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Separate and Unequal Independent Walking Standards for Blind Toddlers

Since 1841 when Perkins began accepting the first blind children into the first school for the blind, educators met the children at the door seeing a great many needs before them. Yet, not one believed that they should first find a way to make the children safer as they moved about their new school and beyond.

     Hatton, Bailey, Burchinal & Ferrell (1997) review of literature on developmental delays in blind toddlers, reported that children with mobility visual impairment or blindness (MVI/B) and their families expressed a natural fear of walking into the unseen (Brown & Bour, 1986; Jan, Robinson, Scott, & Kinnis, 1975; Sonksen, Levitt, & Kitzinger, 1984).”


Age - 19m B60MSI Walking Skill - under the picture of the -year-old boy lying on floor "0" and under the picture of the same boy walking independently wearing a belt cane the letter "c".

     This fear has typically been expressed as an obstacle to blind toddlers walking well. One that many educators felt could be overcome if parents did not let their fear cause them to ‘restrict their blind child’s movements for safety reasons’ (Hatton, et.al., 1997).

     Despite the many obvious downsides of toddlers with MVI/B being encouraged to walk without a two-step safety buffer, current opinion believes blind toddlers’ must demonstrate the ability to walk independently without a cane, before they can be taught to use a cane.

     If you say that sentence out loud three times fast perhaps you might hear how absurd it sounds. Blind people are unsafe when they walk without a white cane. In every construction yard grown men post the sign ‘safety first’ and wear proper safety equipment. How can it be safety first for everybody but blind babies?


THE ONSET OF WALKING


In sighted infants, the ‘onset of walking’ is an epigenetic event. Epigenetic means it is not the emergence of the skill “can walk” that is of great importance, it is the world of opportunities now available to the ambulatory child.  Epigenetic event means, children are using their ability to independently walk to engage in activities that build their related systems like language and social skills. Research has found that the later the age of onset of walking, the later the epigenetic effect of walking (He, Walle, & Campos, 2015).

Onset of walking means toddlers have taken their first few steps and now seem to never stop walking. Six months after the first steps, the toddler gait has narrowed, they take longer steps, and they demonstrate adult-like stability and coordination (Vieira, Carvalho, Barela, & Barela, 2019). Overtime, children walk better because they engage in recommended daily physical activity through both spontaneous and organized activities (Adolph et al., 2012; Vieira, et al., 2019).



Blind Toddlers Can Walk. For children born with mobility visual impairment or blindness (MVI/B), the onset of walking does not appear to result in an epigenetic event. Children with MVI/B have been shown to remain at the “can walk independently” description for many years (Ambrose-Zaken, 2022, 2023). Six months after toddlers with MVI/B take their first steps, their subsequent walking experience does not result in the maturing walking abilities described above. Instead, the amount of solo walking logged in children born with MVI/B appears to remain stagnant during the first three to five years of life (Ambrose-Zaken, 2022, 2023).

The Blind Standard of Walking

The Birth to 6 Orientation and Mobility Skills Inventory (B6OMSI) is the only orientation and mobility (O&M) instrument for the assessment of toddlers with MVI/B that has had its validity examined through research. Baguhn (2021) reported an agreement score above 90% on her Delphi Study of the B6OMSI.

An expert panel in the field of blindness and visual impairment reviewed the inventory items and affirmed that computation of a student’s B6OMSI test score would result in a meaningful snapshot of that student’s functioning.

The clinician using the B6OMSI is instructed to rate how much verbal and physical prompting an adult provides the child to achieve the six Walking Skills (a-f) independently. Providing a physical prompt would be like touching the child’s back with a gentle nudge to get the child started. A child who needs physical support like holding a hand would be scored as demonstrating the first B6OMSI Walking Skills sub-skill “(a) takes steps with support (one or two hands held)”. To score “b. Takes 5 Independent steps”, the child must walk those steps unaided, except for verbal and physical prompting.



Table 1 provides the B6OMSI Motor Skill Items and Rating Scale Items. The final sub-skill in each numbered Motor Skill category is highlighted in yellow. In Walking Skills, the final sub-skill is “f. Able to walk with a cane or other object”. Walking Skills item “f.” is the only mention of a cane in that section or in any of the Motor Skill items or Rating Scale items.

In other words, the expert panel consisting of O&M professionals, early intervention teachers and professors all agreed that testing toddlers with visual impairment’s ability to walk independently without a two-step safety buffer is an important test of current functioning, regardless of the severity of the child’s visual impairment.

Yet, given that sighted children are made safe with adequate lighting when their walking abilities are tested so that they can see the surface on which they will take their next step, I question why toddlers with MVI/B are asked to step onto unchecked, unseen surfaces, with no direct white cane tactile protection?

Separate and Unequal Walking Standards for Blind Babies

Six Months not Six Years for Walking Skill Development. The most glaring difference in the walking standards for sighted toddlers and blind toddlers is the expected amount of time to achieve independent mobility. The six-year age range given for blind children’s achievement of the walking skills listed in the B6OMSI is well beyond the 6-months timetable anticipated for sighted toddlers (see Table 1). Most would agree that if a child took his first steps at 12 months and is no further along in walking skills at 18 months, he needs medical or therapeutic intervention.


