Multisensory approaches to executive function assessment in preschool children with visual impairment: a literature review

Executive functions (EF) represent a set of higher-order cognitive processes that are essential for self-regulation, learning, and adaptation. In children with visual impairment, the literature suggests increased vulnerability in domains such as planning, inhibitory control, cognitive flexibility, and working memory. Clinical assessment in this population is challenging due to the limited accessibility of standardized instruments based on visual stimuli. The current review aims to identify challenges in assessment and outline a multisensory approach adapted for clinical use. Based on the reviewed evidence, a new multisensory assessment approach should include tasks targeting the main executive domains and adopt multisensory adaptations (tactile and auditory) to reduce visual load and enhance residual perceptual channels. This approach can lead to a more accurate and clinically meaningful functional profile to: (i) guide early, individualized interventions oriented toward autonomy and participation, and (ii) monitor the effectiveness of rehabilitative intervention.

Executive functions (EF) represent a set of higher-order cognitive processes that enable individuals to plan, make decisions, solve problems, regulate behavior, and monitor their own actions in order to achieve goal-directed behavior (Diamond, 2013). These functions constitute a control system that coordinates and integrates multiple cognitive domains, allowing flexible adaptation to environmental demands (Friedman and Miyake, 2017). The principal components of EF include inhibitory control, defined as the ability to suppress impulsive or automatic responses (Spaniol and Danielsson, 2022); working memory, understood as the capacity to maintain and manipulate information during task execution (Morra et al., 2025); cognitive flexibility, which allows modification of strategies and behaviors in response to environmental changes (Buttelmann and Karbach, 2017); and planning, namely the ability to anticipate the actions necessary to achieve a goal (Blair, 2017; Ferguson et al., 2021).

From a developmental perspective, EF emerge early in childhood and undergo rapid growth during the preschool years, representing a critical period for the development of self-regulation and adaptive functioning (Zelazo et al., 2003). Their maturation continues throughout childhood and adolescence, reflecting both neurobiological development and the influence of environmental experiences that shape self-regulatory and adaptive competencies (Zelazo et al., 2008; Crone, 2009; Best and Miller, 2010; Guare, 2014; Fay-Stammbach et al., 2014; Valcan et al., 2018). Throughout development, EF play a central role in behavioral regulation and adaptive functioning (Zelazo and Frye, 1998; Best and Miller, 2010), supporting emotional and behavioral self-regulation, attention control, information management, and flexible problem solving, with important implications for learning and social competence (Will et al., 2021; Kälin and Oeri, 2024; Soltani Nezhad and Delroba, 2024; Moriguchi, 2014; Bradford et al., 2015).

The development of EF largely depends on the quality of early experiences and on the modalities through which children explore and interact with their environment. Among the various sensory systems involved in this process, vision plays a central role in information processing, behavioral regulation, and the development of higher-order cognitive competencies (Atkinson and Braddick, 2020). Consequently, children with visual impairment may experience alterations in the developmental trajectory of EF due to reduced opportunities for visual exploration and interaction with the environment.

Growing evidence suggests that preschool children with visual impairment are particularly vulnerable to difficulties in executive domains such as planning, inhibitory control, working memory, and cognitive flexibility. However, assessing EF in this population remains challenging because most standardized neuropsychological instruments rely heavily on visual stimuli and have not been specifically designed or validated for children with visual impairment. In this context, multisensory approaches, which enhance tactile and auditory modalities, may represent a promising strategy to obtain a more accessible and ecologically valid assessment of executive functioning.

Therefore, the aim of this narrative review is to summarize the current evidence on EF in preschool children with visual impairment, discuss the main challenges related to their assessment, and present a preliminary multisensory clinical framework, derived from the reviewed literature, to guide the future development of adapted assessment protocols.

