Vision - Its Development in Infant and Child

VISION

ITS DEVELOPMENT IN

INFANT AND CHILD

BY

ARNOLD GESELL, M.D.

FRANCES L. ILG, M.D.

GLENNA E. BULLIS

Assisted by VIVIENNE ILG, O.D.

and G. N. GETMAN, O.D.

PREFACE

The background, scope, and genesis of the present volume are outlined in an introductory chapter which follows. There is not much more which needs to be said by way of preface.

The investigations of the Yale Clinic of Child Development since its founding in 1911 have been mainly concerned with the growth aspects of early human behavior. All told, the behavior characteristics of 34 age levels have been charted, encompassing the first ten years of life. An intensive longitudinal study of a group of five infants in 1927 established methods for a systematic normative survey. These methods included developmental examinations and inventories at lunar month intervals during the first year of life. Concurrent cinema records were analyzed to define significant behavior patterns and growth trends. Special attention was given to the ontogenetic patterning of posture, locomotion, prehension, and manipulation.

Cinemanalysis, both of normative and experimental data, demonstrated that the eyes play an important role in the ontogenesis of the total action system of the total child. The nature and the dynamics of that role constitute the subject matter of the present study.

The adult human eye has been likened to a camera. This analogy has had some truth and much tradition in its favor. But it has tended to obscure the developmental factors which determine the structure and the organization of the visual functions during infancy and childhood. The development of vision in the individual child is an extremely complex and protracted process; for the very good reason that it took countless ages of evolution to bring human vision to its present preeminence.

Our culture is becoming increasingly eye minded with the advancing perfection and implementation of the organ of sight. What is that organ? It is more than a dioptric lens and a retinal film. It embraces enormous areas of the cerebrum; it is deeply involved in the autonomic nervous system; it is identified reflexively and directively with the skeletal musculature from head and hand to foot. Vision is so pervasively bound up with the past and present performances of the organism that it must be interpreted in terms of a total, unitary, integrated action system. The nature of the integration, in turn, can be understood only through an appreciation of the orderly stages and relativities of development whereby the integration itself is progressively attained.

The authors have attempted to achieve a closer acquaintance with the interrelations of the visual system per se and the total action system of the child. This finally entailed the use of the retinoscope and of analytic optometry at early age levels where these technical procedures ordinarily are not applied. The examinations of the visual functions and of visual skills were really conducted as behavior tests, not only to determine the refractive status of the eyes, but also to determine the reactions of the child as an organism to specific and total test situations. The objective findings have been correlated with the cumulative evidence furnished by the developmental examinations, numerous interviews, and naturalistic observations of the children at home and in a guidance nursery. Although the conclusions of our study are preliminary in character, we may hope that they will contribute to a better understanding of the child in terms of vision and a better understanding of vision in terms of the child. The two should not be sundered.

With increased knowledge it is possible that the visual behavior of the individual child will become an acute index for the appraisal of fundamental constitutional traits. Periodic examination of these traits in dynamic activity would throw diagnostic light on their developmental significance. The ocular fundus, being an integral component of the brain, offers a unique avenue for observation of subtle behavior events. In this broadest sense, visual symptoms, both normal and atypical, are closely allied to problems of personality and of mental hygiene. The observable and potentially recordable reactions of the retina may thus yield a more intimate glimpse into the basic individuality of the growing organism. These possibilities cannot be realized without long-range projections of developmental research.

Our own preliminary research has had generous support from American Optical Company through its Bureau of Visual Science. We are deeply indebted to the officers of this company and to the Director of the Bureau, Dr. Paul Boeder, and to his former associate, Dr. Marion Stoll. At an earlier stage of our study (1942-43) we received small but significant grants from the Graduate Clinic Foundation, the Optometric Extension Program, and from the Fluid Research Fund of the School of Medicine, Yale University. In this connection we are especially indebted to Dr. A. M. Skeffington and to former Dean Francis G. Blake.