Why are infants with MVI/B given six years to achieve the motor skills listed in the B6OMSI?  
     Could it be because the B6OMSI standard is extremely difficulty to achieve? The B6OMSI gives infants with MVI/B six years to learn how to walk into any environment without a 2-step safety buffer.

Blind toddlers with the developmental potential to walk should be measured using the same walking skill measurements (e.g., gait, pace, posture, activity time, and number of falls) as sighted toddlers. All blind toddlers should be tested under the same safety conditions as sighted toddlers.

They don’t turn the lights off when sighted toddlers’ walking skills are measured. They shouldn’t ask blind toddlers to walk without a 2-step safety buffer.

Why are the safety standards for independent walking separate and unequal?

Instead of trying to reduce fear and improve children with MVI/B’s safety to ensure their onset of walking is an epigenetic event, the field of blindness has created separate and unequal walking scales for blind babies as they continue to insist they are better off walking into the unseen, just as it has always been.

These field-created assessments are rooted in over a century of evidence from highly qualified practitioners that have seen year after year, decade after decade the undisputed facts. Everyone knows that toddlers with MVI/B:

1.       Cannot walk well by 18 months.

2.       Do not walk as much as they need to for learning, at age 3 years.



And we have always known toddlers with MVI/B are …

  • Delayed in motor milestones and have qualitative differences in locomotion documented by numerous researchers (Brown & Bour, 1986; Ferrell et al, 1990; Fraiberg, 1977; Hatton, Bailey, Burchinal & Ferrell, 1997; Norris, Spaulding, & Brodie, 1957; Traster & Brambring, 1993).

  • Less active than sighted children documented by numerous researchers (Bigelow, 1992; Fraiberg, 1977; Preisler, 1991, 1993; Traster & Brambring, 1993),

    • Due to fear of movement and parental fear of harm documented by numerous researchers (Brown & Bour, 1986; Jan, Robinson, Scott, & Kinnis, 1975; Sonksen, Levitt, & Kitzinger, 1984).”


So, we all agree, the worse a child’s visual impairment, the worse their onset of walking outcomes.

Yet, Howe (1841), Fraiberg, (1977), Ferrell (1990), Bigelow (1992, 1993), Hatton, et. al., (1997) Rogers & Puchalski (1988); Troster & Brambring (1993) and everyone before and since have concluded the reason blind toddlers do not achieve their recommended daily physical activity is they can’t see so they have no external motivation to move.

    Hatton et al., (1997) concluded that children with MVI/B “inability to imitate motor actions” (i.e., see), …probably accounted for” why the children with MVI/B got older and continued to fall behind their sighted peers in development or as they wrote, “the increased divergence of the trajectories of children with visual function of 20/800 or worse over time” (p. 802).


THIS IS WHERE THE SEPARATE AND UNEQUAL WALKING STANDARDS BEGAN.

      Hatton et al., (1997) and others proposed separate standards and assessment criteria for children with MVI/B who, because of their visual impairment, had the greatest difficulties learning to walk on time. They felt that children with MVI/B should not be held to the same standards as other children.

  •   “Future research should explore these alternative developmental pathways, … and identify strategies by which parents and professionals can promote successful adaptation, recommended by Warren (1994), rather than trying to alleviate perceived delays that result from comparisons to sighted children or to other visually impaired children (p. 803).

   

Instead of separate standards, stop asking blind toddlers to do the impossible and risk injury.           

The B6OMSI Measures how many steps children with MVI/B will take onto an unseen surface.

Except for the final milestone “f. Able to walk with a cane or other object”, the B6OMSI Walking Skill sub-skills a-e evaluate how many steps a blind child will take onto an unseen surface. A surface he cannot ever see unless provided with a white cane.

     This is a problem because these assessments are used to drive instruction (Olson, 2003, as cited in Tabb, 2024). These assessments misunderstand the absolute necessity of safety for blind toddlers to thrive. The video created in demonstration of this blog can be viewed by clicking on any of the embedded photos from the video. The video shows children aged 19 to 79months before and after they could safely walk independently.

The goal is to help parents keep their toddlers with MVI/B safe as they explore to learn. Each of the children in the video improved their ability to independently walk only after they were provided the safety of the Belt Cane.

Stop asking parents to patiently wait for their blind toddlers to start walking before they can provide their children with the safety of the white cane. Let's all get behind encouraging blind baby safety first. It's about time.

