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8. Report on theme 1: Residual and functional vision
By Mr Steve Minett
(Information provided by the facilitators: Heather Mason and Christine Arter)
Before reading the selected papers it is important to understand the terminology that is being used. For example, although there is an universal agreement on definitions for such terms as blindness and low vision (WHO 1992), the definition of blindness and legal blindness differs from country to country. Most of the definitions used by countries to define low vision (including WHO 1992) are based upon clinical definitions using a standard measurement e.g. Snellen. These definitions are a reflection of the beliefs that persons (including children) with low vision function in a way that can be predicted by clinical measurements.
However, most of us will be able to give many examples of children with the same eye condition, the same recorded visual acuity score but who function in a very different way.
Sukvinder and Karl, aged 11, had congenital cataracts and visual acuities of 6/60. Sukvinder, the eldest of four children, was highly motivated to use his vision for school work enjoying a range of physical activities such as football and swimming. He moved quite independently around the school and his neighbourhood helping his mother with shopping and tasks within the home. At school, he was very popular and it was difficult to believe on many occasions that he had a severe visual impairment. Karl, who had an older sister was reluctant to read and write print or to use the CCTV that had been bought specifically for him. He shunned any physical activities and constantly brought notes to school to excuse him from swimming. Table manners were very poor, and he persisted in eating as much as he could with his fingers. After PE, he had great difficulties in buttoning his shirt and tying shoe laces! Weekends were spent in bed listening to pop music and being fed finger food. Karl, an intelligent boy, was functioning as a much younger 'blind' child in many respects - he wasn't motivated to make the best use of his vision.
Corn and Koenig (1996) define a person with low vision as 'a person who has difficulty accomplishing visual tasks, even with prescribed corrected lens, but who can enhance his or her ability to accomplish the tasks with the use of compensatory visual strategies, low vision and other devices and environmental modification.' This is perhaps a good one for this workshop rather than the medical one.
Other definitions needed for the workshop are:
It is also important to realise that this terminology may be used differently by different persons. This is demonstrated by Corn and Koenig (1996)
'Educators, rehabilitation professionals and medical professionals have come to use terms such as visual function, functional vision, and visual efficiency in different ways. To educators or rehabilitation professionals visual functioning and functional vision typically refer to an individual's ability to perform a task; often these terms are used interchangeably. Furthermore, these professionals use visual functions to refer to specific visual behaviours, such as fixating on an object and tracking it. To medical professionals, however, visual functions refer to organic features of the eye and visual systems that can be measured clinically, such as visual acuity, field of vision and contrast sensitivity - measures that educators and rehabilitation professionals frequently refer to as visual abilities. Likewise, to medical professionals, the term visual efficiency indicate the absence of limitations on visual functions, whereas to educators and rehabilitation personnel, it relates to how well a person with low vision uses his or her functional vision.'
The papers included for the theme on Residual Vision give an overview of this important area. The first paper, Development of Efficiency in Visual Functioning: A Literature Analysis written by Natalie Barraga gives a historical aspect. This is important as Natalie Barraga was the first person to really change attitudes about the need to stimulate and use the residual vision in young children with very low vision during the 1960s and 1970s. This paper examines the current literature of the 1970s covering the progression of visual functions in early childhood development. An important conclusion arising out of the paper is that the principles which apply to visual development are as valid when the system is impaired as when there is no impairment.
The discussions on terminology and what aspects of visual functions should be assessed to determine visual efficiency and visual functioning are important and this paper highlights the different interpretations by different professionals (please see the comments by Corn and Koenig in the introduction to this section - this problem still exists!). For example, Faye (1976) stated quite clearly that distance acuity measurements alone give little information about the visual capabilities of a young child.
The paper reports some of the early studies of young people using low vision aids. Carpenter (1976) found that 'the self image of the students changed from that of a blind person to that of a sighted person; reading medium changed from braille to print; students changed from listeners to readers; and actions changed from dependence to independence.'
She emphasised the importance of a positive philosophy and psychological support among regular class teachers and the specialists and consultants. We are still struggling with these issues as we approach the new millennium!
The second paper, Residual Vision adapted by Heather Mason from the University of Birmingham course materials for teachers of the visually impaired, gives another overview of the different models of visual functioning and looks at some of the different ways in which functional vision can be assessed. Here is an extract of that paper.
Corn and Koenig (1996) summarise the various theories which attempt to explain how children and adults develop or use their low vision.
The visual abilities are visual acuity, visual fields, motility (eye movements), brain functions, light and colour reception. The environmental cues include colour, contrast, space, illumination, time. The stored and available individuality dimension includes cognition, sensory development, integration, perception, psychological make-up, physical make-up.
Corn suggests that all the components must be present to some degree for visual functioning to occur and that during development, a child's visual abilities 'develop' while other compensations for or hindrances to the visual function can interact.
In contrast the vision training programmes are thought to systematically teach a set of specific visual skill that are normally learned incidentally. This is an important distraction between them.
Such specific skills may include visual attending behaviours, visual examing behaviours and visually guided motor behaviours. Underpinning these are certain visual capabilities such as visual discrimination, fixation and convergence.
