«COLORADO DEPARTMENT OF EDUCATION Visual Screening Guidelines: Children Birth through Five Years Developed for the Use of Child Find Personnel Updated ...»
Visual Screening Guidelines:
Children Birth through Five Years
Developed for the Use of Child Find Personnel
Updated January 2005
Committee Chair and Editor
Tanni L. Anthony, Ph.D.,
State Consultant on Visual impairment
Colorado Department of Education
J.C. Greeley, M.A.
Anchor Center for Blind Children Susan Larson, Ph.D.
Jefferson County School District Catherine Smyth, M.Ed.
Anchor Center for Blind Children Wendy Stoltman, M.A.
Brighton School District Review Committee Jane Amundson, M.A.
Colorado Department of Education Judith F. Harrigan, R.N., MSN Colorado Department of Education Paula Hudson, Ph.D.
Colorado Department of Public Health and Environment Nan Vendegna, M.A.
Colorado Department of Department I. INTRODUCTION The Importance of Vision Screening There are four important points that support the need for early childhood vision screening.
1. Vision problems are not uncommon in young children. One out of every fifth child may have some type of vision concern.
2. Vision problems can have a major impact on the development of a young child, especially in the first years of life.
3. Early identification and intervention minimize the effects of a vision loss on a child’s development.
4. Vision screening may identify concerns that require medical attention.
Purpose of the Guidelines The purpose of these guidelines is to detail recommended early childhood vision screening practices to be used statewide by all agencies providing services to young children, birth though age five. The guidelines are for screening only; they are designed to identify children who need further testing. Children with known visual impairment (with medical documentation from an eye doctor) should be referred to a teacher certified in the area of visual impairment and should not be seen through a vision screening program.
The goal of the Vision Screening Guidelines for Children Birth through Five Years is to assist school personnel in determining a gross estimate of a young child’s visual status.
Screening instruments are not designed or intended to be a comprehensive assessment or a blueprint for educational programming. The screening process is designed to ask the
“Is there or is there not a visual problem that requires further examination?” If there is an identified concern, the next step will be to pursue information about the exact nature of the problem (Mindes, Ireton, Mardell-Czudnowski 1996).
Role of Child Find Personnel in Vision Screening The initial screening should be conducted by trained personnel, as determined at the local level, working with a parent/caregiver/teacher who is familiar with the child. For example, Child Find personnel, the school nurse or teacher certified in the area of visual impairment may provide assistance to the screening process. There are five primary roles
for the personnel who will complete the vision screening:
1. To document the child’s visual performance during the screening.
2. To determine whether the child passes or fails the vision screening.
3. To communicate the results of the screening to the family and appropriate professionals.
4. To ensure the continuation of the screening process, if needed, and make referrals (e.g. schedule a second screening, refer onto an eye care specialist).
5. To follow up on all referrals.
Colorado Laws Regarding Vision Screening Colorado law mandates that public schools have a system of vision screening in place for its students. The current Guidelines for School Vision Screening Programs (Colorado Department of Public Health and Environment, 1991) reviews guidelines for annual vision screening of public school children of preschool, kindergarten, 1st, 2nd, 3rd, 5th, 7th, and 9th grade ages. The regulation citations below review the specific role of Child Find personnel in the vision screening process.
Instructions The purpose of visual screening is to get a gross observation of how well a child is seeing. The steps of taking a family/child history, visually examining the child’s eyes, and completing specific screening tasks, may result in identifying a child that may require further evaluation. Screeners are looking for indications of visual problems, not diagnosing them.
The screening should take about 5-10 minutes to complete. If a child is obviously fatigued or stressed and cannot cooperate with the screening procedures, it will be necessary to reschedule another time to complete the vision screening.
Screening Tips ! Prior to the screening, be sure that you have gathered the correct forms and materials.
! Take a few moments to build rapport with the child. Greet and talk to the child before beginning of the screening activities.
! The order of the screening tasks does not affect outcome. Perform the least invasive and most fun tasks first.
! Make sure the child is securely and comfortably positioned throughout the screening. If the child has a motor challenge such as cerebral palsy or is very young, provide the needed head and trunk support (e.g., infant seat, special chair, parent’s lap).
! Advise the parent not to cue the child in any way during the vision screening activities, if the child is sitting in his or her parent’s lap.
! Use toys, lights, and objects that do NOT make sounds. You want the child to respond to visual stimulation only.
! Use a screening room environment that is quiet and free of unnecessary visual distractions such as people moving around the room.
! Be sure to monitor the lighting in the screening room. Light should not be overly dim or bright. Any sunlight coming in through a window should fall behind the child.
! Children who wear glasses should be screened with their glasses on unless the directions specifically indicate they should be removed.
The following information reviews the components of the vision screening process.
Information is provided about what equipment is needed, the directions for completing the vision screening task, and criteria for passing or failing the task. The forms that accompany these directions can be found in Appendix A.
Parent Interview: Child and Family History
The first component of the vision screening is to gather a history of the child. There are several risk factors for visual problems. The Child Find intake information covers many of these areas. If not, it may be necessary to ask the family about any of the following high risk situations. If this information was not collected through the intake process, a Parent Interview Form can be found in Appendix A. The following factors should be
considered by the vision screening team:
1. The child has a family history of eye crossing, color vision problems, and/or other types of congenital (at birth) visual impairments.