A narrative review of the literature was conducted to identify studies addressing executive functions (EF) and their assessment in children with visual impairment. Searches were performed in the major biomedical and psychological databases PubMed, PsycINFO, and Scopus, considering articles published between 2000 and March 2025. Relevant keywords included combinations of terms such as executive functions, visual impairment, child development, assessment, and neuropsychology. Only English-language articles published in peer-reviewed journals were considered, including original research, observational studies, methodological papers, and review articles relevant to the aims of this review (Figure 1). Furthermore, literature search was updated in June 2026 to ensure that no additional relevant studies had been published since the initial search. No further publications meeting the inclusion criteria were identified.

A final section presents a preliminary clinical framework, derived from the reviewed evidence, for multisensory executive function assessment. The proposed framework is intended to provide a clinically oriented perspective and should not be considered a validated assessment instrument.

The initial screening identified N = 57 publications as potentially relevant to the aims of this brief review. After excluding N = 16 sources that were historical test references, general theoretical background, or not directly focused on visual impairment and executive function assessment, N = 41 publications were retained for narrative synthesis. Among the retained sources, N = 11 addressed developmental, behavioral, adaptive, educational, or participation outcomes in children with visual impairment; N = 5 focused specifically on executive functioning or closely related regulatory difficulties in this population; N = 7 examined visual development, visual impairment, or cerebral visual impairment and their neurodevelopmental implications; N = 7 supported the rationale for multisensory processing, cross-modal plasticity, and sensory compensation; N = 8 provided theoretical or methodological background on executive functions and neuropsychological assessment; and N = 4 addressed early intervention, rehabilitation, or clinical frameworks for children with visual impairment.

Vision and cognitive development in children with visual impairment

According to the literature, vision represents one of the primary sensory channels through which children acquire information from the environment and construct knowledge of the world (Mercuri et al., 2007). During development, the visual system plays a central role in exploration, learning, and behavioral regulation (Atkinson and Braddick, 2020).

Visual impairment, defined as a partial or total loss of the ability to perceive visual stimuli (Bourne et al., 2013), may significantly reduce access to environmental information and opportunities for exploration, leading to developmental delays compared to sighted peers (Loh et al., 2024; Veldhorst et al., 2022; Grumi et al., 2021). Consequently, children with visual impairment may experience challenges in learning, academic achievement, and later occupational outcomes (Loh et al., 2024; Alvarez-Peregrina et al., 2021; McDonnall and Tatch, 2021).

The literature further highlights lower quality of life and greater difficulties in adaptive functioning among individuals with visual impairment (Bathelt et al., 2019; Elsman et al., 2021). More generally, early visual deprivation may exert long-lasting effects on brain functioning and on the development of higher-order cognitive abilities, including EF, which depend strongly on early experiences and environmental interactions (Noppeney, 2007; Bathelt et al., 2019).

Visual impairment and risk of executive deficits

Current evidence indicates that children with visual impairment exhibit increased vulnerability in the development of EF (Bathelt et al., 2019; Choobdary et al., 2020). The reduction or absence of visual input alters environmental exploration and information acquisition, affecting processes of cognitive and behavioral regulation (Merabet and Pascual-Leone, 2010; Alon et al., 2010). In this sense, visual impairment represents not only a sensory condition, but also a developmental variable capable of influencing the trajectory of executive function development.

Children with visual impairment more frequently exhibit difficulties across the principal domains of executive functioning, including planning, inhibitory control, cognitive flexibility, and working memory (Choobdary et al., 2020; Heyl and Hintermair, 2015; De Carlo et al., 2014; Zihl and Dutton, 2015; Chokron and Dutton, 2023). These difficulties may have significant implications for adaptive functioning, autonomy, school participation, and social interactions (Choobdary et al., 2020). However, the early identification of executive vulnerabilities remains challenging due to the lack of assessment instruments adequately adapted for this population.

