Cerebral Palsy and Visual Impairment in Children:
of Collaborative Practice in Scotland
Chapter 4 The Roles of the Professionals
4.1 The Community Paediatrician
by Aisla Sinclair
A community paediatrician is a doctor who specialises in looking after children with chronic illness and disability in a community setting. He/she works out of clinics, health centres, nurseries and schools and in close co-operation with other agencies - education, social work and the hospital-based services - to help children, within the constraints of their disability, to make the most of their education and achieve their maximum potential.
A community paediatrician with a special interest in visual impairment will have experience and skills in neurodevelopmental assessment which will have been extended to cover visual function in greater depth and detail. They will seek all background information there is about a child, with a detailed medical history, a thorough medical and developmental examination, a view of investigation results plus a collation of information from health visitors, GPs, paediatricians, ophthalmologists, orthoptists and other medical and non-medical professionals who have been involved with the child, in order to establish or confirm a diagnosis. Diagnosis is usually related to cause.
Assessment tools used by the paediatrician will be a mix of medical examination and functional assessment which will include both observation and task setting. The Reynell- Zinkin Scales (Reynell & Zinkin, 1979) can be used. They are a graded series of those observations and tasks which have been designed as a measure of development in a child with visual impairment.
Diagnosis leads on to treatment which may be medical but more often harnesses the expertise of other agencies - teacher of children with visual impairment (TVI), teachers, speech and language therapists, occupational therapists and physiotherapists, educational psychologists. This diagnosis-treatment process parallels the assessmentintervention system of other agencies. While all agencies may have the same goals, they tend to use different terminology. The community paediatrician is at the interface between the acute services and the community. It should be their role to convert the information passing between the various agencies into a common language, which can then be used in communication between parents and professionals and to plan strategies for the support, education and development of the child.
An example of collaborative working between agencies and across the acute/community services divide is in joint assessment.
This has been found to be very useful, for example, where an orthoptist has been able to observe a child during a teaching session with a TVI, that is, in a real setting, rather than in a clinic, with real everyday objects. The paediatrician and the TVI have collaborated to assess development and functional vision at the same time - particularly important for a child with CPVI.
Each professional brings a different perspective. Assessment from different angles gives a more complete picture which is important in a child with CPVI where it is often very difficult to tease out primary, and secondary causes (e.g. is a child’s head drooping because of weak musculature or poor vision), and where visual function might vary in quality and timing from day-to-day
The community paediatrician slots well into the multi-disciplinary team caring for the child with CPVI:
Communication: Facilitates communication between the Acute Services and the community so that information gathering is structured and efficient.
Medical information: Important contribution of medical and neurodevelopmental information.
Co-ordination: Practised in interagency working so that easily takes on a coordinating role.
Overview In collating information and drawing the team of parents and professionals together, the community paediatrician is in a prime position to overview the whole child so that all needs are identified and gaps in provision bridged.
4.2 The Peripatetic Teacher of the Visually Impaired
A peripatetic teacher of visual impairment (TVI) visits children at home, in the nursery, mainstream or special school. The teacher is a visitor supporting both the child and the people who deliver the child’s education. Their role can vary between authorities but involvement begins with a referral which is usually followed up by a functional vision assessment. This is likely to comprise of the following:
- Gathering of background information from those who know the child, such as the parents, class teacher and other specialists already involved. Joint visits are made if possible. Reports from the ophthalmologist are requested.
- Observation of the child in everyday situations in the home, nursery or classroom.
- Identification of an appropriate vision assessment tool. For the child with cerebral palsy, in particular, this will involve assessing more than acuity, including also contrast sensitivity and visual field. Approaches used will range from those recommended in ‘Vision for Doing’ (Aitken & Buultjens, 1992) and Lea Test materials (Hyvärinen, 1995-96) for those with additional difficulties, to the standard Snellen Chart and Maclure Reading Type Test.
A report will follow which summarises the results of the assessment and it will make a number of recommendations concerning classroom practice. The TVI begins to visit the child to help implement these recommendations. The frequency of the visits will vary depending on the degree of visual impairment and whether the child is in a special or mainstream school/nursery or at home. The TVI can offer advice and support in some of the following ways:
- Raise awareness of visual impairment in the school and help other people develop an understanding of the child’s needs and the effect of cerebral palsy on the child’s use of vision: in-service training will be offered to the school./li>
- Suggest any necessary physical changes to the child's environment and position in the classroom; this will require discussion with the child's physiotherapist.
