A Clinician's Guide to Helping Children Cope and Cooperate with Medical Care: An Applied Behavioral Approach

CHAPTER 8. Cooperation with Vision and Hearing Tests and Treatments

138 chapter 8 Cooperation with Vision and Hearing Tests and Treatments in this chapter • Vision and hearing tests have unique features that require systematic planning and preparation to prevent behavioral distress in young children and individuals with intellectual and developmental disabilities (IDD). • The importance of early identification of vision and hearing impairments in childhood is discussed. • Behavior analysis approaches to facilitating child cooperation and adherence with vision and hearing remedies are described from the literature and the author’s clinical work. • Task analysis, desensitization, and counterconditioning techniques tailored to these mildly invasive procedures are presented. • The potential for behavior analysis methods to mitigate the negative developmental impact of early childhood sensory impairments is illustrated through discussion of relevant studies and recommended procedures. 8.1. patient population and target problem(s) The information in this chapter is relevant to infants, preschoolers, and early-school-age children, as well as all individuals with IDD. Sensory impairment in childhood may be part of a multiple-disability disorder or may occur in otherwise-healthy children. Severe sensory deficits in childhood may delay development of walking, talking, adaptive behavior, and socialization .1 Early diagnosis and intervention can limit the impact of some of cooperation with vision and hearing tests 139 these impairments. Furthermore, understanding the nature and severity of the deficit allows for adjustment in educational strategies to emphasize the child’s strengths. However, it can be quite difficult to test sensory abilities such as visual acuity accurately in individuals with IDD and limited verbal skills.1 8.2. assessment procedures Pediatric Visual Disorders The description of vision screening and assessment methods presented in this chapter is based on excellent chapters by other authors, the contents of which are presented in summary below.2–3 Vision screening and examination may be accomplished using examiner observations and eye charts or may require special equipment and specialist training. If the child is verbal and cooperative, or is nonverbal but can point to a figure on a card that matches the figure that the child is viewing on a distance chart, visual screening is possible. However, it cannot determine visual acuity with precision, only the range of the child’s visual function. Many methods of vision screening and testing are currently available and have been well validated, and their appropriate uses have been summarized for pediatricians and other child health professionals.4 Recently a national survey of pediatricians was conducted to evaluate their practices with regard to preschool vision screening. Screening at age 3 was only done by 35% of pediatricians, whereas the percentages increased to 75% and 66% at ages 4 and 5, respectively. The most common barriers to screening were that it is too time-consuming, there is no specified reimbursement for doing the screening, and many children are uncooperative . Indeed, lack of cooperation was a major barrier because only 49% of the sample was cooperative enough for their screening results to be valid. Interestingly, the authors’ suggested solutions involved purchase of different equipment and seeking a mechanism of reimbursement, but they did not consider the possibility that behavioral training might be helpful for increasing child cooperation with screening.5 Other authors have reported similar percentages of cooperation problems (42%) when screening typically developing 2- to 3-year-old children6 and when attempting to screen children with IDD (51%).7 In the latter study, the authors suggested that making the screening test simpler might be helpful but would result in more imprecise results. The suggestion was 140 helping children cope with medical care referral to a pediatric ophthalmologist, but no information was given as to how the ophthalmologist would be better at managing cooperation problems . Again, in neither of these studies was the possibility of behavioral intervention considered. Even when interaction with the child is limited by severe IDD, important clinical information can be obtained through direct observation of the child. Observation can determine if the child gazes at and fixes his or her eyes on objects, people, and faces and tracks movement in all directions or in some directions and not others.2–3 Restricted visual fixation or tracking indicates that more thorough evaluation by a pediatric ophthalmologist is needed. These tests also typically require more technical equipment and increasing levels of child attention and cooperation. Examples include the optokinetic nystagmus, preferential looking, electroretinogram, and visual evoked potential (VEP) tests.2 Optokinetic nystagmus testing requires the child to look at a rotating cylinder...