During the prosecution of the present study over a period of ten years, we have had the benefit of innumerable instances of cooperation both professional and lay. We have drawn freely upon various specialists in the fields of Optometry, Ophthalmology, Orthoptics, and Psychology. We are particularly indebted to Dr. George Crow, Dr. Frederick Brock, and Professor Samuel Renshaw. Mrs. Louise B. Ames as Curator of the Yale Films of Child Development, rendered generous assistance in the preparation of the illustrations of this volume. Her own studies in the field of child development have proved of great value in our investigation. Miss Elisabeth Wetsel has given unstinted service in the details of preparing the manuscript and index for publication.

We have been in long continuing indebtedness to the staff of the Yale Guidance Nursery, including Miss Janet Learned, Miss Anne Lockwood, and Mrs. Ludmila Glasscock. In a similar way we are indebted to Headmaster Henry Welles, to Supervisor Paulina Olsen, and to the teaching staff of the New Canaan Country School who facilitated in every way our periodic contacts with the children under developmental investigation from year to year. Finally and comprehensively, we should like to express our debt to the truth seeking spirit and intelligence of the parents who cooperated so consistently throughout the long program of investigation. Equally impressive and essential was the spontaneous cooperation of the children at every age level—in infancy, the preschool period, and the school years. They responded to every reasonable demand. We owe them a return in improved understanding and more enlightened guidance.

ACKNOWLEDGMENT

AMERICAN OPTICAL COMPANY through its Bureau of Visual Science has given generous support to the research program of the Yale Clinic of Child Development. This support has made possible the special investigations in the field of Developmental Optics published for the first time in the present volume.