- Advise upon adaptation of reading materials or alternative communication aids. When applicable a print size is recommended, or alternatively the size of symbols or types of signs may be discussed with the speech and language therapist.
- Give training in how to use specialist equipment and monitor its use, for example, low vision aids, specialist technology, or Lilli Nielsen’s ‘Little Room’ (Nielsen, 1992).
- Teach the child strategies such as making use of a reading marker.
- Discuss with the teacher targets for the child’s IEP.
- Negotiate on behalf of the child, for example if a reduced amount of classwork is necessary.
- Offer individual teaching of skills that the child with CPVI may find particularly difficult, such as scanning, tracking, or handwriting.
- Continue to observe the child's vision so that changes can be detected early.
- Develop a relationship with the child's parents as soon as possible. This is best when a referral is made immediately after diagnosis, and the TVI can begin by visiting at home and maintain contact when the child starts school, or ensure introductions are made between parents and a new TVI. The TVI provides support for the parents as well as the child and can liaise between home and school.
- Suggest any other agencies that could be involved.
Case study of peripatetic teacher’s involvement with a child with cerebral palsy and visual impairment in a special school
Richard has cerebral palsy, is registered blind and has profound learning difficulties. He was referred by a multi-disciplinary pre-5 assessment team for support from a peripatetic teacher of visual impairment at the age of one year. Weekly home visits began. His vision was assessed using 'Vision for Doing'. He was attentive to stimuli to the other senses but it was uncertain whether he had light perception. He started nursery at a school for children with complex needs at age two and visits from a VI teacher continued. Staff were encouraged to keep an open mind about his vision and to continue to observe his response to light. There were joint observation sessions which staff have continued in between visits.
The VI teacher recommended that Lilli Nielsen’s 'Little Room' was introduced when Richard started at the nursery. The VI teacher suggested some appropriate real objects to begin with and made the initial structured observations.
The 'Movement Gesture and Sign' approach described by Lee and MacWilliam in 'Learning Together' (2002) was recommended then discussed with Richard's speech and language therapist and class teacher. The VI teacher helped staff to identify initial movements that Richard made that could be interpreted as gestures and nurtured into his unique signs.
Richard was referred to Bobath Children's Therapy Centre Scotland and the VI teacher has been able to join in therapy sessions with their physiotherapist and OT. Bobath Scotland also liaises with school staff. Richard is now five years old and is able to sit with minimal support. This has improved his possibilities for play.
Richard's case highlights the value of early involvement from a teacher of visual impairment for a child with cerebral palsy, visual impairment and other difficulties. Severe visual impairment is not just another disability. In cases where the home visiting teacher is from another specialism, regular joint visits could produce similar benefits.
Aitken, S and Buultjens, M (1992) Vision for Doing. Edinburgh: Moray House Publications. Available for downloading at www.ssc.education.ed.ac.uk
Hyvärinen, L (1995-96) Vision Testing Manual. Villa Park, Illinois: Precision Vision.
Lee, M and MacWilliam, L (2002) Learning Together: A creative approach to learning for children with multiple disabilities and visual impairment. London: RNIB.
Maclure Reading Type for Children. Harlow: Clement Clarke International Ltd.
Nielsen, L (1992) Space and self. Copenhagen: SIKON.
Reynell, J and Zinkin, P (1979) Reynell-Zinkin developmental scales for visually handicapped children. Chicago, IL: Stoelting Co.
4.3 The Vl Teacher in the Special School/Unit for Children with Multiple Disability and Visual Impairment (MDVI)
The VI teacher in a school for MDVI is responsible for a small group of children, some of whom may have cerebral palsy and a visual impairment (CPVI). The teacher’s role would come under the following headings:
Visual assessment using a number of methods
- Functional assessment materials, e.g. 'Vision for Doing', Lea Hyvärinen's materials.
- Ongoing observation.
- Ongoing assessment.
- Ongoing evaluation of assessment.
The Vl teacher within the special school for those children with more complex needs may use materials to assess the child’s functional vision, e.g. ‘Vision for Doing’ and those of Lea Hyvärinen, rather than the standard tests used for mainstream children. This, together with ongoing observation of a child in everyday situations, gives a better picture of how well they use their residual vision. Ongoing evaluation and assessment is extremely important if the teacher is able to monitor any changes and plan appropriately for the child’s educational needs.
