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Understanding the emotional needs of children who are blind.

The emotional development of young children who are blind may be at risk because of constraints on the children's capacity to share and respond to the feelings of others. In typical development, eye contact and voice contact are integral to first relationships (Trevarthen & Aitken, 2001). When children cannot see, they are dependent on familiar voices and experiences in interaction to understand themselves in relation to others (Loots, Devise, & Sermijn, 2003). Although the lack of vision may influence other aspects of their development (Ophir-Cohen, Ashkenazy, Cohen, & Tirosh, 2005), it is the lack of early social experience that may lead to long-term difficulties in social understanding (Brown, Hobson, Lee, & Stevenson, 1997). These findings in the literature highlight the challenges for caregivers to interact in ways that enable children who are blind to understand more about themselves and others (Preisler, 1997; Recchia, 1997).

Studies of interaction between caregivers and young children with little or no vision have shown that parental style can meet these challenges by being adaptive to the children's needs for detailed descriptions (Perez-Pereira & Conti-Ramsden, 2001) without being overly directive (Campbell, 2003). These studies and that of Kekelis and Prinz (1996) have considered issues of maternal style and child outcomes, rather than the emotional availability of parents and children to each other. Further study is needed to understand more about how parents respond to the emotional needs of children.

Emotional availability (Biringen, 2000) is a construct that can be used to describe the quality of parent-child interaction. The Emotional Availability Scales (EAS; Biringen, Robinson, & Emde, 2000) were used in a study of children who are deaf or hard of hearing (Pressman, Pipp-Siegel, Yoshinago, & Deas, 1999), but there has been no similar study involving children who are blind. The purpose of the study reported here was to explore the quality of interaction in two mother-child dyads in a play context. In addition, the frequency of mothers' references to themselves and others was investigated to determine how often such information was provided.

METHOD

Two case studies are presented to explore the ways in which blindness affects mother-child interaction, particularly the emotional availability of mothers and their children to each other. The two cases were selected because of their contrasting interaction styles. The university ethics committee approved the study with written parental consent.

Participants

The participants were referred by an agency for visual impairment services that provided early intervention support (biweekly home visits from an occupational therapist). Both mothers were professionally trained nurses. Both children, given the pseudonyms Matt and Amy for this report, had been diagnosed with retinopathy of prematurity (ROP) and had no light perception. In spite of the difficulties associated with prematurity (Hatton, Bailey, Burchinal, & Ferrell, 1997), both children were developing within the expected range, and, at age 19 months, both were reported to be using a few single words.

Procedures

Interaction between the mothers and their children involving play with favorite toys was recorded at each family's home. Prior visits by the investigator ensured that each session that was recorded was a familiar process for the mothers and children. The 20-minute videotaped episode was then transcribed and analyzed using the following assessments.

* Frequency of maternal input, calculated using a computerized system (MacWhinney, 2000).

* Frequency of personal references, as a percentage of maternal input, using the categories described next.

* Emotional availability, evaluated using EAS (Biringen et al., 2000).

Although the frequency of maternal input is important in itself for language development in children (Hart & Risley 1999), it also provides a basis for calculating the relative frequency of particular features, such as personal references. Coding of maternal input for such references was developed as four subcategories of reference to the child (Category 1) and four categories of maternal reference to self and others (Category 2). The reliability of coding was established with the investigator and an independent coder sampling 50% of the transcript pages, reaching an agreement of .86 using Cohen's kappa (Bakeman & Gottman, 1997). Examples of the subcategories were as follows.

Category 1. The four subcategories of Category 1 were naming or describing the child's physical features (such as, "That's your pretty hair"); describing the child's general appearance (for instance, "Oh, pretty Matt!"); describing internal states and feelings (for example, "You woke up in such a lovely mood"); and inferring the child's wants, needs, or intentions (such as, "Want to give her a hug?").

Category 2. The four subcategories of Category 2 were naming or describing physical features (for example, "Find Mommy's nose"); describing one's general appearance (such as, "Oh, pretty Teddy"); describing internal states and feelings (like "I thought I was very good"); and inferring wants, needs or intentions (for instance, "He wants a kiss").

EAS was chosen because they evaluate the interactive qualities of both adults and children. The scales are not a quantitative measure of discrete behaviors, but require trained observers using clinical judgments and contextual cues (see Biringen, 2000, for validation of EAS as a research tool and procedures for training observers).

The scales consist of four parental dimensions and two child dimensions. The descriptors for each dimension include a range of responsive behaviors that include, but do not depend on, the child being able to see. The four parental dimensions were as follows:

1. Sensitivity: the parent's ability to read and respond appropriately to the child's cues, to maintain a positive affect, to be sensitive to timing and transition, to be flexible and creative in play, and to resolve conflict or misunderstanding.

2. Structuring: the parent's ability to structure the child's play appropriately, follow the child' s lead, set rules, and show parental bids or suggestions that successfully guide the child's involvement in an unforced way.

3. Nonintrusiveness: the parent's ability to be available to the child without being too directive, stimulating, or protective.