CONTENTS

PREFACE

ACKNOWLEDGMENT

INTRODUCTORY

  1. THE EYES OF TODAY AND TOMORROW

  2. ORIENTATION: THE BACKGROUND AND SCOPE OF THIS STUDY

  3. THE EVOLUTION OF THE HUMAN ACTION SYSTEM

  4. THE MOTOR BASIS OF VISION

PART ONE

THE GROWING ACTION SYSTEM

  5. THE GENESIS OF VISION

Embryo and Fetus

The Fetal-Infant

The Neonate

  6. INFANCY

  4–16 Weeks

16–28 Weeks

28–40 Weeks

40–52 Weeks

12 Months

15 Months

  7. THE PRESCHOOL YEARS

18 Months

21 Months

2 Years

2 1/2 Years

3 Years

3 1/2 Years

4 Years

  8. THE SCHOOL YEARS

5 Years

6 Years

7 Years

8 Years

9 and 10 Years

PART TWO

DEVELOPMENTAL OPTICS

  9. THE VISUAL DOMAIN

10. THE COMPLEX OF VISUAL FUNCTIONS

11. THE YOUNG EYE IN ACTION

12. THE ONTOGENESIS OF VISUAL BEHAVIOR

13. MALDEVELOPMENT AND CHILD VISION

Amentia

Cerebral Injury

Blindness

PART THREE

DEVELOPMENTAL APPRAISAL

14. A DEVELOPMENTAL HYGIENE OF CHILD VISION

Infancy

The Preschool Years

The School Years

15. THE CONSERVATION OF CHILD VISION

APPENDIX

A. Examination Sequences and Procedures

Preschool Years

School Years

B. Ontogenetic Gradients of Visual Behavior

1. Eye-Hand Coordination

2. Postural Orientation

3. Fixation

4. Retinal Reflex

5. Projection

C. Selected References

INDEX

LIST OF ILLUSTRATIONS

CHAPTER ONE

Figure   1. Eyes fixate eyes

Figure   2. Eyes at work and play at home

Figure   3. Sport places a premium on visual skills

Figure   4. Television focuses a multitude of eyes

CHAPTER TWO

Figure   5. Photographic dome for systematic cinema recording

Figure   6. The action photographs of a 44-week-old infant

Figure   7. Developmental examination crib

Figure   8. Cinemanalysis procedures

Figure   9. Visual fixation points of examining table

Figure 10. A 6-week-old infant reacts to the dangling ring

Figure 11. The dangling-ring test at 20 weeks

Figure 12. Ring-and-string situation for the 36-week-old infant

Figure 13. Preschool developmental examination setup

CHAPTER THREE

Figure 14. Conditioned retinal-oriental-fixation reflex

Figure 15. Periophthalmus

Figure 16. Tarsius Spectrum

Figure 17. Cave-man drawings

CHAPTER FOUR

Figure 18. Eye-hand behavior in Infant B at 1, 6, 8, 12, 20 weeks

Figure 19. The tonic-neck-reflex in two infants, age 6 weeks

Figure 20. Eye-hand relationships

Figure 21. Reaction at 28 weeks to pellet

Figure 22. The child rakes near pellet

CHAPTER FIVE

Figure 23. Human embryo, age 18 days

Figure 24. Human embryo, P. G., age 8 weeks

Figure 25. A sensory nerve ending of an ocular muscle

Figure 26. Fovea centralis of the human fetus of 24 weeks

Figure 27. Tonic-neck-reflex pattern of a fetal infant

Figure 28. Flickering after pursuit eye movements of fetal infant

Figure 29. Ocular close-up of mature-stage fetal infant

Figure 30. Eye and body postures of neonate, Boy D.D.

Figure 31. Head and eye postures: 2-13 days, Boy D.D.

Figure 32. Head and eye postures: 13 days—24 weeks, Boy D.D.

Figure 33. A drowsing neonate, age 9 days

Figure 34. Diurnal cycle of Infant D.D., age 6 days

Figure 35. Diurnal cycle of behavior of Infant D.D.

CHAPTER SIX

Figure 36. Visual-behavior patterns at 4 weeks of age

Figure 37. Comparative-action photographs of infant D.D., at 8 and 12 weeks

Figure 38. Visual-behavior patterns at 16 weeks

Figure 39. Near vision: 24 weeks, Girl A

Figure 40. Visual-behavior patterns: 28 weeks, Boy D

Figure 41. Eye-hand patterns: 32 weeks, Girl A

Figure 42. Visual-behavior patterns: 40 weeks, Boy D

Figure 43. Visual-behavior patterns at 1 year

Figure 44. The infant’s reactions to his mirror image

Figure 45. Visual-behavior patterns at 15 months

CHAPTER SEVEN

Figure 46. Visual-behavior patterns at 18 months

Figure 47. Visual-behavior patterns at 2 years

Figure 48. Visual-behavior patterns at 2 1/2 years, Girl T.

Figure 49. 2-year-old builds wall

Figure 50. 3-year-old builds bridge of three blocks

Figure 51. Visual-behavior patterns at 3 years, Boy D.D.

Figure 52. Visual-behavior patterns at 3 1/2 years

Figure 53. Visual-behavior patterns at 4 years

CHAPTER EIGHT

Figure 54. Visual-behavior patterns at 5 years

Figure 55. Visual-behavior patterns at 6 years, Girl T.

Figure 56. 7-year-old at radio

Figure 57. The 8-year-old school child works well at group tasks

Figure 58. The child from five to ten

CHAPTER TWELVE

Figure 59. Fixation test: The dangled bell

Figure 60. Examination setup for retinoscopy

Figure 61. Projection test

Figure 62. Targets for projection tests

Figure 63. Targets for projection tests

Figure 64. The play yard of the Yale Guidance Nursery

Figure 65. Play equipment releases motor behavior

CHAPTER THIRTEEN

Figure 66. Blind boy, M.F., age 16 weeks

Figure 67. Blind boy, age 28 weeks

Figure 68. Blind boy, age 40 weeks

Figure 69. Blind boy, age 12 months

Figure 70. Blind boy, age 18 months

Figure 71. Blind child plays with sighted companions in the Guidance

 Nursery

Figure 72. Blind boy, age 3 years

Photographic Sources

Figures 1, 2, 6, 7, 8, 10, 39, 41, 46 are reproduced from Gesell et al., An Atlas of Infant Behavior, New Haven, Yale University Press, 1934.

Figures 23-35 (Chapter V) are derived from Gesell, Arnold (in collaboration with C. S. Amatruda), Embryology of Behavior, New York, Harper & Brothers, 1945.

Figure 40 is reproduced from the Encyclopaedia Britannica Film, Life Begins.

The eye is the first circle; the horizon which it forms is the second; and throughout nature this primary figure is repeated without end.

