11234990705_81e744dae9_zPhoto by Phalinn Ooi via Flickr

Today’s guest bloggers are Drs. Sheree Fetkin and Charles Boulet.  
Dr. Sheree Fetkin is a California native who completed optometry school with honors at Midwestern University, Arizona College of Optometry in Glendale, Arizona. She went on to the east coast for residency training in vision therapy and rehabilitation at SUNY College of Optometry. She currently practices in Tampa, FL at the Walesby Family Vision Center where she sees primary care and pediatric patients in the morning and participates in hands on vision therapy in the afternoon. She is currently in the process of obtaining her fellowship from the College of Optometrists in Vision Development.
Dr. Charles Boulet is a graduate of the University of Alberta with degrees in Neuropsychology (1989) and Education (1991), and a doctorate in optometry from Pacific University in 2008. Dr. Boulet consults on cases pediatric learning and development difficulties related to vision, and maintains a full time private practice in Black Diamond, AB. He is an author, researcher, speaker/lecturer and travels extensively throughout Alberta for professional training events. He is also a software developer and his company VisionMechanic, Inc. has recently released the first of a series of tools for vision and motor skills assessment and development (visionmechanic.com). Dr. Boulet maintains a number of web-based information and advocacy sites including drboulet.com, and vild.info, and is a co-sponsor of the Calgary Vision Event 2015 which takes place September 2015 – see vild.info/cve2015.html.

Many school-aged children struggle with learning problems, many of which are reading-related, or related to motor control, balance, and coordination. As vision is tightly integrated across and within sensory and motor elements required for classroom learning, observing visual behaviour alongside developmental milestones provides fascinating and useful insight into the status of the whole child. Exploring these ideas allows doctors to explore important questions such as ‘to what degree is vision affecting behaviour’ and ‘to what extent are other sensory and motor control skills and abilities contributing to observed visual functional deficits’.

The mature human visual system undergoes an intricate and elaborate process that is not complete at the time of birth, but rather develops as a result of many complicated processes over the first year of life. Some aspects of development continue to evolve passively into adolescence and adulthood. If left uncorrected, visual impediments to learning and development can and will disrupt the course of development. This can lead to visual anomalies or other unwanted behavioural adaptations that can adversely affect many aspects of life, from medical and emotional health, to the capacity to adapt to a classroom, or perform gross or fine motor tasks.

The American Optometric Association recommends that a person receive their first eye examination at 6 months old, 3 years, and school entry age. At these ages, an infant or child is expected to be able to perform at certain levels based on normal subcortical motor and sensory integration, and cortical specialization and refinement. Inquiring about the child’s developmental history and status at a child’s first few eye examinations helps to better anticipate the child’s expected level of vision function, and visa versa.

This multipart series reviews an array of physical, cognitive, and visual developmental milestones, and how these interact to influence child growth, ability, and health.


Getman states, “A child is taught nothing- he learns everything- and vision is the supreme mechanism a child possesses for the interpretation of his world. All other mechanisms are important for a total child, but they are all subservient to vision.”  Visual development greatly contributes to and facilitates the preparation of a young child to meet the demands of the world, including success in the modern school learning environments.

Early in life, especially during critical periods of development, abnormal visual and sensory input from the environment can retard or alter overall varied aspects of development of the child. Optometric diagnosis and management of the vision anomalies can lead to a stronger and more functional visual system with far-reaching impact. In order to treat these visual disorders, which are often associated with developmental delays, it is important to understand normal expected human developmental milestones. Understanding these milestones, as well as normal human vision development stages, guides the eye care practitioner in diagnosis and provision of the appropriate treatment tailored to each child’s individual needs.

Child Development

Child development is a biological process governed by natural laws.  As a result, child development proceeds in a recognizable pattern with certain behaviors emerging in a sequential fashion.

6 Months

The sixth month is a decisive point in development.  At this time, an infant should be capable of turning over from a supine to a prone position. When in the prone position, the infant is expected to lift the head a considerable amount and display support with the arms and a sense of balance. By lifting the head, babies are expanding their visual field and their visual world, opening themselves up to more visual experiences, and preparing the visual system for growth and development. If sitting, the infant may display the ability to balance for brief moments at a time, and if he or she is pulled up onto their feet, they should possess the ability to balance. When supine, the infant should stretch out the arms and hands and grasp for objects within and outside of reach, and pick up objects and look at them in an observational manner.  If reaching for objects, especially those outside of reach, it can be assumed that the baby is seeing them, at least partially. Socially, an infant should express some level of shyness when meeting an unfamiliar face, and they should recognize and react to changes in facial expression.  Seeing and understanding social cues and nuances begin at a very early age and recognizing facial expression requires a certain level of acuity. The implication is that vision development is essential to the baby’s social and emotional well-being. Sound formation development, including laughter occurs and even when alone, the infant should be making sounds.  Hearing and localization of sound should be mostly intact and an infant should detect the inherent difference between a loving and strict tone of voice.  Reacting to and the ability to localize sounds displays a sense of multimodal coordination of the visual and auditory systems.