Individualised Educational Programme (IEP)
- Assess the target needs of the child - short term/experiential/long term.
- On-site collaboration with other professionals: speech and language therapists; physiotherapists; occupational therapists; mobility specialists; visiting specialist subject teachers, home link, hearing impairment.
- Co-ordinating information from other professionals.
- Recording targets - to draw up IEP.
- Carrying out IEP.
- Ongoing assessment of achievement level of child - recording.
- Ongoing assessment of delivery method of IEP - evaluation.
Every child has his/her own specific needs so a plan is necessary to meet these needs. Depending on the child, targets may be short (experiential) or long term. Meeting with other professionals is important at the planning stage so that they can have input in their particular area. The teacher can then co-ordinate the information and record the targets within the programme. It is then the duty of the teacher and her classroom team to carry out the programme daily. There must be ongoing assessment of the achievement level of the child and method of delivery of the IEP to make sure the child is meeting his/her potential.
- Communication at review meeting and parents nights.
- Input to IEP.
- Two-way communication through home/school diary.
- Reinforcement of work at home.
It is essential that the parents have an input at the planning stage and also that there be ongoing communication to ensure continuity in targets set.
- Responsibility for classroom team.
- Organise and communicate method of carrying out IEP.
- Oversee ongoing work.
The teacher has responsibility for the classroom team. It is his/her duty to organise and communicate the method of carrying out the IEP and to oversee the ongoing work.
Ed was a 5 year old boy who, after routine surgery, developed complications and was brain damaged, blind, with severe cerebral palsy and a speech impediment. It was decided at a meeting of the Visual Impairment Assessment Team that he should attend a school for multiply disabled and visually impaired children.
A review was attended by the class teacher, parents and a number of other professionals. Each had assessed the needs of the child and reported to the meeting. The class teacher then met on a one-to-one basis with the physiotherapist, speech and language therapist and mobility education officer to establish what their input would be to the IEP.
The teacher then gathered all the information and produced the IEP. Since the child had an SEN auxiliary it was important that the teacher established with her exactly what was required and monitor the child’s progress to assess whether any adjustments to the IEP or approaches to delivery were required. The other professionals also met regularly with the teacher to assess the progress and give advice if required. The classroom team used ongoing observation between visits to the ophthalmologist, to look for any sign that Ed’s sight could be returning. The parents were kept informed by home/school diary, noted any developments and how they were progressing with work at home.
They had asked to have Ed referred to Bobath Children’s Therapy Centre Scotland for an assessment and possible treatment sessions. The class teacher supplied a report initially and then at the start of each block of treatment sessions. She also attended sessions in the first block and thereafter the SEN auxiliary attended at least twice in each block. This ensured continuity between all those working with Ed, giving the best possible movement and positioning opportunities to enable him to access his education programme and reach his full potential.
4.4 The Social Worker
Social workers assess the needs of the child within the context of the family, supporting parents through the emotional impact of the grief, sorrow and loss they feel when told their child has a disability. Support is also provided to the wider family, e.g. siblings and grandparents, if required.
Information regarding welfare benefits and concessions is made available. Claims by families in need can be supported if required. Information is provided about voluntary agencies on both local and national level where parents can access additional information and services.
The social worker can offer support to a family to care for their child by arranging appropriate respite care either in the family home or in another environment, if required, either for parents or siblings, to give them a break from caring. Summer Play schemes are arranged during the summer school holidays that families can access. In conjunction with other professionals, for example teachers of the visually impaired, an assessment of need for provision of specialised equipment, toys, etc, for home use to maximise the child’s development and education can be made. Provision can be on a permanent loan basis or by application to appropriate statutory or charitable funding sources.
Transition from children’s services to adult services
The social worker supports the family and young person at the transition from education to adult services. The Future Needs Assessment, involving joint working with health and education colleagues, identifies the young person’s needs and makes arrangements for any continuing or higher educational training and assessment of the young person’s need for support, to assist their transition to adulthood.
Where there are concerns that a child may be abused, the locally agreed procedures for child protection need to be activated and addressed in the same way as for any other child in this situation. In this situation the partnership between the various agencies is invaluable, especially where a worker knows the communication system used by the child/young person and is able to help with informing and participating in the process of assessment.
4.5 The Speech and Language Therapist
Gillian Callander and Shona Gillespie
Introduction to speech and language therapy
Children with a visual impairment and cerebral palsy often have difficulty with talking, listening, interacting and understanding. This may create problems in communicating with and understanding the outside world. A speech and language therapist helps these children to achieve their communication potential.
