Vision for Doing
Assessing Functional Vision of Learners who are Multiply Disabled
Thinking about the learner
Before going on to discuss how we think it is best to approach your work with learners who have multiple disability, it might be profitable to spend some time thinking about how you may already bring together your information about a learner. What would you want to know? What would form your assessment questions?
In setting out our ideas, we admit to having had to examine closely our own partiality, if not bias. We then tried to adopt what might be a terminology that we hoped would be, if not common to the reader, at least familiar. We were anxious to avoid the possibility of misunderstanding. In fact we try to enter your own world, to share your frame of reference, a theme we discussed in the previous chapter.
Setting the scene
Think for a moment about a young person you know who is multiply disabled. Now try to answer this question.
In what ways did you think of that young person ?
You might have answered in one of the following ways:-
- by thinking of his or her name;
- by whether or not you warm to this person;
- by how he or she communicates;
- by details of the person's particular set of impairments
Sooner or later, if pressed hard enough, you would no doubt have begun to describe your chosen person along the lines of certain characteristics or personal aspects of that young person, eg; how she perceives the world, what she understands about her world, how she acts in the world, how she communicates with people and other animate things in the world (and they with her). In the same vein, you might have been interested in looking at what holds her interest; as well as how all of these different characteristics unfolded in her own personal lifetime.
In addition to these personal aspects you may well have given some consideration to those different settings in which your chosen learner can be found whether at home, school, hostel, day centre and so on. You could no doubt think of ways in which the learner seemed to differ across these settings.
Each of these different settings would be likely to be associated with different opportunities. Making best use of these requires also an analysis of the resources at your disposal. These could cover human support resources, equipment resources and perhaps written reports.
Suppose then you had come this far. Now you want to try out some new activity with the young person who has multiple disability. Having taken into consideration all of the above personal aspects, settings, and resources, you would be in a strong position to give some thought to what you wanted to try to do and how you wanted to bring this about. We could reasonably call this a stage of working out learning objectives.
The personal aspects, settings, resources and learning objectives available will all interrelate. Each represents a characteristic to do with that learner. Each is potentially a part of the process of assessment. It is therefore helpful if we look in a little more detail at what we mean by personal aspects, environments or settings, what constitutes resources, and learning objectives.
We begin by taking a look at the characteristics which comprise personal aspects of the learner.
A few years ago people began to reject what was termed a "medical model" of assessing children's needs. It was felt that children were being labelled, categorised as being 'physically handicapped' or whatever. Although this rejection was in many ways justified, its outcome has been for the 'baby to have been thrown out with the bath water'. Now, it is not uncommon to hear of professionals refuting any need for understanding of the particular nature and effects of a young person's disability.
By including other factors such as settings and resources within the assessment, we hope to focus on factors other than these 'within the learner" aspects. We would like this process to be thought of as one of ">diagnostic teaching". In this view there is an essential place for improving our understanding of personal aspects. What then are these personal aspects? As this book is about vision, a good starting point would be to consider those personal aspects which are involved in receiving information through the senses.
Information through the senses
When thinking of which characteristics of the learner you would want to know more about, at some point you would probably consider how well she detects information on the events, objects and places in her world. She does this by the information picked up through light, sound, pressure, and chemical information. We normally refer to this as using the senses: of sight, hearing, touch, smell and taste. (Some would want to include proprioception1 here, but its exclusion does not affect our discussion). Figure 2.1. shows the relationship between the information and the sensory channel which is 'tuned into' that information. The different lengths of the boxes indicate how much more 'information' is conveyed through vision when compared with other senses. The learner therefore detects information about events, objects and places in the world through these channels. Through each of the channels or sensory modalities the learner comes, to a greater or lesser degree, to understand the world.
Appropriately, we begin with a list of the kind of things vision allows us to do - its functions. This would be expected to include giving information:-
- where an event occurs;
- how far away;
- foreground v background;
- size of object(s);
- whether moving or stationary;
- features that distinguish one object from others.