Challenges in the assessment of EF in children with visual impairment

Despite the central role of EF in children's cognitive and adaptive development, their assessment in children with visual impairment represents a significant clinical and methodological challenge (Bathelt et al., 2019). Most neuropsychological instruments used in clinical practice have been developed and standardized on sighted populations and rely extensively on visual processing, rendering them largely inaccessible or inadequate for children with low vision or blindness. Commonly used measures include the Stroop Color–Word Test (Stroop, 1935), the Wisconsin Card Sorting Test (Berg, 1948), the Tower of London (Shallice, 1982), the Trail Making Test (Reitan, 1958), the Wechsler Digit Span subtests (Wechsler, 2014), and developmental batteries such as the NEPSY-II (Korkman et al., 2007).

Because many of these instruments require visual discrimination, symbol processing, or manipulation of graphic materials, performance may reflect perceptual limitations rather than actual executive functioning (Warren, 1994). As a result, clinicians may underestimate children's cognitive competencies and obtain a distorted interpretation of their functional profile (Chaudry and Davidson, 2001). Furthermore, informal adaptations of traditional tests may affect the validity and reliability of assessment (Aprile et al., 2020), while raising concerns about the ecological validity of measures that often fail to reflect how children with visual impairment explore and interact with their environment (Joyce et al., 2022).

These limitations highlight the need for adapted, multisensory, and ecologically valid assessment tools capable of providing a more accurate and functionally meaningful executive profile.

A multisensory and early approach to the assessment of EF in children with visual impairment

Scientific literature on EF in children with visual impairment is still emerging; however, available evidence indicates vulnerabilities in inhibition, working memory, attention, and cognitive control compared to sighted peers (Bathelt et al., 2019; Heyl and Hintermair, 2015). Given the central role of EF in cognitive and adaptive development, these findings highlight the need to reconsider assessment and intervention models for this population (Bathelt et al., 2019; Choobdary et al., 2020).

The reduction or absence of visual input requires children to rely more heavily on alternative sensory channels, particularly touch and hearing, for environmental exploration and information processing (Hötting and Röder, 2009; Cattaneo and Vecchi, 2011). Accordingly, cognitive development can be viewed as a multisensory process grounded in the integration of perceptual information and active interaction with the environment (Bremner et al., 2012; Gori et al., 2014). These characteristics support the adoption of rehabilitative approaches that enhance residual sensory channels and promote early cognitive and behavioral regulation, particularly during the highly plastic developmental period of early childhood (Pasqualotto and Proulx, 2012; Sonksen and Dale, 2002; Dale and Salt, 2007; Bavelier and Neville, 2002; Lewis and Maurer, 2005).

There is also a need for assessment models capable of more accurately capturing executive functioning in children with visual impairment (Pereira and Conti-Ramsden, 2019). Assessments based exclusively on visually mediated tasks may provide a partial representation of children's competencies; therefore, functional and multisensory approaches are needed to identify both difficulties and compensatory strategies and to inform individualized interventions (Lueck and Dutton, 2015; Fazzi et al., 2005).

Within this framework, the present work proposes a clinical perspective aimed at supporting the development of assessment and intervention protocols adapted for preschool children with visual impairment, with the goal of promoting executive function development, autonomy, and participation (Sonksen and Dale, 2002; Dale and Sonksen, 2002).

Assessment of EF in children with visual impairment: a proposal

Despite the body of evidence emerged in this review, no standardized and accessible tools are currently available for the analysis of EF in children with visual impairment, rendering this field a significant clinical and methodological challenge. Available protocols have been developed on sighted populations and rely extensively on the visual modality, with the risk of providing unreliable and difficult-to-interpret measures in children with low vision or blindness (Bathelt et al., 2019; Choobdary et al., 2020). In this context, the need emerges to develop adapted assessment tools capable of providing a more accurate interpretation of executive functioning in this population.

