J. Paediatr.

Child Health (2000) 36, 226229

Early motor development of blind children

O LEVTZION-KORACH,1,3 A TENNENBAUM,1 R SCHNITZER 2 and A ORNOY 1,3
1Jerusalem Institute for Child Development, Israeli Ministry of Health, 2Bney-Zion Medical Center, Haifa and
3Laboratory of Teratology Hebrew University Hadassah Medical School and Hadassah Hospital, Jerusalem, Israel

Objectives: The purpose of this study was to assess the characteristic motor developmental pattern in blind children in
Israel.
Methodology: The study compared the developmental data concerning 10 motor skills of 40 blind children to a control
group of sighted children and to the motor developmental milestones of the Bayley Developmental Scale and the Revised
Denver Developmental Screening Test.
Results: The motor development of blind children was delayed, the delay being significant in all 10 motor skills that were
examined. This delay emphasizes the major importance of vision as a sensory input modality for the process of sensory
motor development.
Conclusion: An adequate stimulating environment and proper parental handling could potentially shorten the motor
developmental delay but probably not eliminate it entirely.

Key words: blind children; motor delay; motor development.

Vision is considered the most important sensory input modality
for the process of sensorymotor development,1 therefore a
different sensorymotor development is expected from blind
compared to sighted children. Previous studies,24 have suggested
that there is a significant delay in the motor development of blind
children compared to the sighted; blind children with no other
abnormality tend to develop in a characteristically different
pattern. However, many blind children have associated develop-
mental impairments that may affect their motor development.
The neuro-anatomic basis for motor development according
to the present hypothesis is that increasing nerve fibre myelin-
ization with synapse formation are the major factors contributing
to the normal development.5 Freiberg3 and Freiberg and
Adelson4 concluded that motor skills such as head and trunk
control and postural functions that require neuromuscular matu-
ration appeared within the expected range for sighted children.
Other studies have found a significant delay, average of 6 months,
in lifting the head when in the prone position in blind children
compared to the sighted.1,6
The different studies agreed that there is a delay in the initi-
ation of mobility of the blind child.79 The infant has to realize
that a person or an object is present before he is motivated to
reach out and get it. This concept of permanence of people and
objects is largely learnt through vision. Sound itself is not a
satisfactory substitute for forming an internal image of an
object. Until a baby has acquired these concepts he will not be
motivated by sound to reach or move.7 Localization of sound is
learnt by the infant through a process that begins after birth.
From a very young age the child will turn his head towards the
direction of the sound. The sighted child will then begin to
Correspondence: A Ornoy, Hebrew University Hadassah Medical
School, Jerusalem, Israel. Fax: 972 26758430;
email: Ornoy@cc.Huji.ac.il
O Levtzion-Korach, MD, Pediatrician. A Tennenbaum, MD, Pedia-
trician. R Schnitzer, MD, Pediatrician. A Ornoy, MD, Professor of
Teratology.
Accepted for publication 1 December 1999.
develop an auditoryvisual association, while the blind child
will be less capable of searching for the source of the sound.
The blind child has to concentrate more on developing the
auditorytactile association. In order to stimulate this associ-
ation, the parents are often taught to substitute the visual
impression by a tactile stimulus. For example, it is recom-
mended to bring the hand towards the source and not the
source towards the hand, so that the child will receive a good
tactile conformation of his auditory experience.1
Freiberg concluded that the ability to reach for an object
based on a sound stimulus (an ability which is referred to as
reach on sound ability) is the rate limiting phase for the motor
development of the blind child.3
The question that remains is the role and influence of the
environment on the motor development of the blind child. The
environment seems to have a major influence on the develop-
ment of sighted children. To emphasize this, Freedman and
Cannady demonstrated that the motor development of sighted
children who suffered from severe environmental deprivation is
delayed even compared to the development of blind children.8
The role of the environment in motor development is empha-
sized in different studies. Norris et al. hypothesized is that in
an optimal environment with adequate stimulation, the motor
development of the blind child will be normal.2 However, due
to various constraints placed on learning in blind children, it
may be expected that motor development will be delayed.9 This
is especially evident when other impairments such as mental
retardation are also present.9
To learn the actual role of an adequate environment, Freiberg
and Adelson designed a developmental guidance program.4 The
program encouraged physical and language contact between the
parent and the child and provided many different stimulations to
the blind child. Their results were that blind children who
participated in this program developed some skills earlier than
other blind children, but were still late compared to sighted
children. The conclusion is therefore, that an adequate environ-
ment with sufficient stimulation can shorten the developmental