Anyone, with the parents' consent, can refer a child to Speech and Language Therapy. Parents of the child can also make a direct referral to the service. Very young children are usually referred by a doctor or health visitor. As the child gets older, teachers at nursery or school may feel it would be helpful to make a referral.
The role of the speech and language therapist
A speech and language therapist will work with the child, the parents and other important people in the child’s environment to assess how the child:
- interacts and plays with others;
- understands spoken language;
- understands the environment;
- uses gestures, sounds or words to communicate;
- eats, drinks and swallows.
The child will be seen in one or more of the following places:
- Health Centre/Clinic/Child Development Centre;
After all the information has been collected the speech and language therapist will work with the parents and other professionals. This may involve:
1. Support and advice for the people who work with the child through encouraging useful communication at home and in the nursery/school environment. Parents and carers are helped to use communication which is appropriate to the child’s level of ability. Training may be provided through workshops in any aspect of communication and/or eating and drinking skills.
2. Individual or group work with the child to support development of:
- Interaction skills: children with visual difficulties and cerebral palsy may have problems in the areas of listening, taking turns, shared attention, and may not be able to make eye contact, see facial expressions or understand body language. These difficulties can cause problems in forming social relationships and in taking part appropriately in conversation. For example, if a child is unable to see facial expressions then they will not know if the person they are interacting with is happy/sad, enjoying the interaction or bored. If they are unable to make eye contact then their conversational partners may feel that the child is uninterested or not listening.
- Information gathering: information gathered by children with visual difficulties and cerebral palsy will require to be gained through the use of senses other than vision and may be limited in the area of touch. This will affect how language develops as the way in which they explore and learn about their environment will be different from that of a child without difficulties. Communication skills may be delayed and sometimes will not follow the normal pattern of development. For example, there can be difficulties in using the correct personal pronouns, keeping to the current topic of conversation, and developing appropriate vocabulary.
- Speech sounds: it is common for children with cerebral palsy and visual impairment to have difficulty in producing the correct sounds required to produce clear speech.
- Eating, drinking and swallowing skills: there may be a physical or behavioural difficulty in this area due to visual impairment and/or motor problems.
- Augmentative communication (using gesture, signing, symbols, technology): this can be useful in developing additional communication skills for these children.
3. Written information to the relevant people involved in the child’s care. This may be in the form of advice sheets or more formal reports.
At all times the speech and language therapist works in partnership with parents, education staff and other relevant professionals, e.g. physiotherapists, occupational therapists, social workers, and medical staff. Every child is an individual and as a result, therapy is planned to suit differing needs. These needs may change as the child grows and develops. Therapy input must therefore be flexible to meet these changes.
4.6 Optometrists, Opticians, Orthoptists and Ophthalmologists
It is often very confusing for parents to understand what all the different eye professionals do whose names begin with 'O'. The names all sound the same. They all do quite similar things but with some very important differences. It is useful for parents to know what they do, so they know which professional is responsible for providing what service for their child. That way they can turn to the right professional at the right time to meet their child’s needs.
An optometrist is a person who examines eyes to see if spectacles will improve vision. He or she can measure visual acuity and pressure within the eye. By using specialised equipment an optometrist can also perform a full examination of all the different parts of the eye. Some optometrists may also recommend and prescribe drops to treat eye conditions. Optometrists write a spectacle prescription that is given to the patient and passed on to an optician.
Many optometrists will only rarely see children with cerebral palsy and visual impairment. It is worth finding out in your area if any optometrists have a special interest in examining and prescribing for children with cerebral palsy. There is increasing evidence that children with cerebral palsy have difficulty focusing on near objects (accommodation). It is useful to have your child’s distance (about 6 metres away) and near (within 30cm) visual acuity assessed. If a child’s distance vision at 6 metres is better than their near vision the child may be very long sighted and/or have weak accommodation. Often a reading prescription, either as bifocals or a single focus pair of reading glasses will make the visual world within a child’s arm reach clearer and more interesting.
An optician is a person who makes spectacles based on a prescription. He or she can decide on the best type of lens and spectacle frame to suit the individual. Optometrists and opticians often work together.