The proposed protocol is grounded in the literature reviewed in this article and was developed by the multidisciplinary team of the Fondazione David Chiossone (Genoa, Italy). It is addressed to children with visual impairment aged 3–5 years and adopts a multisensory approach centered on compensatory sensory channels and bodily experience. At this developmental stage, EF undergo rapid maturation and are strongly influenced by early experiences and environmental interactions (Garon et al., 2008). The protocol systematically explores inhibitory control, working memory, cognitive flexibility, and planning through play-based activities designed to be accessible and meaningful for children with visual impairment.

Specifically, the protocol includes five tasks for inhibition, five for working memory, four for cognitive flexibility, and four for planning. Each activity incorporates tactile and auditory adaptations to reduce visual load and promote the expression of the child's actual competencies. The centrality of tactile and auditory channels reflects the typical modalities of exploration and learning in children with visual impairment.

Among the planning tasks, one activity involves reproducing a model composed of tactile tiles while keeping the original configuration available as a reference. A second task requires the child to reproduce a tower composed of tactile cubes mounted on a rod, organizing the sequence of actions necessary for its reconstruction (Figure 2).

For the assessment of inhibitory control, the child is required to touch a sequence of tactile tiles and verbally identify only those characterized by specific textures, while inhibiting responses to nonrelevant stimuli. Working memory and cognitive flexibility are explored through objectmanipulation tasks requiring the maintenance, updating, and shifting of response rules. Working memory activities include auditory and tactile span tasks, sequential recall of sounds or objects, and everyday play situations requiring the retention and manipulation of information. Cognitive flexibility is explored through games in which children are asked to switch between changing tactile or verbal rules, adapt ongoing responses, and inhibit perseverative behaviors following new instructions.

Taken together, these tasks allow observation of performance, problem-solving strategies, processing times, and action-monitoring processes, providing a functional profile of executive competencies and supporting the monitoring of developmental progress over time. At this preliminary stage, task performance is interpreted through both quantitative and qualitative clinical indicators. Quantitative criteria are based on the number of correctly completed items or inhibited responses, with performance classified into descriptive levels such as absent, emerging, or present, according to the child's age and task demands. Qualitative observation also considers response latency, execution speed, need for prompts, error monitoring, and self-correction.

The assessment of EF represents the starting point for the design of neuropsychomotor intervention and the definition of targeted rehabilitative goals (Anderson, 2002). Early intervention based on adapted multisensory assessment is particularly relevant during the first years of life, given brain plasticity and the presence of sensitive developmental windows (Sonksen and Dale, 2002; Dale and Salt, 2008).

The present review highlights the relevance of EF assessment in preschool children with visual impairment, emphasizing the need for assessment approaches that adequately account for the developmental consequences of reduced or absent visual input. Although EF difficulties are consistently reported across the reviewed studies, particularly in planning, inhibitory control, cognitive flexibility, and working memory (Bathelt et al., 2019; Heyl and Hintermair, 2015; Choobdary et al., 2020), the available evidence does not currently allow reliable estimates of their prevalence because of the marked heterogeneity of study populations, visual impairment characteristics, and assessment methods.

Rather than representing only a sensory deficit, visual impairment should be considered a developmental condition that influences environmental exploration, multisensory integration, and the maturation of higher-order cognitive processes (Noppeney, 2007; Merabet and Pascual-Leone, 2010; Chokron and Dutton, 2023; Cattaneo and Vecchi, 2011; Bremner et al., 2012; Pasqualotto and Proulx, 2012). This perspective reinforces the need for assessment procedures specifically adapted to children who rely predominantly on non-visual modalities.