delay, although not eliminate it completely.
Early motor development of blind children
The purpose of the present study was to assess the charac-
teristic motor developmental pattern in blind children, without
associated impairments, in Israel. Understanding this pattern
may help in the guidance of parents and teachers and subse-
quently help to adjust the parents expectations from their blind
child.
METHOD
The research population
We obtained data on the motor development of 40 blind
children who were under 5 years of age between the years
1973 and 1993. Twenty-seven children, of whom 20 were
Arab, were examined and evaluated in the Hana Chushie
Developmental Center in Haifa and 13 children were evaluated
in the Jerusalem Institute for Child Development. All children
were blind from birth or became blind during the first 6 months
after birth, and were otherwise normal. The causes of blindness
in these children are specified in Table 1. We excluded from
our study children who were multi-handicapped and those who
were born before 32 weeks gestation or with a birthweight of
less than 1500 g. With both Arabs and Jews in the research
population, we were able to compare the motor development of
blind children in the two ethnic groups.
The control group
The control group was composed of 24 sighted children up to
the age of 18 months. Nineteen of them were referred to the
Jerusalem Institute of Child Development because of suspected
motor developmental delay as they had failed a routine develop-
mental screening test in the well baby clinic. All these children
were examined and were found to have normal psychomotor
development. The developmental achievements of both groups
of children were ascertained from their medical records. The
other five children were randomly selected from the general
population and added to the group.
The childrens motor achievements were compared to the
motor developmental milestones of Bayley Developmental
Scale10 and the Revised Denver Developmental Screening Test
(DDST),11 according to their age. These motor developmental
milestones are for sighted children.
Table 1 The aetiology of blindness in the research population
Diagnosis No. children
Leber congenital retinal amaurosis 9
Microphthalmos 8
Anophthalmos 6 hypotonic at some point in their development. Unfortunately, we
Retinopathy of prematurity 4 did not have enough data to draw conclusions from this finding.
Retinal detachment 3 A finding not directly related to motor development was the
Tapeto retinal degeneration 2 comment by many parents that their blind child ate a very
Non specific retinal abnormalities 2 limited range of food and avoided solid food particularly.
Norries disease 1
Familial vitreo retinal degeneration 1
Anterior segment dysgenesis 1 DISCUSSION
Bilateral retinoblastoma 1
Unknown 2
Total 40
227
The motor skills that were examined were as follows:
rolling, crawling, standing alone with support, sitting up from a
supine position, walking with help, walking alone, walking up
the stairs with help, standing on one foot, jumping on two feet,
and walking up the stairs alone. Many files had missing data
concerning some of the motor skills, and for each skill the
number is given separately (Tables 2,3).
Based on previous studies, it is known that parents are able
to describe quite accurately their infants motor developmental
milestones.12 In order to receive the developmental data from
an additional source, we asked parents to complete a question-
naire, which was also translated into Arabic. The parents were
asked to specify the age of the child when he/she first accom-
plished these 10 different tasks. The parents of several sighted
children from the control group also answered the question-
naire. The parents answers matched those of the medical files
of the children.
Statistical analysis
We compared the blind childrens motor achievements to those
of the control group and to the developmental milestones of
the Bayley Developmental Scales and DDST according to the
average age of achieving each milestone. For this comparison,
we used the one-sample t-test. For the comparison of the motor
achievements between the blind children and the sighted
children (control group), and for the comparison between the
blind Arab children and the blind Jewish children we used
the two-sample unpaired t-test.
RESULTS
In the comparison of the blind children to the standard mile-
stones (Tables 2,3), a very highly significant delay (P < 0.001)
was found in all the motor skills.
The group of blind children in the pre-walking motor skills
were significantly delayed in comparison to controls (P < 0.05)
except in the skill of sitting from a supine position (P = 0.07,
Table 2). The only significant (P = 0.02) difference between
the development of the Arab and Jewish blind children was in
the age of rolling (Table 2). All post-walking motor achieve-
ments were delayed in the blind children, without any differ-
ences between the Arab and Jewish children (Table 3).
There were no differences in the milestones described,
between the motor development of the control children, and the
DDST and Bayley Developmental Scales (Tables 2,3).
Apart from the delay in the achievement of various activities,
there were some skills such as crawling and standing on one leg
that many blind children, up to the age of 5 years, did not
perform at all. Many of the blind children were noted to be
Delayed motor development was found in activities that require
maturation of the spine and the nervous system and in the
228 O Levtzion-Korach et al.

