University of Edinburgh
 

Vision for Doing

Assessing Functional Vision of Learners who are Multiply Disabled

Part 2: Carrying out the assessment

Introduction to Part 2

In the second part of the book we present ways of assessing the specific effects of visual impairments in learners who are multiply disabled. The understanding gained can then be used in planning the structure of new materials and curriculum (as in Part I we use the word 'curriculum' in its widest sense). We offer some suggestions which might be incorporated into curriculum design.

In PART 2 we assume the reader is already familiar with the contents of PART 1. PART 2 forms the bulk of this book. It is split into three related chapters. Each of these chapters has several sections. At the beginning of most sections instructions are given on how to transfer the results of that section to a Summary Chart in Section 18. Although these instructions are quite consistent among sections, they are not identical. Having carried out one or two sections, you will soon become familiar with the approach.

Chapter 5 Starting Off

Section 1

We begin by inviting the user to describe simple biographical details about the learner.

Section 2

The next section is the place to include additional background information which may or may not be available. If available it will come in the form of written reports, such as medical reports and Records of Needs. Many of the terms used to describe vision may well not be familiar. So in this section we discuss some of those terms you are likely to come across.

Section 3

In the third section we ask you to begin observation of the learner. At this stage you will only be observing and integrating these observations with the ones you have made on the many other occasions you have been in the company of the learner.

We now start to glean information about how the learner makes sense of his world through senses other than vision. If you want to refresh your memory as to why emphasis is placed on non-visual areas of assessment, you can refer back to Chapter 3. It contains a detailed explanation of how we arrived at this strategy.

This is the "how to" part of assessing vision and is the biggest chapter of the book. You might expect this as the title of the book is Vision for Doing. You do not require special materials or six computers to carry out the directions therein. You need only your own 'willing eyes' along with materials that are readily available.

Sections 8 - 18

Chapter 7 is sub-divided into 11 sections, Numbering of sections allows a more manageable foray into visual assessment. These sections are organised in a particular way, and an explanation of this structure is given at the beginning of Chapter 7.

At the end of these three chapters, you have an opportunity to summarise all the information you gathered during the assessment. This comes in the form of a one-page summary of all the sections. This will give you an at-a-glance profile of the learner. Use it to decide the areas of intervention on which to concentrate.

The way to use the Summary Chart is to carry out each of the sections in Chapters 5, 6 and 7. At the beginning of each section you will find guidance on how to convert your results for that section into summary form. As you complete each section you are shown how to transfer the summary to Section 18.

Have a look at the diagram at the beginning of Section 18. You will see that there is a single row corresponding to each of Sections 1 to 17. By the time you have finished your assessment you will have an at- a-glance profile of the learner's abilities. Section 18 itself tells you how to use this profile to guide you in selecting topics for curriculum development.

When working with a learner who is multiply disabled, it is essential - where it exists - to bring together information that may already be available within the school or centre, in school medical records or previous assessments done by other professionals. This process may help you uncover details that will prompt you to ask further questions.

The Leraner Background Information

When working with a learner who is multiply disabled, it is essential - where it exists - to bring together information that may already be available within the school or centre, in school medical records or previous assessments done by other provessionals. This process may help you uncover details that will prompt you to ask further questions.

Principal players1

Aside from the parents or other carers many professionals will have a role to play in reporting on the learner. A brief description of the roles of these professionals may help you to narrow the search for reports.

Clinical medical officer (also known as school clinical medical officer among other titles)

This person is responsible for the medical welfare of children from birth until leaving school. Unlike the GP, he or she will have a formal link between education and health. This person will often be the source of background information on the learner's disabilities.

Educational psychologist

Usually employed by the Education Authority, this person provides support, guidance and information to parents, teachers and other professionals in respect of pre school and school-aged learners. Often Education Authorities will have an educational psychologist who specialises in the area of visual impairment. This person is charged with the responsibility of drawing up a Record (or Statement) of Needs. This document can be a rich source of information on many aspects of the school-aged learner's functioning.

Educational visitor

An experienced teacher, employed by the Education Authority, who visits the home and works with parents of pre school children who have disabilities.

Occupational therapist

May be essential in assessing the most appropriate seating and positioning for learners of all ages. With the learner who is multiply disabled, an understanding of positioning may put you well on the way to introducing new opportunities for learning.

Ophthalmologist

A medical consultant, mostly based in hospitals, who specialises in the diagnosis, testing and treatment of eye disorders.