4. Hostility: the parent being overtly hostile, threatening, harsh, or frightening or showing covert signs of boredom and impatience.

The two child dimensions were these:

1. Child's responsiveness: the child's willingness to engage with the parent, following a bid or suggestion, and the affective quality of the response.

2. Child's involvement: the child engaging the parent in play, balanced with autonomy.

Agreement between the investigator and an independent rater for EAS was .89 (Pearson's r).

CASE DESCRIPTIONS

The following case descriptions highlight the characteristics of emotional availability and maternal use of personal references. They were identified through an analysis of the recorded play episode. The results of the assessments are discussed in relation to each case.

Case 1: Matt and his mother

Frequency of maternal input and personal references. Matt's mother made occasional comments about Matt and what he was doing. Of the 74 maternal utterances in the 20-minute play session, 14.86% referred to Matt's features, states, or intentions; 9.45% referred to those qualities in others (in this instance, a doll); and 1.35% referred to herself. Much of what the mother said was to encourage play, (such as, "You make it go"), but with few labels or descriptions of any attributes.

Sensitivity. In this interaction, Matt's mother was rated as generally sensitive, meaning that she was able to read and respond appropriately to Matt's cues. She was warm and responsive to Matt's initiatives most of the time and responsive to his emotional cues, such as crying at his father's departure ("You're upset because you want to be out there") and excitement when playing with a doll ("What's Dolly doing?").

Parental structuring. Much of this interaction showed inconsistent structuring; that is, apparently following Matt' s lead, but not matching comments to what Matt was actually doing and saying. For example, when Matt was exploring the doll's hands, his mother's comments were about babies crying. Rather than scaffold through turn taking, she waited for Matt to do something to which she could respond.

Parental nonintrusiveness. Matt's mother was nonintrusive. She occasionally used distraction or suggested that Matt play with another toy. Parental hostility. Matt's mother showed no signs of either overt or covert hostility, re maining warm and gentle throughout the interaction.

Child's responsiveness. Matt' s mother invited Matt to come to her when he pulled himself to stand. She touched his free hand to signal that she was close by, but after eight requests, he stayed turned away from her. When playing with the doll, he made few responses to his mother's comments.

Child's involvement. Matt reached out to the sound of the door closing and clapped his hands, perhaps to emphasize his feelings of frustration. In this way, he successfully involved his mother. While early words can be used to involve parents, Matt's three identifiable words in this interaction (doggie, good, and jump) seemed confined to his own actions.

Case 2: Amy and her mother

Amy's mother provided a running commentary as she played with her daughter. With 258 utterances in the 20-minute observation, this was more than three times the frequency provided for Matt. She made more references to Amy's features, states, and intentions (22.09%) and more references to herself (6.58%) than Matt's mother did with Matt. Unlike the relaxed watching and waiting that was observed in the interactions between Matt and his mother, this play period was informative and busy. In the following example, the mother followed Amy's lead and linked herself and others through shared references to personal features.

Amy: (Touches her hair.)

Mother: Yeah, that's your pretty hair.

Mother: Where's my pretty hair?

Mother: (Shaking her hair over Amy's hands.) Where's Mommy's pretty hair?

Mother: Where's Mommy's pretty hair? She hasn't got any (laughs).

Mother: That's Amy's pretty hair, isn't it, huh? (Touches Amy's hair.)

Mother: That' s Amy' s.

Sensitivity. Amy's mother was generally sensitive to Amy's cues, as in the example just presented, and looked for different ways to engage Amy in play. However, she became impatient when Amy persisted in rubbing her eyes and smacked her hand before she successfully used distraction: "Let's go for a walk. I'll hold both your hands; that way you can't rub your eyes."

Parental structuring. Amy's mother was able to structure play successfully. In a lengthy sequence of finding toys in a bucket, she praised Amy with each new find and named and described the toy. When Amy began to tire, her mother hugged and kissed her for being clever and introduced something new.

Parental nonintrusiveness. The play session was intensive and seemed somewhat intrusive, with sudden changes of activity, sometimes missing Amy's latent response.

Parental hostility. Apart from the hand smack, the mother showed some signs of frustration when Amy was slow to respond.

Child's responsiveness. Amy smiled from time to time and responded to her mother's bids by shaking her head, vocalizing, and clapping her hands. She searched for toys in a bucket and maintained the reciprocal sequence of finding something for her mother to talk about.

Child's involvement. Amy had limited strategies for taking initiatives that would involve her mother. Twice she reached out and held her mother' s hair, but most of her actions and vocalizations were responses to her mother's initiatives.

DISCUSSION

These case descriptions exemplify differences in parental responses to children's blindness. Amy's mother adapted to Amy's blindness by providing a great deal of verbal information and structured play, while Matt's mother provided warmth and encouragement, but comparatively few words and little information that would meet Matt's need to understand more about others. Both mothers made themselves emotionally available in the interaction, but with Amy's mother, this availability came through active involvement with Amy, and with Matt's mother, it came through acceptance of Matt' s initiatives. The contrast in interactive styles supports suggestions in the literature that parents of children who are blind may find alternative strategies to meet their children' s needs (Perez-Pereira & Conti-Ramsden, 2001).