We are deliberately restricting the potential list of functions of vision. (In the previous chapter, we fleshed out in more detail these functions of vision). We have set out the above selection merely to emphasise that impairment to sight alone could affect one or more of these functions. But what about impairment to hearing, to touch, to taste and to the sense of smell?
For each of these other potential channels of information about the world, a creditable list could readily be determined. Each list would represent ways for us to gain better under standing of that learner's capacity to hear, to touch, to smell and to taste. In doing so we would soon come across two major problems.
One problem would lie in the sheer size of the emergent tome. You, the reader, would baulk at being asked to wade through such a task.
The second problem would be one of interpretation. Was failure on Item X due to difficulties with sight or with hearing, or what?
We therefore need to have some shorthand method for describing a learner's ability to detect information through each sensory channel. From this description, we will improve our understanding of how sight is used by the learner.
Learning, knowing and remembering about the world
In order for a learner to make links between information about the world (through the senses) and his or her own movements (acting on the world), there also needs to be some way for a learner to make these associations - that is he or she needs to be able to learn. You may already think about these as the cognitive abilities of the child. These could include:-
- how well a person learns
- whether and how she attends to what goes on around her
- how good her memory is.
Each of these could be broken down still further, in the same way as we indicated in the previous section. You might therefore want to follow up with questions that:-
- investigate a child's memory for events, or facts, or faces, for layouts of buildings, for abstract versus concrete nouns and many other areas;
- explore how well a child represents sights or sounds in his world - that is whether and how well these are stored in memory;
- look to see how well an adult integrates information through sound and sight, through sound and touch, or through sight and touch;
- consider how much a child can understand about events, objects and places in the world.
As with Information through the Senses of course, impairment to any of these and other functions associated with Learning, Knowing and Remembering may well result in disability.
A familiar pattern is beginning to emerge. For any reasonable description to be given of an individual learner's abilities, a vast number of questions would have to be asked. And impairment to the ability to learn, think and remember will clearly have a significant effect on how a person interprets information coming through the senses.
We must avoid confusing a possible sensory cause for some lack of response with a cause based on impairment to learning, thinking or remembering. We also need some means of integrating our methods of assessment, and thereby of reporting what we have found.
Acting in or on the world
Detecting information about the world is not enough. The young person will also, to a greater or lesser extent, have to be able to act on or in his world.
At this point, you may well question this assumption. If so, consider this real world example. Suppose as a result of a road accident, a person is in a coma. How would you know whether that person is able to detect information about his or her surroundings? That person would have to have some - albeit very minimal - means of movement2. Without some minimal movement, you would be unable to tell if a person could register information about his surroundings. There would not have to be much movement, only a very little.
Some of the actions (or movements) you would consider would be:-
- head movements;
- tongue protrusion;
- eyebrow raising;
- walking towards an object;
Seems a relatively short but comprehensive list? Or does it? Each one of these items could justifiably be sub-divided. Does 'reaching' include 'grasping'? Is reaching visually initiated or is it visually control led? And so on. The same argument applies to the other items. Indeed many more items, ones which you may well have thought of, could augment this list.
If we do not somehow include in our assessment some notion of actions - physical movements - we meet a familiar problem. Suppose a person with multiple disability does not reach (however it is defined) for an object. Is the lack of response due to problems with sight? Or with physical abilities? Or some other?
Again these issues indicate that we need to develop a system of shorthand in our assessment to encompass this problem. It should still meet our criterion of giving more information about the sight of the learner.
A special way of acting in the world can be seen in communication. Usually we think about this in a social way, the child or adult communicating with people or animals. There are two general personal aspects of communication. The first lies in the child's reception or comprehension of another person; the second is in how the learner herself expresses needs, requests, intentions, statements - eg; through some form of language such as sign or speech, or through drawing and writing.