—RALPH WALDO EMERSON

INTRODUCTORY

CHAPTER 1

THE EYES OF TODAY AND TOMORROW

AMONG ALL LIVING CREATURES, man is the most eye-minded. Nothing does he treasure more than the apple of his eye. Myth, language, folklore, proverbs, art, and poetry abound in allusions to the magic, the mystery, the power, the evil, and the charm of the eye. To Thoreau the human eye is a noble feature. . . . It is the focus in which all rays are collected. It sees from within, or from the center, just as we scan the whole concave of the heavens at a glance, but can compass only one side of the pebble at our feet. . . . The eye revolves upon an independent pivot which we can no more control than our own will. Its axle is the axle of the soul, as the axis of the earth is coincident with the axis of the heavens.

Less poetic, but still superlative is Aristotle’s realistic comment: All men by nature desire to know. An indication of this is the delight we take in our senses; for even apart from their usefulness they are loved for themselves; and above all others the sense of sight. For not only with a view to action, but when we are not going to do anything we prefer seeing to everything else. The reason is that this, most of all senses, makes us know and brings to light many differences between things.

All the vast science and technology accumulated since Aristotle’s day have strengthened the truth of his words. The science of biology has demonstrated that the human eye is virtually a vestibule to the brain, and that stereoscopic vision with its cortical elaborations is the crown jewel of organic evolution.

The preëminence of vision in the sensory-motor construction of the human action system is reflected in the input and output arrangements of retina and brain. The retina, with its multibillion sensitive points and polarities, is receptive to an enormous range of impressions. Retina and brain are sensitive enough to detect the light of a candle 14 miles distant. Speaking as a neurophysiologist, McCulloch points out that the eye alone has more than 100,000,000 photoreceptors, each of which is either signaling or not signaling at a given moment. This means that the eye can exist in 2¹⁰⁰,⁰⁰⁰,⁰⁰⁰ states, each of which corresponds to a unique distribution of stimulation. . . . Each eye transmits as much information to the brain as does all the rest of the body. It can send in a million impulses per millisecond. For the whole organism, including eyes, the input has a maximum of three million signals per millisecond.

Modern technology reflects a significant emphasis on the function of vision. It has clothed the naked eye with light-gathering devices which penetrate deeper and deeper into microscopic and into sidereal space. The visual hunger of cultural man is insatiable. He can never see enough. Inaudible sound he translates into visible waves. Hearing alone does not sate him. If the pulsation of brain potentials is communicated to him through sound magnification, that does not suffice. He must see the waves graphically recorded on a smoked drum, for his closer scrutiny and for the sweeping glances impossible by ear. It is not enough to infer a gene; he must behold it through the agency of ultramicrophotography. The cathode ray oscillograph is used to expand time and to show visually on the end of a luminescent tube what happens in as small an instant as .000000001 of a second. Photographic records have recently been made of subatomic particles which survive for only a millionth of a second, and which are only fifty to sixty times larger than a single electron.

Photography affords supercyclopean vision. It is a third eye. The camera collects the images; and the chemical emulsion of the film serves both as a receiving and as a recording retina. But even the most sensitive photographic plate has limitations. So the insatiable astronomer contrives lead-sulfide photoconductive cells which will lift the veil of interstellar clouds and enable him to see the invisible. He builds at Palomar a 200-inch camera which reaches to stars and universes a billion light-years away. With the aid of photography and this gigantic eye, he has moved his far-point vision to a distance of 60 × 60 × 24 × 365 × 1,000,000,000 × 186,000 miles; for light travels at a speed of 186,000 miles per second. The human eye is attuned to this velocity, which according to the doctrine of relativity is the top limiting velocity in the universe.

FIGURE 1. Eyes fixate eyes.

The infant is 12 weeks of age.

FIGURE 2. Eyes at work and play at home.

The function of vision, as Aristotle hinted, is to reveal. Technologic vision does not replace organic vision, it enhances and enriches it. The most remarkable technologic extension now developing in the womb of time is television—an instantaneous electronic method of transmitting visual images over the long reaches of earthly space. This miracle, at one paradoxical stroke, both penetrates and abolishes space. It brings the visual and the auditory world into simultaneous focus. It should in time bind distant peoples into closer psychologic unity and understanding.

Already we are promised transoceanic interviews, which will bring participants separated thousands of miles onto the speaking screen of a family living room. Leaders of nations from opposite sides of the earth will appear face to face, through two-way television.

FIGURE 3. Organized sport places a high premium on visual skills.

