification of the near point stimulus tends to compensate for some of the hyperactivity and frequently increases the span of attention. The optometrist must remember, however, that these children are not being trained to become an island within themselves, but that one of the goals in vision training is to teach them to cope with their own immediate environment and having met that challenge, to then meet the challenge of many different environmental conditions.

The mentally retarded child may attempt to compensate for his difficulty by trying to control his environment through temper tantrums and other antisocial behavior, or by the other extreme expedient, becoming completely withdrawn. A measure of the optometrist's skill is the effectiveness with which he controls the child's attempts to manipulate the environment. In general, the retardate shows patterns of social adjustment characteristic of that of a much younger child. Patience and understanding during the training program is of the utmost importance. The mentally inadequate child's thought processes function at a slower rate than those of the normal child. It is as though the patient were being observed functioning in slow motion. The optometrist should make every effort to control himself and at least outwardly manifest no impatience as he waits for the mentally retarded child to perform a seemingly simple task.

These children need affection, security, social recognition, a sense of achievement, and participation in new experiences. There is probably nothing so destructive to the defective child than to be assigned tasks which are beyond his power of comprehension. Vision training should be begun on a level considerably lower than the level at which the child functions and if at all possible, training devices used early in the program should consist of materials familiar to the child. The vision-training program outlined for the child must be planned in

terms of the individual capacities of the child as a whole. The cerebral palsied retardate cannot be expected to begin training on the balance board, nor can the autistic intellectually disadvantaged child be expected to verbalize freely during training.

No vision-training technique, no matter how elaborately or brilliantly conceived, can be expected to raise the IQ of a defective child. However, the elimination or diminution of the visual perceptual problem will allow the child to function more efficiently and make better and more economical use of his capabilities.

REFERENCES

1. Murphy, Lois Barclay. "Personality in Young Children." New York City; Basic Books, Inc., 1956.

2. Burton, Arthur and Harris, Robert E. "Clinical Studies of Personality." Vol. 2, New York City: Harper & Bros., 1955.

3. Fouracre, M. H. "Learning characteristics of brain-injured children." "Exceptional Children," 120, January 1958.

4. Noyes, Arthur P. and Kulb, Lawrence C. "Modern Clinical Psychiatry." Fifth edition, Philadelphia and London: W. B. Saunders Co., 1958.

5. Solley, Charles M. and Murphy, Gardner. "Development of the Perceptual World." New York City: Basic Books, Inc., 1960.

6. Strauss, Alfred A. and Kephart, Newell C. "Psychopathology and Education of the Brain Injured Child." Vol. 2, New York and London: Grune & Stratton, 1955.

7. Gibson, James J.

erside Press, 1950.

"The Perception of the Visual World." Boston: The Riv

8. Kephart, Newell C. "Visual behavior of the retarded child." Am. J. Optom. & Arch. Am. Acad. Optom., 35 (3): 125–133, 1958.

9. Alexander, Theron. "Mental subnormality: illusions and directions." ternational Record of Med., 172 (2): 80-86, 1959.

In

10. Kugelmass, I. N. "Symposium on the mechanism and management of mental deficiency in infants and children." International Record of Med., 172 (2, 3, 4) 1959.

VISION CARE OF THE MENTALLY RETARDED CHILD: A PRELIMINARY REPORT

(Harold N. Friedman, O.D.1)

Visual analysis of a mentally retarded child should be an integrated factor in determining the evaluation and treatment of such a child. The youngster's environment might be blurred, distorted, or even suppresed in some parts of the visual field. This could so handicap the child as to prevent his response to all or part of the mental tasks given to him. In select cases, a program of vision training might greatly benefit in orientating the child to a more normal environment.

What battery of tests can be used to diagnose visual problems of mentally retarded children? Most of the usual diagnostic tests in the refractive sequence are useless. They are, in a practical sense, impossible to use. Mentally retarded children do not have the patience and, in most cases, the intelligence to respond properly to the tests. Second, at their mental level, the usual diagnostic tests would not disclose what we want to know.