Table 2 Pre-walking motor achievements (mean ages in months)

Arab blind P value for

Bayley and All blind Jewish blind children Sighted children comparison
Denvers children children (Haifa) examined in Jerusalem between
milestones (n) (n) (n) (n) the groups

Rolling 4 (D) 8.2 2.2 6.6 1.3 9.3 2.3 5.7 1.1 P1 < 0.001
(18) (5) (10) (9) P2 < 0.001
P3 = 0.02
Crawling 8 (D) 13.2 4.0 12.0 2.2 12.8 4.1 9.6 2.3 P1 < 0.001
(24) (8) (12) (7) P2 = 0.007
P3 = 0.27
Standing alone 8.1 (B) 14.4 4.7 13.6 3.0 15.1 5.7 10.5 2.4 P1 < 0.001
with support (23) (8) (13) (11) P2 = 0.003
P3 = 0.16
Sitting from a 8.3 (B) 11.9 2.4 11.3 1.9 12.2 2.6 9.3 1.1 P1 < 0.001
supine position (17) (5) (12) (6) P2 = 0.07
P3 = 0.64

Bayley (B) and Denver (D) milestones, the Bayley Developmental Scale and the Revised Denver Developmental Screening Test. P1, Comparison
between the blind children and the standard milestones; P2, comparison between the blind children and the sighted children in the control group;
P3, comparison between the Arab blind children and the Jewish blind children.

Table 3 Postwalking motor achievements (mean ages in months)

Jewish blind
Bayley and All blind children Arab blind children
Denvers children (Jerusalem) (Haifa)
milestones (n) (n) (n) P value

Walking with help 9.6 (B) 16.6 5.5 14.8 4.2 18.2 5.4 P < 0.001
(21) (7) (10)
Walking alone 11.7 (B) 19.3 4.1 19.4 3.2 19.1 4.8 P < 0.001
(19) (5) (12)
Climbing up the stairs with help 16.1 (B) 28.8 7.1 25.9 4.4 31.4 9.1 P < 0.001
(19) (8) (7)
Standing on one foot 22.7 (B) 52.4 9.6 P < 0.001
(10)
Jumping with two feet 23.4 (B) 40.0 10.9 P < 0.001
(12)
Climbing up the stairs alone 25.0 (B) 38.3 15.8 P < 0.001
(10)

Bayley (B) and Denver (D) milestones, the Bayley Developmental Scale and the Revised Denver Developmental Screening Test. P, comparison
between the blind children and the standard milestones.