In baseball, all eyes fixate, with postures poised for sudden unpredictable shifts. The ball speeds across the plate in 3/10 of a second. The batter has 1/50 of a second in which to connect. It’s all in your eyes and timing, says a champion batter. (Acme Photo)

When millions, as individuals in their households, witness the same spectacle, they will not be so subject to mob psychology. On the basis of what they see, they may frame calmer judgments. One prophet reports that a push-button device for registering opinion is in an experimental stage of development. Millions of such video votes could be instantaneously totaled and classified by an electronic computer! Vision as language thus assumes a role in socialization, and in molding the social psychology of the individual.

Television will enormously diversify the channels of vision, because telecasting is not under the restrictions of the beholder’s own oculomotor fixations. Using multiple, mobile cameras, television can transmit a spectacle viewed from multiple, shifting angles. The optimal scenes are continuously selected in the control room. Through montage manipulation, modulated intensifications and coincident projection, reinforced by sound effects, the television screen will mirror what an Argus-eyed son of Zeus might witness.

Not only the eyes of scientists and technicians, but the eyes of common men, women, and children have been tremendously augmented through modern invention. And the end is not yet. Our civilization is becoming increasingly eye-minded. The tasks for the growing eyes of children are multiplying and intensifying. Radio, with its exclusive appeal to the ear, has somewhat lightened the environmental pressures, but radio is now uniting with video, and voice and vision merge. We are entering an electronic Look-See-Pic-Screen age, and education will place a relentless premium upon alert, accurate, and swift vision.

The culture sets its visual premiums in many different ways—in science, in the arts, in recreation and sports, in craftsmanship and industry. The challenges, rewards, and competitions are innumerable. For example, the American glorification of baseball has various psychologic sources; but not the least is the extraordinary visual tension it creates in the players, the umpire, and the keenly watching crowd, which through television may embrace a nation.

The visual demands of school, factory, and urban life are often excessive and distorting. Fortunately, vision is the most adaptable of all physiologic functions, and the chemical events of eye and brain are the least fatigable; for they have amazing powers of rapid restitution. But statistics show that the eyes are not altogether ready to meet the strains of present cultural conditions. Visual maladaptations, not to say defects, are mounting alarmingly in the years from five to ten. The increase of myopia among children and adults has serious portent. The frequency and varieties of strabismus in the early years of life indicate numerous unsolved problems—optometric, ophthalmologic, and surgical. A deeper insight into the complicated development of the visual functions of infants and school children is essential to further scientific control.

FIGURE 4. Television focuses a multitude of eyes upon a single scene. (Courtesty of Allen B. Dumont, Inc., and Acme Photo)

The development of vision in the individual child is complex, because it took countless ages of evolution in the race to bring vision to its present advanced state. Human visual perception ranks with speech in complexity and passes through comparable developmental phases. Moreover, seeing is not a separate, isolable function; it is profoundly integrated with the total action system of the child—his posture, his manual skills and coördination, his intelligence, and even his personality make-up. Indeed, vision is so intimately identified with the whole child that we can not understand its economy and its hygiene without investigating the whole child.

Vision therefore may become a key to a fuller understanding of the nature and the needs of the individual child. He sees with his whole being. Eye care involves child care. The conservation of vision, particularly in the young child, goes far beyond the detection and correction of refractive error. Acuity is only one aspect of the economy of vision. How does a child use his eyes in personal and in practical situations? How does he shift from far to near tasks, and vice versa? Are central and peripheral vision in balance? Do his eyes team coördinately? If not, is his strabismus resolving? Does he show visual competence in his handling of toys, tools, eating utensils, crayon, pencil, primer? If he has any difficulties, are they due to his temporary immaturity or to a more permanent intrinsic visual deviation, or to faulty cultural arrangements? How does his visual behavior comport with his general behavior? Do we need a broader kind of visual hygiene to protect the growing eyes of today and the eyes of tomorrow?

To answer such questions we need a more ordered knowledge of the child as a growing organism. His visual history begins in the darkness of the uterus. His patterns of visual behavior transform in lawful sequence through the stages of infancy, of preschool childhood, and the school years.

CHAPTER 2

ORIENTATION: The Background and Scope of This Study

THE HEARING EAR and the seeing eye, the Lord hath made even both of them. In the present volume we attempt to examine some of the natural laws and wonders which are inherent in the formation of man’s supreme sense: vision.

