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Updated: Nov 4, 2025
Author Spotlight: An Automated Method for Assessing Visual Acuity in Infants and Toddlers Using an Eye-Tracking System
Published on: March 17, 2023
Identifying when children with visual impairment share attention: A novel protocol and the impact of visual acuity
Andrea Urqueta Alfaro1, Stefania Vacaru2, Walter Wittich3
1School of Optometry, Université de Montréal, Montréal, Quebec, Canada; Institut Nazareth et Louis-Braille du CISSS de la Montérégie-Centre, Montréal, Quebec, Canada.
Insights
Infants with visual impairment (VI) can be assessed for Coordinated Joint Engagement (CJE) using a new, reliable protocol. Lower visual acuity in these children was associated with reduced CJE, highlighting the importance of vision for social interaction.
Area of Science:
- Developmental Psychology
- Pediatric Ophthalmology
- Infant Behavior
Background:
- Coordinated Joint Engagement (CJE) is crucial for child development but challenging to assess in infants with visual impairment (VI).
- Existing methods for indexing CJE rely on visual cues like gaze shifting, limiting research in VI populations.
- A need exists for vision-independent methods to study CJE and its relationship with visual function in infants with VI.
Purpose of the Study:
- To develop and validate a novel protocol for identifying CJE in infants with VI, utilizing behaviors not dependent on normal vision.
- To explore the association between CJE and key visual functions, including visual acuity (VA) and contrast sensitivity (CS), in infants with VI.
Main Methods:
- A protocol comprising 9 vision-independent CJE indices was developed and applied to video recordings of 20 infants with VI and their caregivers.
- Inter-coder reliability was established using Cohen's Kappa.
- Linear regression analysis examined the relationship between visual function measures (VA and CS via Preferential Looking and Visual Evoked Potential) and CJE.
Main Results:
- The developed protocol demonstrated high inter-coder reliability (Kappa = 0.98 and 0.90).
- Key observed CJE indices included body orientation to caregiver, gaze switching, and vocalization.
- Visual acuity, measured by Preferential Looking, was the sole significant predictor of CJE, explaining 26.8% of the variance.
Conclusions:
- A novel, reliable protocol effectively identifies CJE in infants with VI using vision-independent behaviors.
- Findings suggest a correlation between lower visual acuity and diminished Coordinated Joint Engagement in infants with visual impairment.
Background:
In Coordinated Joint Engagement (CJE), children acknowledge that they and their social partners are paying attention to the same object. The achievement of CJE, critical for healthy development, is at risk in infants with visual impairment (VI). Research on CJE in these children is limited because investigators use a child's gaze switch between social partner and object to index CJE. Research is needed that identifies CJE in children with VI using behaviors that do not require normal vision and that explores the relationship between CJE and visual function. This study aimed to (a) develop a protocol for identifying CJE in children with VI, and (b) explore the relationship between CJE and infants' visual acuity (VA) and contrast sensitivity (CS), measured with Preferential Looking (PL) techniques and Visual Evoked Potential (VEP).
Methods:
A protocol that included 9 indices of CJE that did not require normal vision was developed to code videos of 20 infants with VI (mean age =1 year, 6 months, 27 days) and their caregivers. The percentage of CJE episodes in which each index was observed was calculated. Inter-coder reliability was measured using Cohen's Kappa. Linear regression analysis was used to examine the relationship between the infants' visual function and CJE.
Results:
Inter-rater reliability between a first coder and each of two second coders were 0.98 and 0.90 for determining whether the child participated in CJE. The following indices were observed the most (in 43-62 % of CJE): child's body orientation to caregiver, gaze switch between caregiver and object, and vocalization to caregiver. The only significant model included VA (measured with PL) as a single predictor and explained 26.8 % of the variance in CJE.
Conclusions:
The novel protocol can be used to identify CJE in children with VI with good inter-coder reliability. The data suggest that children with lower VA exhibited less CJE.
