Early Intervention Services in developing countries Lea Hyvärinen, MD, PhD, FAAP www.lea-test.fi Beijing 2010 APAO Course: Assessment for Early Intervention

Early Intervention means 2 Early Intervention means Early detection of the disorders Early treatment of treatable conditions Assessment of Functioning Early intervention starts as soon as a visual impairment is detected as an integral part of examinations and treatment, at 0-3 years of age or later, if the damage occurs later.

3 Clinical examination gives the foundation for the assessment of visual functioning orthoptists, therapists, nurses, optometrists, technicians, parents, teachers OBSERVATIONS Photo: Miguel G. Alvares, MD Brazil

4 Clinical examination gives the foundation for the assessment of visual functioning Detection grating acuity Fixation to penlight, to picture, following, saccades, accommodation, convergence, visual communication, refraction, spectacles Hiding Heidi test OKN Photo: Miguel G. Alvares, MD Brazil

5 Fixation sticks Fanz’ picture of smiling face

LEA Gratings symmetric presentation 7 LEA Gratings symmetric presentation Grating acuity is NOT convertible to visual acuity (VA), optotype acuity.

Contrast sensitivity Hiding Heidi test 8 Contrast sensitivity Hiding Heidi test

Coherent Motion – ’Pepi’ figure in motion 10 Coherent Motion – ’Pepi’ figure in motion www.lea-test.fi MOTION PERCEPTION

Vision loss affects development of following areas of functioning: 11 Vision loss affects development of following areas of functioning: - communication - interaction - motor development - spatial concepts - orientation in space - object permanence - language Since vision is important in the development of these central functions, it is mandatory to assess visual functions often and carefully to answer the question ’How much vision there is for the development of each these functions?’. We watch the development of these functions. – Is the use of vision normal?

12 Eye contact – starting communication on day 1

13 Day 1

Visual communication >> bonding 14 12 weeks Visual communication >> bonding

What if visual communication is not possible? 15 What if visual communication is not possible? Corneal cloudiness and shallow anterior chambers at birth.

After corneal transplant 16 After corneal transplant - born blind - clear cornea from 5th to 15 weeks of age - awareness of vision - early intervention - baby reached normal motor milestones

At 2 years - born blind - clear cornea from 5th to 15 weeks of age 17 At 2 years - born blind - clear cornea from 5th to 15 weeks of age - early intervention - healthy child Normal motor development

Impaired vision affects 18 Impaired vision affects development of following areas of functioning: - communication - interaction - motor development - spatial concepts - orientation in space - object permanence - language Since vision is important in the development of these central functions, it is mandatory to assess visual functions often and carefully to answer the question ’How much vision there is for the development of each these functions?’.

Communication – at 8 weeks 19 Communication – at 8 weeks

Infants at great risk Eye contact, eye movements, expressions 21 Infants at great risk Whenever there is a deviation from normal interaction / communication infant’s visual and auditory functions need to be carefully assessed. Eye contact, eye movements, expressions Train health care nurses, therapists, paediatricians

Infant groups at risk - small prematurely born infants 22 Infant groups at risk - small prematurely born infants - intellectual disability - hearing impairment - motor problems, hypotonia - twins - certain syndromes, Down - after accidents, infections Start early intervention even when no eye disease is present, train vision. Baby Tadoma

PVL Delayed motor functions 23 PVL Delayed motor functions Combined effect of visual and motor disorder delays the development of an infant in all functional areas.

Constricted visual field 24 Constricted visual field Large illuminated ball used by child’s own therapist.

Accommodation difficult to measure when the infant does not look at 26 Accommodation difficult to measure when the infant does not look at Mother’s face and voice used as the target.

Eye contact when reading lenses give a clear image on the retina 27 Eye contact when reading lenses give a clear image on the retina

Visually active ten weeks later: improved visual and motor functions 29 Visually active ten weeks later: improved visual and motor functions RE: GrA less than in LE > training as a part of physiotherapy

30 Accommodation This infant had had infantile spasm and had been totally inactive for several weeks because of the medication and abnormal brain function. She looked through the adult person without any accommodation. Again, when the image was made clear with reading lenses, the infant looked at the adult person with good eye contact for the first time in her life.

Compensating accommodation 31 Compensating accommodation

34 Vision loss affects development of following areas of functioning: - communication - interaction - motor development - spatial concepts - orientation in space - object permanence - language Since vision is important in the development of these central functions, it is mandatory to assess visual functions often and carefully to answer the question ’How much vision there is for the development of each these functions?’.

Head control Holding the infant on the shoulder across the thigh 35 Head control Holding the infant on the shoulder across the thigh on small wedge Vertical lightbox

Playmat for learning orientation in space 36 Playmat for learning orientation in space Light coloured surfaces rough, dark surfaces smooth > vision and touch coincide: where there is a colour edge, there is also a tactile edge. The two senses do not compete but activate the brain functions that fuse together visual and tactile information.

37 Structured play situation Finnish version (needs to be modified for other countries)

I moved! I moved again, the same thing happened! 39 I moved! I moved again, the same thing happened! Start stimulation without delay, coordination of vision and movement.

Siblings and grandparents training 40 Siblings and grandparents training Parents need the support from their family, extended family, neighbours and other families with children who have developmental problems (peer support).

”Little room” made of a brown paper box 41 ”Little room” made of a brown paper box Vision, touch, echoes, measuring space with his own body, these experiences support development of awareness of space, orientation in this little space and awareness that objects that the infant lets go do not disappear (= object permanence).

43 Flickering light catches attention, easy to combine with eye-hand coordination

44 Vision is a learned function.

start early intervention early! 45 Because vision is a learned function start early intervention early!

53 Vision care Early detection of problems Assessment of functioning Early intervention as an integral part of examinations and treatment.

Look for impaired vision among disabled children. 54 Vision Impairment 60-75 % of VI infants have multiple disabilities - intellectual disability, Down Syndrome - motor impairment, CP - hearing impairment - chronic illness - 20% of VI children have ”CVI”, problems in processing visual information in brain functions Look for impaired vision among disabled children.

Early Intervention Services in developing countries 55 Early Intervention Services in developing countries Lea Hyvärinen, MD, PhD, FAAP www.lea-test.fi Beijing 2010 APAO Course: Assessment for Early Intervention