12 Months

The child is expected to be able to sit on his or her own and exhibit a sense of balance. A one-year old child should also be able to pull up to a standing position, and in some cases, stand independently without assistance. This is a critical age for mobility, with the child being able to crawl, display controlled rotation and balance, stand unsupported, and in many cases, take a few steps. Mobility is imperative to the expansion of experiences, especially those that are visual. Mobility allows expansion of their visual world and helps facilitate visual development. Development is strongly influenced by actively “doing” things. Looking, exploring, touching, and reaching are necessary behaviors which must be repeated in order to be learned and developed. Mobility creates a myriad of opportunities to “do” things and interact with the environment. Socially and emotionally, the child generally understands when he or she is being reprimanded or praised, and should exhibit good eye contact and social contact. Inferences on fixation ability and gross visual acuity can be made by maintaining eye contact, or by presenting appropriate and clear and easy targets such as laser spots on a table, or a penlight. The child should be able to say 1-3 words, react to his or her name, and to strive to produce more sounds by playing with its tongue and saliva.

3 Years

3 years is an especially important time socially, emotionally, and cognitively. A child is establishing improved control of motor movements, partly through expanded spatial understanding and manipulation.6 This is exemplified by their ability to run, jump, and tiptoe. Coordination is being developed and organized, and locomotion is expanded to tricycles and big-wheels. The toddler is now capable of obtaining objects beyond his/her reach, and overall development is strongly dependent upon vision to begin that process by visually grasping objects beyond arm’s length. The 3-year-old can begin to pour things from a pitcher or a carton, usually with the guidance of both hands, displaying a sense of more refined prehensile control. Accuracy and efficiency of the more refined motor control expected for this age can give insight to relative judgments about depth and understanding egocentric spatial relationships.

A three-year-old toddler should demonstrate certain cognitive milestones. Attention becomes an important factor in cognitive function and is displayed in short bursts lasting several minutes at a time. Imaginative and imitative play becomes an important part of exploration and experimentation, which leads to the development of visualization skills. Language is also expanding at this age, with a vocabulary of nearly 1000 words. Personalities are also beginning to be established and quarreling with other children is often noticed to begin around this age.


For schoolaged children, ages approximately 4-6 years, there are several things that are expected developmentally. In terms of organizational skills and fine motor capability, it is expected that a 4-year-old child can copy a square, 5-year-old child should be able to copy a triangle, and 6-year-old child should be able to copy a diamond. Since it is expected that a 3-year-old toddler can stack 9 blocks, it is expected that a school-aged child can stack the same amount and likely more. Four-year-olds are also expected to be able to complete a six-piece form board, and, at 6 years old, they should be able to complete the split six-piece form board.  Stacking blocks and organizing shapes into a form board provides inferences on visual motor capabilities, as well as eye-hand coordination skills for the child. In addition to stacking and observing, the child also explores by shaking, banging, throwing, and dropping the objects of regard. Repetitive exploration facilitates recognition, and, eventually, inferences about the block, toy, or object can be made by the child.


This first part has reviewed fundamental milestones in a child’s physical development, and what might be expected generally regarding motor, cognitive, and to some degree visual and social skills. Part 2 will place greater emphasis on clinical assessment of visual development.

14773580082_74e2f654a4_oPhoto from North Carolina Christian advocate [serial]” (1894) via Flickr


Getman, Gerald N. How to Develop Your Child’s Intelligence: More Successful Adulthood by Providing More Adequate Childhood. Wayne: Research Publications, 1962.

Barber A, ed. Infant and Toddler Strabismus and Amblyopia. Behavioral Aspects of Vision Care. Vol. 41. Number 2. Santa Ana: Optometric Extension Program Foundation, Inc., 2000.

Flehmig, I. Normal Infant Development and Borderline Deviations. New York: Thieme Medical Publishers Inc., 1992.

Brayden R. Normal Development: 3 Years Old. Children’s Health Network., 25 Sept. 2012. Accessed on 2014 Dec 20. Available from: http://www.childrenshealthnetwork.org/CRS/CRS/pa_devthryr_pep.htm

Baxstrom, C. Vision Development. College of Optometrists in Vision Development 42nd Annual Meeting. Fort Worth, Texas. 2012. Lecture.