Visual science has made brilliant contributions to our knowledge of the eye as an optical organ. There is a vast amount of basic information on the efficiency, the mechanism, and the neurophysiology of seeing, derived from studies of the mature, adult eye. There is, however, a relative paucity of information on the genesis and growth of visual functions. Somewhat paradoxically, we know rather more about the evolution of vision in the race than we do about its development in the child. Perhaps this is because the eye and the connecting brain have had such a venerable history, and the salient stages of their structural transformations are therefore writ large in the anatomies of living species from fish to man.

In the gestation and growth of the individual child, this venerable history is condensed and revised within the narrow limits of years as contrasted with eons. The development of visual functions in infancy and childhood is so subtle, swift, and esoteric that it does not declare itself in conspicuous stages. Moreover, one tends to think of the eyes and the vision of the child as operating in the same manner as they operate in the adult.

This, of course, is a gratuitous assumption. Unfortunately, the human infant can not tell us exactly how gratuitous. He can not report to us the subjective essence of his visual experience; nor can microscopic sections of his retina and cortex tell us precisely how and what he sees. But evidence is not altogether wanting. By careful attention, the curious-minded observer can detect the outward signs of vision, and can cautiously deduce some of its underlying processes. The baby uses his eyes to perform overt acts of vision; presently he uses his hands to perform yet more complicated acts in which the eyes lead or follow. Later he points with a gesturing hand. Still later he names what he points to, thus bringing hand, eyes, and speech into union. Even during his preschool years he responds coöperatively to tests of visual experience adapted to his interests and capacity. At the age of four he begins to report visual introspections by word of mouth, and thus he becomes an articulate participant in a formalized examination. As he grows older, the reciprocity between child and examiner increases and it is possible to analyze the visual functions in considerable detail. But to interpret the nature and the import of these functions it is always necessary to observe the total child. For the Lord hath made the seeing eye part and parcel of an indivisible, integrated, growing action system.

FIGURE 5. Photographic dome used to secure systematic cinema records of infant behavior patterns at lunar month intervals. (Courtesy of LIFE Magazine.)

The delineative action photographs of An Atlas of Infant Behavior were selected from these cinema records. Two silent cameras ride on the quadrants of the dome. The infant is examined in the crib. The dome is encased in a one-way-vision screen, which conceals the observers from the infant, but permits full view of his behavior.

The intimate interdependence of the visual and action systems is nowhere more significantly displayed than in the sequences and trends of child development. Some thirty years ago, the Yale Clinic began a series of studies of the forms and the growth of the behavior patterns of the human infant. Our approach was inclusive rather than topical, for we were systematically interested in the total child and the total aspect of advancing stages of maturity. In due course, we charted the behavior characteristics of normal subjects at thirty-four progressive age levels from birth to ten years. The original charting took into account four major fields of behavior as follows:

1. Motor Behavior: posture and locomotion; prehension and manipulation; gross and fine motor coördination.

2. Adaptive Behavior: self-initiated, induced and imitative behavior; learning; resourcefulness and exploitiveness in new situations.

3. Language Behavior: vocalizations; vocal signs; gestures; comprehension of words; speech and reading.

4. Personal-social Behavior: reactions to persons; responses to overtures and commissions; adjustments to life situations in home and school.

Various methods of approach were used to secure systematic data in the foregoing behavior fields: periodic examinations of behavior, naturalistic observation, parent interviews, and analysis of cinema records. For a detailed description of these methods the reader must be referred to previous publications* which report the basic developmental surveys as follows:

a. A normative survey of infant behavior at lunar-month intervals from 4 through 56 weeks

b. A naturalistic survey of a small group of infants at lunar-month intervals

c. A periodic study of the feeding behavior of infants

d. A normative survey of the preschool period, at tri-monthly and semi-annual intervals from 15 months to 5 years

e. A sequential study of the maturity traits of school children at annual and semi-annual intervals from 5 to 10 years of age

f. A developmental study of a group of fetal-infants, with postconception ages of 28 to 40 weeks

g. Clinical studies of maldevelopment throughout infancy and childhood.

The developmental investigations listed above built up a cumulative