Again many opticians will only rarely see children with cerebral palsy and visual impairment. It is challenging fitting a comfortable spectacle frame that a child with cerebral palsy will tolerate. Children who are developmentally under the age of 2 years do not usually enjoy wearing glasses, even if they see better with them. Children who are developmentally between the ages of 2 and 4 years are more likely to tolerate wearing glasses but may still try to pull them off, even if they are seeing better with them. It is important to persevere with children of these developmental ages as once they are used to their glasses they will benefit from seeing more clearly.
It is also important that the frame sits correctly on the face so that the child is looking through the correct part of the lens. By using a soft silicone nose piece, light plastic lenses and frame and well fitting curled ear pieces, children with cerebral palsy are more likely to wear glasses and benefit from better vision.
An orthoptist is a person who assesses vision and eye movements. They use methods of assessing vision that are most suitable for young children. They can assess squints and patients complaining of double vision. They usually work in eye clinics with ophthalmologists.
It is often more difficult to accurately and confidently assess vision in children with cerebral palsy. Orthoptists can use observation skills, forced choice preferential looking tests and matching symbol and letter tests to try to say what level of vision a child may have. The different types of test are better for assessing children of different developmental ages and abilities.
Children with cerebral palsy may have special difficulties with vision that other children are less likely to have. Often children will be able to see a very small single symbol when presented in isolation but be unable to see the same symbol when crowded together amongst others. Instead the child may only be able to see crowded symbols when they are much larger. This is known as 'crowding'. This can sometimes be a reason why children have unexpectedly poor reading speeds for their visual acuity and age.
Children with cerebral palsy and visual impairment can also have limitation of smooth following and fast position changing eye movements. Difficulties with eye movements can also lead to unexpectedly poor reading speeds.
It is important that when your child is examined by an orthoptist a suitable test is used and that crowding and eye movement difficulties are specifically examined for.
An ophthalmologist is a person who has qualified as a doctor and specialised in the diagnosis and treatment of eye conditions. They can prescribe spectacles and drugs. Most ophthalmologists will perform surgery although they may specialise in different types of surgery.
Children with cerebral palsy are at risk of suffering from visual field loss and complicated forms of brain related visual impairment (agnosias and apraxias). It is important that your ophthalmologist asks about these and examines for them. Ophthalmologists can also check to see if a child needs glasses, just like an optometrist. If a prescription is to be made, tell the ophthalmologist which optician you intend to use so a copy of the clinic letter can also be copied and sent to your optician. That way the optician will understand more clearly the needs of your child.
An ophthalmologist should oversee and co-ordinate all the vision aspects of the care of a child with cerebral palsy. It is their responsibility to disseminate information to the crossdiscipline team concerned with all other aspects of the child’s health. It is helpful to ask your ophthalmologist to copy clinic letters to all members of the cross-discipline team on your behalf. It is also worth asking for a copy of any clinic letters or other written correspondence for yourself to keep in a file at home. Making photocopies of these letters for teachers, occupational therapists, physiotherapists, social workers or optometrists can be very useful when they wish to work with your child.
4.7 The Physiotherapist
The role of the physiotherapist is to enable the child to move as smoothly and effortlessly as possible to access his environment, both in terms of moving safely about the environment, including transfers involving self care activities, and also in terms of finding suitable positions where the child can explore play materials.
Children are heavily dependent on sensory information to guide and adapt movement skills. We learn to refine movement by feeling how we move, using feedback from various sensory receptors in our bodies which tell us, for example, where our head and limbs are in space, how fast we are moving, and using our eyes for visual monitoring. We use this information to guide and adapt movement patterns in order to function efficiently according to the demands of the environment and the task. The developing child thus acquires a large repertoire of movement patterns. Head and trunk control are vital to support movements of our bodies through space, to help us to balance, and to provide a base from which to develop refined use of vision and hand movements.
Whatever the type (classification) of cerebral palsy, the possibilities for efficient use of sensory feedback will be limited. This will influence the child’s motor abilities to move and explore his environment. The child with cerebral palsy thus develops a somewhat limited repertoire of movement patterns. Balance will become compromised and movements will tend to be awkward in gross and fine motor terms. Where the child has hypertonia/spasticity (stiffness of muscles), for example, repetition of these patterns tends to result in the child becoming stiffer, with patterns becoming even more limited. This stiffness will result in permanent loss of range of movement in the joints in the child’s body (contractures). Difficulties in adapting and adjusting are characteristic of the child with cerebral palsy and therefore this child has to work hard at maintaining a position in space. Effort also unfortunately results in increasing stiffness. Extra effort is imposed when the child is expected to maintain a position and attend to a learning task.