The reviewed evidence also suggests that currently available neuropsychological instruments may underestimate EF in children with visual impairment because they frequently depend on visual processing (Warren, 1994; Chaudry and Davidson, 2001; Aprile et al., 2020; Choobdary et al., 2020; Joyce et al., 2022). Although several adaptations have been proposed, including tactile modifications of standardized tasks, verbally mediated (auditory) administration procedures, and functional observational approaches, these strategies generally target specific executive function components rather than providing a comprehensive assessment. Moreover, most available adaptations consist of modifications of visually based instruments and have limited psychometric validation in children with visual impairment (Warren, 1994; Chaudry and Davidson, 2001; Aprile et al., 2020; Joyce et al., 2022). In this context, the proposed multisensory protocol offers a clinically oriented framework that integrates tactile materials, auditory cues, and functional observation to evaluate executive abilities while minimizing visual demands. Beyond task performance, this approach allows clinicians to observe problem-solving strategies, exploratory behaviors, processing times, and self-monitoring, providing useful information for individualized rehabilitation planning (Giofrè et al., 2017; Anderson, 2002; Dale and Salt, 2007; Fazzi et al., 2005, 2021).

The preschool years represent a particularly appropriate period for this type of assessment, given the high levels of neuroplasticity and the responsiveness of executive function development to environmental experience (Zelazo and Frye, 1998; Garon et al., 2008; Lewis and Maurer, 2005; Fay-Stammbach et al., 2014; Valcan et al., 2018; Guare, 2014). Early identification of EF vulnerabilities may therefore support timely neuropsychomotor intervention and contribute to more individualized rehabilitation pathways.

Overall, adapted multisensory assessment may represent an important step toward more inclusive and ecologically valid models of care for preschool children with visual impairment, supporting executive function development, participation, autonomy, and long-term adaptive outcomes (Fazzi et al., 2005; Bathelt et al., 2019; Elsman et al., 2021; Loh et al., 2024).

Limitations and future directions

Despite the clinical value of the proposed approach, the assessment of EF in children with visual impairment still presents important methodological limitations. The protocol was developed within routine rehabilitative practice and therefore requires systematic evaluation of its psychometric properties, including reliability, construct validity, and sensitivity to change (Strauss et al., 2006; Anastasi and Urbina, 1997).

Future studies should examine the ecological validity of the proposed measures and determine the extent to which task performance predicts adaptive functioning in everyday contexts (Chaytor and Schmitter-Edgecombe, 2003). Another limitation is the absence of normative data, highlighting the need for standardization studies on representative samples of children with visual impairment to establish developmental profiles and reference criteria (Nunnally and Bernstein, 1994; Strauss et al., 2006).

Multicenter studies will be essential to evaluate the generalizability, replicability, and feasibility of the protocol across different clinical settings and levels of visual impairment (Hulley et al., 2013). Future research should also compare the performance of children with visual impairment and typically developing peers to better characterize executive function developmental trajectories (Cohen et al., 2013). In addition, future systematic reviews and, where feasible, meta-analyses will be important to provide a more comprehensive synthesis of the available evidence and to strengthen the evidence base supporting executive function assessment in children with visual impairment.

A long-term objective is the development of a standardized version of the protocol, including an operational manual, structured materials, and shared administration procedures, to facilitate its integration into clinical practice (AERA et al., 2014; Hulley et al., 2013). Accordingly, the proposed framework should be considered a preliminary clinical proposal requiring formal psychometric validation before implementation as a standardized assessment tool. Future studies will also be required to refine the scoring procedures, evaluate inter-rater reliability, and determine whether qualitative and quantitative indicators can be integrated into a standardized scoring system.

The preliminary clinical framework proposed in this work highlights the need for adapted approaches to the assessment and support of EF in preschool children with visual impairment. Given the importance of EF for cognitive, academic, and social development, and the vulnerability of this population, the lack of accessible and validated instruments remains a significant limitation. The multisensory approach described in this review addresses this gap through an early assessment model based on multisensory tasks and functional observation, capable of capturing both difficulties and compensatory strategies. Assessment thus becomes an integral component of the neuropsychomotor rehabilitative pathway, guiding intervention planning and monitoring developmental progress over time. Future validation, standardization, and multicenter studies will be essential to strengthen the reliability of the proposed instrument and promote more inclusive and evidence-based models supporting autonomy, participation, and wellbeing.