What exactly do we want to know? We want an accurate determination of the child's visual acuity at near and distance as is possible to obtain. We want to know the child's general refractive error: is he myopic, hyperopic, astigmatic, anisometropic, and to what extent? We want to know as much as we possibly can about the child's ocular motility, binocular coordination, and body-hand-eye coordination. If we can determine these data and can rely on their accuracy, we can then combine our findings with those determined by the practitioners in medicine and psychology to work out a program to aid the mentally retarded child better adapt to his environment.

1 Consultant optometrist, the Clinic for Mentally Retarded Children, Flower Fifth Avenue Hospital, New York, N.Y.

BATTERY OF DIAGNOSTIC VISUAL TESTS

Our experience at the Clinic for Mentally Retarded Children have led to the adoption of several tests that are working successfully in measuring visual abilities and inabilities of mentally retarded children.

To measure visual acuity, regular and reduced Snellen picture charts are used. When examining mentally retarded children, we forget about recording results with the usual Snellen fraction. The children do not hold still long enough. With practice and keen observation, however, we get a very good determination of acuity.

Monocular acuity is very difficult to obtain because the children will not generally tolerate eye patches for any length of time. However, by playing such games as "pirate" we often succeed in getting a good determination of monocular acuity. Notations for acuity are either "adequate" or "nonadequate" for near and far. It may take from 15 to 20 minutes to come to a conclusion.

To obtain an accurate impression of the refractive error of a mentally retarded child is no small accomplishment. The task is greatly simplified with the use of a television set as a fixation target. We are not so much interested whether the child is a -1.50 or a -2.00 diopter myope; we are interested whether the child is a myopic or a hyperopic; isometropic or an anisometropic, or if there is with-the-rule or against-the-rule astigmatism. And this differentiation can be made with a retinoscope, a trial set, and a TV set.

In order to get a picture of the mentally retarded child's ocular motility, binocular coordination, and body-hand-eye coordination, many diagnostic procedures are used. Because of the erratic behavior of the mentally retarded child, examiners train themselves to catch every response.

To begin, the child's eyes are observed carefully during the "get acquainted" stage of the examination. This observation and a simple cover test will reveal obvious ocular deviations. A cover test is possible on every child.

A 15-diopter prism is next placed base down in front of one eye. The child is asked how many of a simple object he sees both near and far. This test assumes the child has a mental age capable of distinguishing 1 from 2. Where this assumption is valid, we can diagnose suppressions.

A penlight is used as a fixation target and the child is asked to fixate nine positions in the visual field. The light is then moved horizontally and vertically across the field and the child is requested to follow it. These procedures are first allowed with no restrictions of head movements; then an attempt is made to restrict head movements. Most mentally retarded children react unfavorably when head movements are restricted and it often takes considerable time to get accurate impressions of eye pursuit movement ability. Upon completion of the aforementioned procedures we have a judgment of eye fixation and pursuit responses and of limitations of extraocular excursions.

STICK AND RING TEST

After adequate demonstrations, the child is asked to hold a thin stick and put it through a ring held by the examiner. This tests the ability of the child to perceive the correct spatial location of the ring, and the ability to coordinate visual feedback with arm and hand placement. Recorded information includes: (1) which hand reaches for the stick; (2) would an attempt be made to pierce the ring when it was held by the examiner, or is the attempt made only when the child holds both the ring and the stick, or is any attempt made at all; (3) is any attempt successful; and (4) what are the relative positions of the two eyes during the test.

Attempts made only when the child was holding the ring and the stick indicate the need for tactile reenforcement to solve any complicated visual task. In the instances where unsuccessful attempts were made, eyes, as observed, did not fixate on the task indicating an inability to coordinate eyes with hands.

DETERMINING VISUAL AGE

The preceding battery of tests were attempted on 30 children. With every child we obtained an accurate determination of "visual age." By "visual age" is meant the stage of development of the whole visual process of perception.

The examination gives the following information: at what stage of development is the child's voluntary fixation and pursuit movements? Are there total or partial suppressions in the child's visual field? Is there a paresis of any of the extraocular muscles? Is the child's uncorrected refractive error hindering the natural development of vision and total learning ability?

Once we have this information we can try to go further. The first step would be, of course, to correct any adverse refractive error and note the effect on the mental and visual age of the child.