As part of the model, Hall & Bailey have suggested three ways for teaching specific behaviours
This is only a brief summary of some of the main theories addressing different aspects of visual development and functioning. They do not attempt to explain all the individual variations but do give a good foundation for understanding this important area.
As residual functioning can be improved in most cases by the use of low vision aids (also called low vision devices), the third paper, Guidelines for teachers and parents of young people with a visual impairment using low vision aids (LVAs), looks at the different types of LVAs and issues to deal with assessment and training. This is an adaptation of some recent research (Mason and Mason,1998) examining the usage of low vision aids by young people with a visual impairment in mainstream secondary schools.
These guidelines summarise all the important information relating to types of low vision aids and gives practical advice on activities for encouraging usage within the mainstream setting and at home. An important aspect of the guidelines is devoted to training programmes. This short section gives examples (Training programmes for using LVAs, Elements of a training programme, Principles of training and Criteria for successful use of LVAs) of the information contained in the Guidelines.
The design and content of a training programme is going to depend upon the type of LVA and to some extent upon the age of the pupil. These suggestions come from a range of sources, for example Jose (1984), Cowan and Sheplar (1990), Bennett and Mason (1995) and Erin and Paul (1996).
Most programmes include (depending upon the type of LVA)
Training should never be considered as a 'one-off' activity. Whilst it may be useful to have some kind of checklist, it should never be assumed that the pupil cannot improve existing skills. Of importance is the speed at which the young person can search through or read text for the information they require. Such skills depend upon good techniques and upon practice. and will incorporate aspects of the individual skills mentioned above.
Although it may seem like common sense, it is important with all training programmes to start with (if applicable)
As skills develop, these variables can be changed. Training in the use of any LVA moves the young person from familiar to unfamiliar situations and from supported to unsupported use as an independent and highly motivated user.
It is also important to notice the posture and position of the body, head and eyes. Poor posture or tension in any parts of the body especially the neck or arms will lead to rejection.
The same research by Mason and Mason asked teachers what criteria they use for determining successful usage of the LVA by the young person. The order of the number of positive responses were:
Most of these are highly valuable personal judgements made about the pupils in the context of their work. However, it may be that there is also a need for a more structured approach which enables teachers to assess and plan for the use of LVAs using observable, measurable competencies to teach the skills in a timely and developmentally appropriate manner. As competencies can be defined as knowledge and skills which are measurable and for which some objective criteria for successful performance have been established the two approaches complement one another. The competency based approach has added advantages in that it is possible to involve far more people in the process including the visually impaired learner themselves and their family.
As the working environment is so important for the effective use of residual vision, the final paper by Jeanette Lomas and Barbara Ackerley entitled An Environmental Audit gives good practical suggestions for an environmental audit within a school. As more and more pupils with a visual impairment are receiving their education with the mainstream, it is important that before placement, the suitability of the school environment is considered. This paper gives clear and straight forward suggestions how this can be done. It poses an important question - how can we ensure the right kind of environment for learning so that the physical conditions of a school so not create barriers and turn an impairment into a handicap?
The reader is asked to consider the visual environment, the sound environment, the tactile environment and the social environment of the child and supplies a good check list for this to be done. For example, if we consider the aspect of lighting within a classroom, it is important to consider:
It can be seen from this brief example, that unless the learning environment is right for the child with low vision, they will be unable to make the very best use of their residual vision - the theme of this workshop!
As an area of study, low vision is both important and well-resourced. The study of low vision, in particular residual vision and functional vision, is established as an essential topic for a training programme for specialist teachers of children with a visual impairment. The list of required competencies of a teacher of VI children produced at the first ICEVI Teacher Training Workshop makes this clear by including for example 'the principles of assessment of functional vision', and 'appropriate strategies to enhance functional vision'. However low vision is not an isolated topic: an understanding of the implications of low vision is needed in almost all aspects of the training course. There is a large amount of relevant literature readily available on the subject of low vision. Examples and sources are given in the reading material in section 1 above and the bibliography in section 6 below.
For this workshop the discussion group did not set out to provide new knowledge in the area of residual and functional vision. Its main aims were to look critically at the subject matter in the light of the group members' experience and to reappraise it, suggesting new priorities that are appropriate in the context of modern Europe. The group has attempted to give a new perspective on an established body of knowledge, and to suggest ways in which the implications of low vision may be introduced to teachers training in the field of visual impairment.
The discussion group was asked to work for two days in the context of a teaching unit for training teachers of children with a visual impairment in the subject area of residual and functional vision. The four aspects of the main theme were chosen for discussion:
On the first day, after the introductions, the facilitators encouraged the members of the group to provide information relevant to the first topic by taking part in a 'brainstorm': ideas were put forward and recorded on the blackboard as they occurred to the members of the group. No priority or particular order was specified. This process allowed all of the members of the group to participate when they felt able to do so, and to contribute points that that were important to them. It also allowed the individuals to learn about each other and to gain an impression of the commonality of the issues as well as differences in settings, countries and cultures. Topic 2 was introduced in a similar way. For the third topic a selection of proformas and checklists for low vision assessment procedures were distributed and studied and their strengths, weaknesses and differences were discussed.