activities that require sensory stimulation in order to initiate.
Our findings differ from those of Freiberg3 who concluded that
there was no delay in the activities that require the maturation
of the nervous system. There are several possible explanations
for the motor delay. An infant can accomplish many motor
skills only after he/she has developed a good body image and
has realized what their potential capacities are.7 It has been
shown that blind children have a different, qualitatively poorer
idea of the human figure; the torso appears to them long and
very narrow with disproportionately big arms and hands.1
Our impression of the higher incidence of hypotonicity was
described in other studies as well.13,14 A study by Scranton
et al.14 has shown a higher incidence of ligament laxity, foot
deformity and scoliosis in blind children with no other
handicap compared to sighted children. They attributed their
result to postural and gait abnormalities which are commonly
seen in blind children. Other studies showed that hypotonicity
of various degrees can be found in up to 30% of blind children
who are otherwise neurologically normal.1,5,13
We found a delay in activities that require the ability to
maintain good balance, such as standing on one leg. The delay
could be related to the later emergence of the lateral righting
responses of the head and trunk (i.e. the Landau response, the
forward protective response (parachute)), and the equilibrium
reactions in response to tilt, responses that were found to
be delayed in blind children. In humans the neuroanatomic
pathways for these non-visual protective and equilibrium
reactions are yet to be determined, although it is thought that
vestibular, neck proprioceptive and asymmetrical tactile stimu-
lation have a role in the development of these postural
reactions.5 This stimulation is usually provided by the father,
who often plays with his children by moving them in space
Early motor development of blind children
thus providing them with postural changes that stimulate their
proprioceptive and vestibular senses. The father of a blind child
tends to withhold this kind of play because he is afraid he
might frighten the child. The delay in tilt reactions can also be
explained by the inability of the blind child to use his vision to
monitor his postural adjustment in order to restore a vertical
orientation.
The only significant difference in the motor development
between Jewish and Arab blind children was in their age of
rolling (Table 2). The Jewish blind children roll over two
months on average before the Arab children. Differences in
motor development among different populations have been
known for many years. African infants learn motor skills earlier
than do American and European infants. Many causes have
been suggested to explain this difference; innate racial differ-
ences, traditional methods of child care, maternal attitudes and
anxieties during pregnancy, the altitude at which the children
live, the amount of sunlight, cultural practices, nutrition and
health.15,16 In our study the difference can be related to the
tendency of the Arab parents to lay their infant supine. Blind
infants dislike lying prone, but in places (such as the Institute
for Child Development in Jerusalem) where they insisted in the
past that parents lie their child on its stomach, the child rolls
over earlier. This recommendation has changed with the
new data associating lying prone with sudden infant death
syndrome.
A child, whether blind or sighted, has basic needs in order to
progress in its motor development, such as neuromuscular
maturation, a good body awareness and image, acquirement of
the concept of permanence and the ability of localizing a sound
together with the active urge of exploring. As sensory stimu-
lation is required for the development of many of these
abilities, the delay found in the motor development of blind
children may be expected. The importance of sensory inputs in
the process of motor development leads us to expect a delay in
the motor development of children with different sensory
handicaps, for example, deaf as well as blind children. Few
studies showed a delay in the motor development of the deaf
children compared to the standard milestones and compared to
a normal control group.17,18
Our study has several methodological problems that need to
be considered. Firstly, the study group is relatively small and
not all items were examined in all children. However, appro-
priate statistical analysis has shown the validity of the results.
Secondly, most of the control group children were infants who
failed a routine developmental screening test but were found to
be normal on a comprehensive medical and psychological
developmental examination using the Bayley Developmental
Scales. The fact that they were normal at examination enables
us to use them as controls. Thirdly, in spite of the fact that
the blind children were found on examination not to have
additional disabilities, it is still possible that some minor
229
neurological impairments would have been found at an older
age (i.e. inattention, hyperactivity, behavioural disorders or
learning disabilities). However, even when found, they do not
seem to have a major impact on the motor development of the
children.
An adequate environment and proper parental instruction
may shorten the motor developmental delay but probably not
eliminate it completely.
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