If the visual age of mentally retarded children is lower on the developmental scale than the child's mental age, we may have room to improve both. Obvicusly, a child with subnormal pursuit and fixation eye movements will find it extremely difficult to read. A child who cannot visually localize in space will have difficuty with locomotion. An attempt can be made by visual training to raise the visual age to the child's mental capabilities, usually far below the child's chronological age. As with the diagnostic procedures, different and unique visual training methods must be used with mentally retarded children.

If a visual training attempt is successful, we generally find an increase in the child's mental age with the child becoming better orientated to his environment. This may just be the help the mentally retarded child needs to improve his level of mental development.

THE EYE CLINIC APPROACH TO THE MENTALLY RETARDED
(Elwood H. Kolb, O.D.1)

Members of organized optometry have two community obligations to the mentally retarded: First, as professional men and women, they have an obligation to care for their visual need; second, as civic-minded individuals, they should assume an obligation to assist local units of the National Association for Retarded Children in their endeavors to better the way of life of mentally retarded children and adults.

If we are to aid in caring for the visual needs of the mentally retarded, it is necessary for us to learn where to find the patients. This should not be too difficult in view of the fact that 3 percent of the population are mentally retarded. The task, however, is made difficult by the unfortunate fact that many mentally retarded are still being hidden behind closed doors by their families. Local units of the AOA can best offer their services by contacting the nearest chapter of the National Association for Retarded Children.

Before implementing the offer of his optometric organization, the individual optometrist should familiarize himself with the general problem of mental retardation. Information on the subject can be obtained from the National Association for Retarded Children, 386 Park Avenue South, New York 16, N.Y., or from the nearest chapter; 2 or from the U.S. Department of Health, Education, and Welfare, Washington, D.C. Other articles in this issue of the Journal and an article by the author which appeared in the December 1962 issue of the Journal of the American Academy of Optometry should be of value.

The families of mentally retarded individuals want and need help, but offers of help must be above suspicion of any commercialism or paternalism.

There are but few eye practitioners who have examined any significant number of mentally retarded individuals. Until such time as our individual practitioners become more experienced in caring for these people, it is our opinion that the mentally retarded may best be handled with the following approach:

(1) Examinations should be conducted in a physical facility where other mentally retarded are present, i.e., a clinic arrangement.

(2) The clinic should be conducted by organized optometry in conjunction with a unit of the National Association for Retarded Children.

1 Member of faculty, Pennsylvania State College of Optometry; director, Eye Clinic, Lehigh County Chapter, Pennsylvania Association for Retarded Children, Inc.

2 The local chapter may be found in the telephone directory under "retarded children" or under the county designation, or it may be contacted through the United Fund or the Community Chest.

(3) A team approach utilizing members of other health professions is desirable but not essential.

(4) Clinic fees, based on the ability of the individual to pay, should be charged. Fees might be distributed to any or all of the following: The local retarded children's unit; the local optometric society; the doctors doing the examining; local service groups. It should be borne in mind that the expense of caring for a mentally retarded individual is considerable, that it is a lifetime expense and not one of limited duration as in an illness.

(5) Clinic facilities should provide for the development of visual habilitative procedures that will prove themselves of value with this type of patient.

(6) A followup procedure to determine the effect of a lens correction or an habilitative technique should be available.

(7) Care should be exercised to see that the doctor-patient relationship is never violated. Clinic authorization forms should provide the examiner with freedom to discuss the results with other professionals working in the area of mental retardation.

(8) Inasmuch as many of these patients have been examined in diagnostic clinics, it must be clearly understood by the patients that such examinations often determine the presence of ocular pathology or visual problems but that these clinics do not necessarily correct for the visual problems.

The line of reasoning followed by the Lehigh County Eye Clinic is that the relief or correction of any handicap will ease the problem of retardation at least a little bit and that the correction of more than one handicap will help even more. Families concerned with the problem of mental retardation must be made to realize this. Most parents accept advice and cooperate.

The mentally retarded can be helped. And optometry has the moral responsibility and the resources to assist.

Dr. TRAMONTI. I would also like to submit a copy of the report, 1960 White House Conference on Children and Youth, "The Importance of Vision to a Creative Life in Freedom and Dignity.”

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