We could spend some time describing in detail specific aspects of communication ability which could in some way be impaired. It will come as no surprise that this exercise would also result in us having to add many items to our list. Indeed several excellent assessment tools are available for those who wish to pursue this further. Our problem lies in giving sufficient attention to various aspects of communication, but not so much as to obstruct our true task - acquiring a better understanding of the effects of visual impairment.
As a parallel outcome of our assessment, we would certainly expect to improve our awareness of the effects of that visual impairment on the learner's strategies for communication.
Differences in the learner's confidence in a task, and in her confidence in people will have an effect on the manner in which she approaches new events, people and places. Her mood will affect the likelihood of completing an activity. She will be motivated through likes and dislikes. This area is often the hardest to try to understand, and yet it is often the most important determinant of whether a learner will engage in an activity.
We can go a long way to making the most of learning through fun opportunities. We could begin by allowing the learner to dictate the pace, by following the learner's lead. By capitalising on a learner's initiations, we enrich our own understanding of that individual's personality
We will return to this issue in more detail in Chapter 4, where we set out our principles of practice.
Above we tried to set out those characteristics that are probably in your mind when you think about an individual child or adult. Most of these terms will we hope be familiar to you, and may indeed already be the concepts you yourself use when thinking about how you plan your activities and timetables.
No doubt you are becoming impatient, saying "So what? There is nothing new here." In some sense you would be right. But we have taken this approach for an important reason. Above we set out isolated areas to cover personal aspects - information through the senses, action, learning, knowing and remembering, and personality. We wanted these to be familiar to you, to try to use the same language to describe characteristics of a learner that you yourself might use. What then is the problem? There are in fact two problems.
The first problem is that you will come to an appreciation of a child's abilities not just through isolating each of these characteristics from one other, but through familiarising yourself with how they interact with each other. This results in appreciation of a unique combination or set of characteristics. For instance, a memory disorder will apparently affect certain aspects of seeing - to take a simple example, without a memory for words or letters, a person would be hard pressed to read back the letters of an eye chart.
The problem for the assessor lies in trying to understand whether the learner cannot see the letter on the chart (an impairment to sight), or cannot identify the letter (a problem of memory, perhaps). Take another example. If a young child does not begin walking, is this because of physical disability or is it due to visual impairment? By presenting distinct categories as we have done, we would not allow for interaction among these. We need a way of getting round this problem.
Our second problem is one we have also mentioned else where. We have to come to grips with an assessment schedule that is manageable, while at the same time being comprehensive enough for the purposes for which it is de signed - assessing functional vision. For each of the areas we have outlined above, we could readily (with some help!) have developed a detailed assessment procedure for profiling a learner. What would have been the result? You would have a useful compendium for supporting a table which has a broken leg but, as a tool for assessment, it would not be very helpful. By the time you had found the section that might be relevant, the learner would long since have gone, to sleep How do we reach a compromise?
Faced with assessing the needs of a learner, you would not determine all of the possibilities which might pertain: rather you will use broad initial indicators to constrain the form and content of future finer grained investigations. Moreover, in thinking through the combined implications of any tests performed, you would rely on previous experience from other cases with those or related features; again, constraining and sorting this material is a complex task.
An example may help to illustrate our intended approach. Suppose that in a cursory assessment of hearing, a child is found to understand a wide vocabulary of spoken words. What does this tell us? For one thing, it tells us that hearing is (depending on the child's age, it might also tell us that it has always been) relatively intact. But this finding tells us much more. What else might it tell us?
There are many other incidental findings:-
- there is useful memory;
- there is ability to discriminate among settings;
- there is ability to respond selectively across a variety of settings.
Thus an item purportedly assessing hearing is actually indicating various aspects of cognitive functioning as well as hearing. So long as this technique is well controlled and purposeful, rather than happening by accident, it can be a powerful mechanism for narrowing our search. It is of most use when investigating a specific aspect of functioning - in our case we will be using it to assess vision where several impairments are present in varying degrees.