2. The child has a medical history that includes any of the following conditions:
! prenatal virus (e. g., rubella, toxoplasmosis, cytomegalovirus, herpes) ! prenatal exposure to drugs, alcohol, and/or environmental hazards ! prematurity and/or low birth weight ! administration of oxygen while hospitalized after birth ! cerebral palsy or hearing loss or a syndrome (e.g., Down syndrome) ! neurological problems such as a seizure disorder and/or hydrocephalus ! traumatic brain injury (e.g., Shaken baby syndrome, accidents, child abuse) ! postnatal (after birth) infection which results in a high fever (e.g. meningitis) ! ongoing medication such as an anticonvulsant In addition to the intake information that has been typically gathered, it is important to ask the following questions on the day of the interview.
! Do you have any concerns about your child’s vision? If yes, please describe your concerns.
! If your child has motor coordination problems, do you feel these difficulties are tied to poor vision (e.g., not seeing steps or slight changes in floor surfaces)? The purpose of this question is to note whether the child may have a depth perception concern that could go undetected in the vision screening.
! Has your child ever been seen by an eye doctor (optometrist or ophthalmologist?)
If glasses were prescribed, is the child wearing the glasses today? Yes No If not, what is the reason the child is not wearing his or her glasses?
Vision Screening Items Visual Inspection of the Appearance of Eyes and Eyelids
Equipment: There is no equipment needed for this item.
Instructions: Face the child at his or her eye level. Observe the child’s eyes and eyelids to note whether or not there are any obvious problems with their symmetry, alignment, and general health. If the eyes and eyelids appear to be normal, check the first box and move onto the next section. If something does not appear normal, move to the items under “Concern Areas.” □ Pass: Eyes appear symmetrical, aligned, and without evidence of problems.
Results: If there are concerns about the child’s eye(s) and/or eyelid(s), the child will fail the vision screening and should be referred for further evaluation.
Pupillary Response (present from birth):
Equipment: Use a penlight that does not make a noise when it is turned on’ Instructions: If the child wears glasses, they should be removed. Face the child at his or her eye level. Direct the penlight four to six inches from the center of the child’s forehead. Turn on the light for two to three seconds while observing the right eye for pupil constriction. Turn off the penlights and watch for pupil dilation. Wait a minute and repeat the procedure for the left eye.
Pupils should change size, getting smaller with the directed beam of a penlight and larger when the penlight is removed. Pupils should react equally to changes in light.
Note: Seizure medications, neurological problems, and other medications can inhibit this response. If abnormal responses are noted, ask the parent about medications the child is taking. Regardless, an abnormal pupillary response would warrant failure of the vision screening.
Muscle Balance (slight muscle imbalance is typically okay before 6 months of age):
Alternate Cover Test.
Equipment: occluder, penlight/monster penlight cap or small toy Instructions: Limit distractions in the room. Do not touch the child’s face with the occluder at any time during the test. The target object (e.g., penlight with monster cap, small toy) may need to be manipulated or changed to maintain a young child’s attention.
Position the child sitting in caregiver’s lap or independently in a chair. The room should be quiet to reduce unnecessary distraction. Sit across from the child and align your eyes with the child’s eyes. Hold the target object (e.g., penlight with monster cap) about 12 inches away directly in front of the child. Get the child to fixate on the object for 2-3 seconds – this can be checked by moving the object back and forth and watching the child’s eyes follow.
! Cover the child’s right eye with the occluder, watching the left eye for any movement.
! Leave covered for 2-3 seconds.
! Quickly move the occluder across the bridge of the nose to cover the left eye, watching the right eye for any movement.
! Wait 2-3 seconds after the cover is moved to permit fixation of the now uncovered eye.
! Move the cover from the left eye back to the right eye, across the bridge of the nose, watching the left eye for any movement.
! Allow 2-3 seconds for fixation. Repeat procedure several times to be assured of observations.
See the next page for a visual description of the procedures.
Criteria for passing: If the child is over 6 months of age, the child passes the Alternative Cover Test if neither eye moves. The child over 6 months of age fails the test if the observed eye moves, horizontally or vertically.
Results: If there is no redress movement in either eye, the child will pass this screening indicator. If there is redress movement in either eye, the child will fail this indicator and should be referred for further evaluation.
Corneal Light Reflex Test If the child passes the Alternate Cover test, it is not necessary to do the Corneal Light Reflex Test. If the results from the Alternate Cover Test are not clear, follow through with the Corneal Light Reflex Test.
Equipment: penlight Instructions: Hold a penlight 12-13 inches away from the child’s face directly in front of the eyes. Direct the light from the penlight at the hairline in the center of the child’s forehead. The child needs to fixate either on the penlight or an object that may be held near the light. Observe the reflection of the penlight in the pupils of both eyes – the reflection should be centered or equally centered slightly toward the nose (nasal).
Results: If the reflection is symmetrical and centered in both eyes, the child will pass this screening indicator. The child does not pass this screening indicator if the reflection of the penlight does not appear to be in a centered position in the pupil of each eye.
Sensitivity to light, rapid eye movement, and poor fixation observed during this test are also reasons for referral for further evaluation.
Fixation Fixation is the ability to align both eyes on a visual target. By six months of age, an infant can direct his or her gaze to a target as small as a piece of cereal.
Equipment: 12 X 9 inch black mat; one inch silent toy or object; several pieces of cake decoration or cereal pieces such as Fruit Loops.
Instructions: Face the child at eye level. Place the black cloth on a table in front of the child. Place the one inch object on the mat and observe whether the child looks at the object. If the child does not look at the object, it can be picked up and shown to the child.