The second day was used to examine critically the information collected and to process, organise and prioritise it. This was done in a series of group and plenary sessions. In the final plenary session the content of a unit on residual and functional vision as part of a training programme was reconsidered.
The work completed in the two days is summarised in section 4.
This question was used to initiate a 'brainstorm', the first activity carried out by the group in its opening session. It is suggested that a similar activity may be used with a group of trainee teachers to help them to appreciate the wide range of implications that low vision has for a child.
This is the raw material from the brainstorm:
Mobility and orientation, living skills, lifelong learning, reading print, personal awareness and self-esteem, using residual vision to maximum effect, social development, shared experiences with families and other (sighted) children, independence, supporting the mainstream teacher, reading print (access to information and to literature), pictures, changing the attitudes of sighted people, choosing between print and Braille as a working medium, safety in practical lessons and everyday life, cognitive development, vision gives access to technology, the need to encourage more research, teaching skills that enable vision to be used, leisure activities, learning and coping strategies, use of residual vision in employment, emphasise what children with low vision can achieve, efficient use of low vision aids, etc
The discussion group divided into three sub-groups. The first sub-group considered these ideas and made some suggestions for organising them and putting them into order of priority as follows:
This list is given as an illustration of one of the many ways in which these issues can be organised.
This was seen as a complex issue that trainee teachers should be encouraged to explore. The brainstorm encouraged creative thinking and allowed all members of the group to contribute as follows:
Different media for different subject areas, children make their own choice of medium, monitoring and reassessing, strong parental feeling, many factors interact, nature of support, fatigue, speed of use, attitude of teacher, ability to use LVAs, braille as an additional channel for information, personality and character of the child, not a simple choice but a process, parental acceptance, prognosis, new technology makes material available in braille, how stressful the medium is for the child, prejudice, consider the needs of each individual child, motivation, acceptance, attitudes in mainstream (teachers and children), use of braille in class (noise), use of technology, independence, social factors, participation, most VI children have some residual vision.
The second sub-group worked on this raw material and organised the issues in the following way:
The choice of print or braille as a working medium
Take into account the views of the key people named in 1 above. Consider the results of assessment. It is not a simple choice but a process.
There are three possibilities to choose from:
Talk to the classroom teacher about their feelings and anxieties: acknowledge and discuss them - challenge prejudices. Discuss the situation objectively: the new role, the demands created by the visual impairment and the support that you (as a specialist in visual impairment) can offer. Consider the individual needs of the child by examining the available information, for example: eye condition, history of early intervention and progress, assessment results, IEP. Discuss the support network for the classroom teacher and the VI child, including the family, other pupils, you as the support teacher, the whole school.
The teacher will need to modify the teaching approach and to acquire new ways of thinking, to be prepared to try new ways of teaching and to continually evaluate the work. Specialist methods and specialist knowledge will be needed.
Be aware of suitable resources already available: modified large print books, tapes, pictures, maps, models. Co-operate with VI specialist support in the production of modified material for the individual child.
The classroom teacher can be involved, included and supported in the progress of the VI child. The classroom teacher must feel part of the team.
After examining a number of pro-formas and checklists the group made the following suggestions:
Clear introductory information including
Is it designed for the aspects you want to observe e.g. academic skills, ADL, environmental factors (light etc)?
Is it really appropriate for:
Does it give suggestions for further assessments?
Can the information be used in a constructive manner e.g. for IEPs, teaching programmes?
Is it too long/too short?
Is it easy to administer e.g. can one person use it?
Is it easy to read, record information and is there space to add additional information?
Is it a 'one-off' observation or can it be used to record progress over time?
Literature search relating to visual functioning and examples of models of visual functioning
Differentiate between residual and functional vision
Assessing the child's use of residual vision taking account of the whole child in different environments, across all aspects of the curriculum.
Using assessment tools - criteria to critically assess their usefulness and effectiveness:
Incorporating assessment information in IEPs
Develop the ability to design teaching programmes and materials to encourage efficient use of residual vision.
Two intensive days were spent working on the subject of training teachers in the area of low vision. The members of the group felt that two overriding ideas had emerged: first, the importance of the visually impaired child as a unique individual, with special abilities and needs that must be considered, and second, the need for every teacher to think critically and to examine the issues carefully so that the individual child's needs can be met. As a result of the discussion it was felt that the trainee teachers would be encouraged to challenge accepted views, to think critically, to develop a better understanding of issues and to be more creative in their work. It was hoped that the exemplar material given in part 4 above would be of value.
The chairman, facilitators and secretary would like to thank all of the participants for their commitment, enthusiasm, tolerance and patience throughout the workshop. A wide variety of backgrounds and cultures were represented and all were willing to share experiences and to exchange views. Finally our thanks and admiration to those members of the group for whom English is not the first language for working so intensively and skilfully in order to ensure the success of this workshop.
References and further reading
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