What will be contained in our schedule? Because this is an assessment of vision, we will clearly want to retain many options for understanding how the child sees the objects, events and places of her world. At the same time, we need to determine whether there are other possible explanations for this or that apparent level of sight. We need there fore to embed some means for inferring those cognitive, memory, physical and other abilities among assessment areas which are not to do with sight. And this needs to be constrained.
Then where we find good cognitive functioning while ostensibly assessing hearing, at the same time finding only an ability to see the difference between day and night, we will be more confident that it is a problem of sight rather than a problem in more global functioning. Had more global problems in functioning existed', then we would have expected to have found a similar level of functioning in hearing as well as in touch, taste, smell: difficulties would not have been restricted to sight.
Conclusion of personal aspects
There are many Personal Aspects for which the learner with multiple disability could be assessed. To cover them all would create a mammoth assessment tool, which would be too unwieldy to use in practice. We need to get round this difficulty. One means at our disposal is to embed some assessment issues within non-visual items for assessment.
Our understanding of a learner will be enhanced greatly if we try to further our examination of those personal aspects outlined above. However, we also need to look closely at the various settings, surroundings or environments in which a learner happens to be found. Broadly, these fall into home, school, further education, vocational rehabilitation, work (possibly some form of sheltered workshop) and leisure.
One individual, whose Personal Aspects are apparently identical with those of a second individual in one setting, may be found to function quite differently in another setting. For one child, a swimming pool may offer a secure, relaxing, warm and comforting set of surroundings in which to learn. For another child, it may instill fear and alarm. A frightened child does not learn easily.
Where a learner 'prefers' one setting rather than others, there are at least two things you should begin to consider. First try to determine which specific cues, prompts or features are salient to the learner. Are they unique only to that setting? Or can some of these be extracted and transferred to other settings?
Second, ask yourself whether it is possible to set learning objectives within the preferred setting. However, there is one caveat when determining whether to proceed in setting learning objectives in the 'fun' setting. Should the fun go out of it by implementing these new tasks, you might well remove the attraction of that setting. To avoid this, the trick is to make learning fun. In Chapter 4, we outline what we see as being principles to be adhered to, and which, if followed, will more easily ensure that the fun remains. By the time you have looked at personal aspects together with settings, you could probably come up with your own rules of thumb to guide your assessment. This will give a better understanding of the whole child.
There is another method of exploiting variation which is found to occur across settings. Some variation in response to Settings could be due to differences in the physical characteristics of the settings. Analysis of these factors should always feature in our analysis of the setting or environment. Such physical features include the areas of lighting and contrast.
Adjustments can be made to give adequate lighting which will be evenly distributed and free from glare and shadow. Advantage should be taken of natural light using shades, blinds or curtains. Most obviously the learner should not face the light. If on the light side of the room try to avoid her sitting in her own shadow. A dull surface finish is preferable when choosing a table top or other area to work. Lighting is important not only for near vision tasks, but also is important in mobility activities. Moving around may become less dangerous by paying attention to details of lighting. Optimising lighting does not necessarily mean making the light as bright as possible. For several conditions such as cataracts, bright light can become (in many cases) a hazard.
A story might help to illuminate this problem. One of the authors was visiting a child in mainstream secondary school. She had a degenerative central vision problem. At the time of the author's visit, the buzz going round the school was that this girl's vision had unexpectedly and quite suddenly improved overnight. From the same seat she was now reading directly from the blackboard whereas the previous day she had trouble seeing that there was a blackboard present. A remarkable change, if it was true.
Unfortunately the 'improvement' was not real. Close questioning revealed that for the first time, the janitor had cleaned the board thoroughly! Prior to this, the glare reflected from the board because of the remains of unwashed chalk dust had made it impossible for the girl to see any detail. The brighter the light, the worse the glare. On the 'new' board, she was able to see letters and drawings of a similar size to those that she had previously not seen. The able sighted adjust to quite massive changes in lighting and contrast levels. This is done unconsciously.