While more in-depth study is needed to identify positive ways of adapting to children's needs to understand themselves and others, the two cases demonstrate how the construct of emotional availability can be used to describe the quality of relationships in interaction. EAS provides a way of evaluating these qualities, complementing other types of assessment. There are limitations to what may be inferred from two case studies; however, the use of a case study methodology can suggest directions for further research and a focus for early intervention.

IMPLICATIONS AND RECOMMENDATIONS

Parent-child interaction is an appropriate context for intervention because of the potential for influencing both its affective and structural qualities (Kelly & Barnard, 2003; McCollum & Hemmeter, 1997). Intervention that is based on such qualities would need to take into account the challenges of interacting with young children who do not perceive visual cues to the feelings and intentions of others and need to be told about what they cannot see. Goals that are based on the emotional needs of children and are implemented to support parental adaptation and responsiveness will provide a sound basis for relationships.

REFERENCES

Bakeman, R., & Gottman, J. M. (1997). Observing interaction: An introduction to sequential analysis (2nd ed.). New York: Cambridge University Press.

Biringen, Z. (2000). Emotional availability: Conceptualization and research findings. American Journal of Orthopsychiatry, 70, 104-114.

Biringen, Z., Robinson, J. L., & Emde, R. N. (2000). Appendix B: The emotional availability scales (3rd ed.; an abridged infancy/ early childhood version). Attachment and Human Development, 2, 256-270.

Brown, R., Hobson, P., Lee, A., & Stevenson, J. (1997). Are there "autistic-like" features in congenitally blind children? Journal of Child Psychology and Psychiatry, 38, 693-703.

Campbell, J. (2003). Maternal directives to children who are blind. Journal of Visual Impairment & Blindness, 97, 353-363.

Hart, B., & Risley, T. R. (1999). The social world of children learning to talk. Baltimore, MD: Paul H. Brookes.

Hatton, D. D., Bailey, D. B., Burchinal, M., & Ferrell, K. A. (1997). Developmental growth curves of preschool children with vision impairment. Child Development, 68, 788-806.

Kekelis, L. S., & Prinz, P. M. (1996). Blind and sighted children with their mothers: The development of discourse skills. Journal of Visual Impairment & Blindness, 90, 423-436.

Kelly, J. F., & Barnard, K. E. (2000). Assessment of parent-child interaction. In J. P. Shonkoff & S. M. Meisels (Eds.), Handbook of early intervention (2nd ed., pp. 258-289). New York: Cambridge University Press.

Loots, G., Devise, I., & Sermijn, J. (2003). The interaction between mothers and their visually impaired infants: An intersubjective developmental perspective. Journal of Visual Impairment & Blindness, 97, 403-417.

MacWhinney, B. (2000). The Childes Project: Tools for analyzing talk. Hillsdale, NJ: Lawrence Erlbaum.

McCollum, J. A., & Hemmeter, M. L. (1997). Parent-child interaction intervention when children have disabilities. In M. J. Gu ralnick (Ed.), The effectiveness of early intervention (pp. 549-576). Baltimore, MD: Paul H. Brookes.

Ophir-Cohen, M., Ashkenazy, E., Cohen, A., & Tirosh, E. (2005). Emotional status and development in children who are visually impaired. Journal of Visual Impairment & Blindness, 99, 478-485.

Perez-Pereira, M., & Conti-Ramsden, G. (2001). The use of directives in verbal interactions between blind children and their mothers. Journal of Visual Impairment & Blindness, 95, 133-149.

Preisler, G. (1997). Social and emotional development of blind children: A longitudinal study. In V. Lewis & G. M. Collis (Eds.), Blindness and psychological development in young children (pp. 69-85). Leicester, England: BPS Books.

Pressman, L. J., Pipp-Siegel, S., Yoshinago, C., & Deas, A. (1999). Maternal sensitivity predicts language gain in preschool children who are deaf and hard of heating. Journal of Deaf Studies and Deaf Education, 4, 294-304.

Recchia, S. L. (1997). Establishing intersubjective experience: Developmental challenges for young children with congenital blindness and autism and their caregivers. In V. Lewis & G. M. Collis (Eds.), Blindness and psychological development in young children (pp. 116-136). Leicester, England: BPS Books.

Trevarthen, C., & Aitken, K. J. (2001). Infant intersubjectivity: Research, theory, and clinical applications. Journal of Child Psychology and Psychiatry, 42, 3-48.

Julie Campbell, Ed.D., research associate, School of Education, University of Western Sydney, Locked bag 1797, Penrith South DC, NSW 1797, Australia; e-mail: <ccbooks@optusnet.com.au>.
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Title Annotation:Research Report
Author:Campbell, Julie
Publication:Journal of Visual Impairment & Blindness
Article Type:Report
Geographic Code:1USA
Date:Jun 1, 2007
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