The child with athetosis has abnormally wide ranging movements and will tend to hold himself somewhat stiffly in order to achieve function. Again this limits the repertoire of movement patterns available to him, and he also has difficulties with adapting and adjusting.
Difficulties in using visual information can result in the child being fearful to move, which will limit movement patterns. These patterns will also be influenced by the amount of effort the child employs to use his degree of visual skills. Visual field loss may result in the child orienting his head in a particular direction. As head movements strongly influence body postures, movement patterns will obviously be affected.
Optimum learning comes about through our own active learning. The physiotherapist will provide a treatment programme to promote head and trunk control to support the child’s movements and balance and give him the confidence to explore. This often includes ways of improving mobility and strength. Handling techniques will be used where and when necessary, to encourage movement within more normal patterns. The child will be encouraged to develop his own repertoire of movement patterns thus enhancing sensory feedback. This will give the child more possibilities to refine his movement patterns, to be more able to adapt and adjust, and therefore more able to move and function, or to maintain a position and function. Equipment such as seating and standing frames are used to reduce the effort a child employs and to maintain appropriate alignment. Orthoses/splints may also be provided to support joints of the body in alignment.
The physiotherapist recognises the implications of visual field loss but also the importance of maintaining alignment and joint range of movement. Therefore close liaison with the occupational therapist and VI teacher is vital to enhance visual training working towards a realistic position for the child that will enable the child to develop and use his visual skills.
The importance of gaining a working balance between all areas of impairment is emphasised to gain the best outcome for the child. (See Appendix 1 for report on study of working relationships between physiotherapists and teachers.)
4.8 Role of Support Staff/VI Teacher in supporting mobility programmes
Linda Bain, Angie Bisson and Mary Pullen
Mobility support staff work under the guidance of a qualified orientation and mobility (O&M) specialist to ensure the visually impaired person gains confidence and independence. This work involves:
- awareness of the need for independence;
- introduction of sighted guide technique;
- introduction and reinforcement of necessary skills before introduction of use of long cane;
- room familiarisation;
- simple indoor route familiarisation;
- reinforcement of sensory awareness development;
- participation in the delivery and reinforcement of environmental awareness programmes;
- participation in the delivery and reinforcement of programmes aimed at improving communication skills including increasing awareness of body language, age appropriate social interaction and ‘stranger danger’;
- reinforcement of shopping skills;
- experiential exercises involving public transport;
- monitoring of good practice with regard to cane skills and an awareness that individuals may have been taught adapted techniques depending on their own individual special needs;
- knowing what constitutes good practice but referring bad practice or the introduction of new skills to the O&M specialist. Good communication between ALL those involved in delivering the mobility programme is essential;
- keeping up-to-date with educational developments relating to mobility, VI and special educational needs in general.
Role of Qualified Orientation and Mobility Specialist
In terms of devising a comprehensive programme of orientation and mobility a qualified specialist is essential. Their role is to:
- assess the orientation and mobility level and identify needs of the visually impaired person;
- devise a programme of training and implement it;
- advise, support and train others working with the visually impaired person, including mobility support staff;
- identify key areas and skills for trained mobility support staff to implement or reinforce with the visually impaired person;
- to emphasise the importance of cross-curricular mobility education;
- monitor the delivery of all orientation and mobility programmes being implemented by mobility support;
- deliver any outdoor route familiarisation;
- deliver all long cane skills training;
- implement and deliver training in all technological mobility aids;
- implement and deliver all independent travel skills including use of public transport;
- to keep up-to-date with educational developments relating to mobility, VI and special educational needs in general.
4.9 The Educational Psychologist
An educational psychologist may be involved from the early years of a child's life in working with families and other professionals to assess the needs, and advise on the child's programme in nursery or school. An educational psychologist is employed by the local authority and may be based within administrative offices or schools.
Psychologists work with a wide range of children between the age of birth and 19 years who may have additional support needs. They often work closely with teachers and other professionals as a team to help ensure that the child is able to learn effectively in school and achieve their all round potential. Where possible children with additional needs are educated within mainstream schools. Additional resources can be provided and adaptations made to buildings to allow pupils with physical needs to be as independent as possible. If a child's support needs are more complex, placement within a special school may be considered.