The most useful lighting positions are from above or behind the child. To reduce the level of lighting, either blinds or curtains offer an effective means of control. As we saw in the above example, substantially different abilities may be revealed if close attention is given to experimenting with lighting, varying positions and reduction of glare from reflecting surfaces.
Just as improvements in lighting can pay dividends, so too will attention to contrast. The subject of offering improved contrast is at first glance a simple one. Surely simple use of a white background with black foreground will in all cases be optimum? For some individuals the reverse is more helpful, having a black background with white foreground with white reduce the effect of glare.
In the everyday surroundings of the learner, contrast variations may indeed become a great source of difficulty. Consider the example of a child being provided with a light blue background on a table with a yellow object on top. Simple? But the blue background will itself be a foreground to other backgrounds of the floor covering, the walls, perhaps the teacher's clothes. There are, though, some rules of thumb to which may be added some experimentation with the learner:-
a plain background makes it easier to distinguish objects in the foreground. A patterned surface for a back ground offers less contrast between object and back ground. The more busy a pattern, the more difficult it is to distinguish the object(s). (See Figure 2.2.)
- movement of the object relative to its background often helps the object to stand out.
- similar colours merge together. For instance, the clothes one wears may make it very difficult for a child to locate one's presence. It is often useful to have available a jacket, apron or overalls easily distinguished by the child.
- try to avoid too many shadows.
- depth changes may be accentuated by improving the contrast between two surfaces.
Unlike our discussion of Personal Aspects, there is no shorthand way of presenting findings obtained over different settings. You have to try out these settings, to aid your understanding of the learner.
Having carried out this our second stage in the cycle of assessment, it is possible to move on to identify the resources that are available for use within each environment. This is our third stage in the cycle.
For each learner and within each setting, variation will exist in the resources that can be made available. Resources can be of many types, of which the most easily recognised will be human, equipment and written reports. In these times, where emphasis is too often placed upon physical buildings, it is useful to remember that most important resource of all: people.
Do not be constrained in your thinking as to the kind of help which may be offered or what you might seek. Broadly, this kind of help falls into categories of:-
- practical help, eg; class assistant or volunteers;
- advocacy, useful in the implementation of Records (Statements) of Needs;
- specialised skills, such as speech, physio- and occupational therapies;
The list here is endless and constrained only by one's imagination. People like Lilli Nielsen have drawn attention to a wealth of materials easily obtainable around the home or classroom. Seating and microtechnology will also be areas worth investigating. Assessment of seating and positioning, rather than an option, is for many learners with multiple disability, a necessity and should certainly be investigated at this stage. Occupational therapy may be essential.
Written statement resources
We have already mentioned the use of advocacy in the form of help from other people. In that context we pointed to the use of Records or Statements of Needs. If you are unfamiliar with the contents of this document on behalf of your learner, now is the time to investigate these as resources. Other sources of written statements exist. You might consult written reports - often there is a wealth of information on what the learner could do as a young child which, as she grew older, was turned into what she could not do.
The final stage in our cycle of assessment (of course, being a cycle, it only returns us to the beginning) is to set Learning Objectives. We chose deliberately to keep this section brief. It is an area with which we will be involved in greater depth in the second half of the book. In any case, discussion of learning objectives must, in our view, include principles upon which the learning objectives are based. Without this knowledge, learning objectives would indeed be insufficient. Discussion of these principles is the theme of Chapter 4.
We have come a long way in approaching a common language of terms used to refer to the learner with multiple disability. It has been seen that to focus on Personal Aspects of the learner alone would not be sufficient. Instead assessment can be seen to be a cyclical process, and we have tried to flesh out some of the details of how that process might reason ably be achieved.
In presenting details we have nevertheless discovered that coverage of all of the characteristics of each and every impairment that might pertain, would have created a mammoth volume. Some strategy needs to be adopted to cut down this task. Such a strategy needs to retain flexibility to discover and inform our understanding of the effects of visual disability amongst a constellation of disabilities.
How to accomplish this is our priority in the next chapter.