 

Table 1

The Birth to 6 Orientation and Mobility Skills Inventory Motor Skill Items and Rating Scale

5.       Standing Skills


a. Stands with support (hands held or trunk support)


b. Stands up to 30 seconds after being placed in balanced standing


c. Stands independently


d. Transitions in and out of standing

6.       Walking Skills


a. Takes steps with support (one or two hands held)


b. Takes 5 independent steps


c. Takes 10 independent steps indoors


d. Takes 10 independent steps outdoors


e. Walks independently on various surfaces indoors and outdoors


f. Able to walk with a cane or other object

7.     Hurried Walk/Running Skills


a. Takes 10 hurried steps indoors


b. Takes 10 hurried steps outdoors


c. Runs 20 feet indoors


d. Runs 20 feet outdoors


e. Runs with guide holding hands or prop/rope


f. Runs independently on various surfaces indoors and outdoors

8.     Quality of Independent Walking


a. Stride (demonstrates appropriate stride length)


b. Arm Swing (demonstrates arm swing when walking)


c. Stance (demonstrates appropriate stance phase)


d. Walks with balanced heel to toe foot strike


e. Aligns head, shoulders, hips, and feet when walking


f. Balance (demonstrates balance when walking on typical indoor surfaces)


g. Balance (demonstrates balance when walking on typical more varied outdoor surfaces)


h. Demonstrates walking speed appropriate for conditions

Note. Interviewer asks child representative to choose one of the 5 scores below.

RATING SCALE

0=Student not capable of demonstrating skill or does not need skill. (Zeros do not count against score.)

1=Student does not yet demonstrate skill but may/will need to learn skill.

2=Student only demonstrates skill with verbal and/or physical prompting.

3=Student sometimes (3 of 5 trials) demonstrates skill without verbal and/or physical prompting. 

4=Student often (4 of 5 trials) demonstrates skill without verbal and/or physical prompting.

5=Student consistently (5 of 5 trials) demonstrates skill without verbal and/or physical prompting.

 

Video transcript:

Using the B6OMSI criteria we evaluate children with mobility visual impairment or blindness before and after they are introduced to a Pediatric Belt Cane. Score of a is with support, b is takes 5 independent steps, c is 10 independent steps inside, d is 10 independent steps outside, e. is Walks independently.


Blind due to brain trauma, non-verbal at 19 months- scores a 0 on the B6, with the Belt Cane he takes 10 independent steps inside, the score of c .

Age 2, blind born, she walks with assistance or score of a, with Belt Cane she scores “e”  Walks independently on various surfaces indoors and outdoors with a Belt Cane.

Age 3, CVI,   takes 10 or more independent steps inside, the score of “c”

            Now she scores “e”  Walks independently on various surfaces indoors and outdoors with a Belt Cane.

Walking with the Belt Cane her therapists purposely put a giant garbage can in her way, the Belt Cane bumps into it and she stops and then turns to find a clear path.  Without the Belt Cane her therapist stays nearby with her hands protectively held on either side of her as she walks.

Age 6, CVI, takes 10 or more independent steps inside, the score of “c” you can see she returns to sitting after a series of steps she was verbally and physically prompted to take. With the Belt Cane at least she is safe as she walks independently in the mall with her family.


 

References

  • Adolph, K. E., Cole, W. G., Komati, M., Garciaguirre, J. S., Badaly, D., Lingeman, J. M., & Sotsky, R. B. (2012). How do you learn to walk? Thousands of steps and dozens of falls per day. Psychological Science23(11), 1387-1394. doi:10.1177/0956797612446346. 

  • Ambrose-Zaken, G. (2023). Beyond Hand’s Reach: Haptic Feedback Is Essential to Toddlers with Visual Impairments Achieving Independent Walking. Journal of Visual Impairment & Blindness117(4), 278–291. https://doi.org/10.1177/0145482X231188728

  • Ambrose-Zaken, G. (2022). A Study of Improving Independent Walking Outcomes in Children Who Are Blind or Have Low Vision Aged 5 Years and Younger. Journal of Visual Impairment & Blindness116(4), 533–545. https://doi.org/10.1177/0145482X221121824

  • Baguhn, S. (2021). Early Intervention Orientation and Mobility: A Delphi Study of the Content of the Birth to 6 Orientation and Mobility Skills Inventory (B6OMSI). Journal of Visual Impairment & Blindness115(5), 361–371. https://doi.org/10.1177/0145482X211047626

  • Biringen, Z., Emde, R. N., Campos, J. J., & Appelbaum, M. I. (1995). Affective reorganization in the infant, the mother, and the dyad: The role of upright locomotion and its timing. Child Development, 66, 499–514.

  • Hatton, D., Ivy, S., & Boyer, C. (2013). Severe visual impairments in infants and toddlers in the United States. Journal of Visual Impairment & Blindness, 107, 325–336.

  • He, M., Walle, E. A., & Campos, J. J. (2015). A Cross-National Investigation of the Relationship Between Infant Walking and Language Development. Infancy20(3), 283–305. https://doi.org/10.1111/infa.12071

  • Tabb, C. (2024). Live Binder.

  • The New Mexico School for the Blind (Accessed November 24, 2023). NMSBVI Orientation & Mobility Inventory. https://www.nmsbvi.net/235010_2

  • Vieira, A. P. B., Carvalho, R. P., Barela, A. M. F., & Barela, J. A. (2019). Infants’ Age and Walking Experience Shapes Perception-Action Coupling When Crossing Obstacles. Perceptual and Motor Skills, 126(2), 185–201. https://doi.org/10.1177/0031512518820791

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