For the family, an educational psychologist may become involved from an early age, visiting home to discuss the child’s developmental needs and consider the range of possible nursery and school places available. A nursery or school might need extra resources or adaptations and together with other professionals the psychologist may advise the authority on these, as well as contributing to the child’s teaching programme once there. Some local authorities have multi-disciplinary assessment teams such as a School Advisory Team which provide a framework for people to work together closely and this can be helpful to parents. Whether a more formal system such as this exists or not, it is important for all those involved to meet regularly and monitor the progress of the child.
Psychological assessment of children with complex needs is usually done in an informal way. Working with a child who has both visual impairment and cerebral palsy requires time and careful attention to the implications of both conditions and the way in which together they can affect the child’s learning. Assessment requires getting to know the child informally, for example through observations of play and learning at home and in school, detailed discussion with those who know the child well and linking with other professionals who may employ special assessment tools.
A Record of Needs is a document which draws from the information and views of all those involved, including parents. With older children their own thoughts and opinions are important. At present a Record can be opened from the age of two years but is more usually opened at a transition stage such as when the child moves to school. The Record of Needs may be replaced in the future by a Co-ordinated Support Plan for pupils who are thought to be encountering complex multiple barriers to learning and who need a diversity of services.
The psychologist may help in considering possible schools with parents and children at transition times, working with them and others to come to a decision about the most appropriate educational support and provision.
4.10 The Occupational Therapist and the child with CPVI
To facilitate the development of gross and fine motor skills to promote the child’s level of function with regard to Activities of Daily Living (ADL), e.g. dressing, feeding, playing, etc.
Use of selected, purposeful activities to develop hand skills within the home, at school and during therapy sessions.
Assessment of visual-spatial and visual-perceptual skills in relation to their functional impact on ADL.
Specific activities to develop visual perceptual skills with provision of home/school programmes to support them.
Assessment, advice and referral for provision of specialised seating and other equipment to provide appropriate postural support and access to necessary materials, e.g. adjustable height seating/tables for home/school, etc.
Assessment advice on small aids to assist fine motor skills, e.g. pencil grips, non-slip mats, tilted boards, etc.
Methods of assessment
Through observation and detailed analysis of the child’s performance during selected activities.
Use of specific standardised tests for Motor and Perceptual function.
Methods of intervention
Working with parents/carers to assist their understanding of the child’s needs and aims of occupational therapy. Provision of Therapy programmes and opportunity to work within the home, school and nursery environments when necessary.
Joint working with other professionals, sharing of information at home, school, etc.
David 4 years old, diagnosis of asymmetric spastic diplegia affecting the right side more than left. Low visual acuity, glasses for table work.
David had been known to many members of the multi-disciplinary team through his attendance at a child development centre. He was due to start primary school the following year and his parents were very anxious that he attended his local mainstream primary school. With this in mind, his educational psychologist requested an up-to-date assessment of his pre-school abilities, e.g. fine motor skills, grapho-motor ability (prewriting skills), etc.
David was assessed by the occupational therapist and a special educational needs (SEN) teacher. The assessment indicated that David was significantly behind in terms of visual-spatial concepts and pre-writing skills.
Further assessments from the ophthalmologist, orthoptist and physiotherapist contributed additional information. David’s glasses prescription was changed and the orthoptist detected a lower visual field defect. The physiotherapist concluded that David’s diplegia affected his posture and position for activities. He tended to rotate and fix his physical and visual attention to his immediate left side and ignore the upper, middle and right areas of space around him. The occupational therapy assessment of his fine motor skills also revealed a neglect of his right hand and a lack of integrating it with his left. This also caused David to be very focused on his left side.
The following year David started on a physiotherapy programme to help him move more freely to both sides and improve his gross motor spatial awareness. The occupational therapist’s programme addressed bilateral hand function, hand/eye targeting and visualspatial concepts at a table top level, and the SEN teacher provided a pre-writing skills programme.
Following a Liaison school meeting prior to his commencement at primary, the following supports were implemented.
The occupational therapist assessed David for a height adjustable school chair, toilet alterations and non-slip table top mats, which were purchased by the Education Service. The school obtained a special needs auxiliary who was able to support David’s physical access around school following advice from the physiotherapist. David also received support from a VI support teacher who helped modify his materials and provided a sloping board for reading and writing.
David’s needs were reviewed at a yearly meeting by the team and educational psychologist and any changes made. The integration to primary has been successful and he is coping well with the curriculum.