If you are able to have the ophthalmologist's medical diagnosis translated into its implications for the learner's functioning and curriculum, you may have little need for this book.

Orthoptist (optometrist in USA)

An additional source of medical information on the learner's (usually a child) visual functioning. Will often be involved in management of a young child's squint. Orthoptists are generally employed by a health authority, and will work closely with Ophthalmologists.

Paediatrician

Working with people who are multiply disabled you will of course not only be interested in the learner's sight impairment.

A paediatrician (especially a Paediatric Ophthalmologist or Neurologist) can synthesise the many aspects of information on a learner's medical condition.

Social worker for the blind

Much of the in-depth intervention available to the school- aged learner stops on leaving school. A social worker who specialises in visual impairment can represent a valuable link into and right through adulthood.

Specialist teacher for visually impaired

Many Education Authorities now employ at least one teacher who specialises in the education of school-aged learners with visual impairment.

Do not despair if you find that none of this background information exists on eye condition, nor a measure of visual acuity, nor information on visual fields, with no mention of whether or not glasses or lenses have been prescribed. It was because of the lack of this kind of information that we found it necessary to set out to produce this book. We would, of course, encourage you to try and build up background information from the headteacher and staff in a school or other centre; from parents or other relatives; as well as from the 'principal players' described above.

However, even without background information you can still use the methods suggested in these guidelines to start finding out yourself whether or not the learner has any useful vision, and if so how much and how well is it used.

We now take a look at the individual items making up the assessment list for Section 2.

What to do next

Refer to the diagram at the beginning of Section 2. This is a list of assessment items. Using the information you already have available (if any), complete the boxes on that page. As a guide to what these mean, the topic headings that follow correspond to the items in the assessment list.

Learner is described as..

In this part we give you the chance to note down whether the learner is described as blind or partially sighted. In the second half of Chapter 1, we discussed the confusion that can result through a learner being described as blind when in fact that person has useful functional vision. You may want to refresh your memory on the details of this discussion.

The other point to note besides the information in Chapter 1 is that a learner may function as blind in one Setting but not in another. In that second setting she may well appear to have useful functional vision. This is especially true when crossing from a familiar into an unfamiliar environment. In Chapter 2 we discussed the need for observing the learner in more than one setting. This is one very good reason for doing so.

General diagnosis..

In this space, you would write the name of the learner's medical condition. Usually, information is available on a learner's condition. For instance, common disabling conditions that could occur might be cerebral palsy, rubella, cytomegalovirus, or a host of other conditions.

Name of eye condition..

It is quite likely that this kind of information will not be found in medical or other records. Several writers have pointed out that it is often the case that no firm diagnosis has been made for a learner's visual impairment. Especially for the parents and relatives of a child this may be very traumatic, affecting for example their decision on whether to have other children. The situation may arise because of similarities to other conditions, but it may be the case that the presence of additional impairments has caused medical personnel not to believe that there is anything further to be gained by offering a diagnosis of eye condition. Where this does happen, then it may be useful to consult further with the medical profession, as it may be possible to refer for further diagnosis.

Where the name of the eye condition is known, this may be helpful in understanding some of the effects of the type of impairment from which the learner is suffering. In such circumstances, you are invited to turn to the Glossary (towards the end of the book) in which a brief description is given of the effects of a few eye conditions occurring frequently in learners who have multiple disability.

Visual acuity..

In an earlier section we discussed what is meant by Vision for Doing or as it is often called Functional Vision. We represented visual acuity as being a particular measure selected from a range of activities our sight lets us perform. Acuity is simply a measure of the ability to see detail. Many of the learners for whom these guidelines have been designed will not learn to read or write, but some may be involved in activities such as looking at pictures. For these activities you need detailed vision and this is what is known as 'visual acuity' sometimes abbreviated to VA.

Visual acuity is a measure of the sharpness of vision in picking out small detail, small shapes, small outlines, and in the case of reading, picking out small letters and symbols. A visit to the optician usually begins with an attempt to obtain a measure of visual acuity'. If this information is available it will be found as a set of numbers. For a rough guide to what these numbers mean, refer to Table 5.2.1.

Most learning activities take place quite close up and even if you think back to your own education, when you were engaged in reading and writing, working with materials on the desk involved what is called Near Vision. Notice that we offer boxes for both eyes along with left and right eyes independently. You may find figures describing the child's VA, but do not despair if you are unable to do so.

Refer to Table 5.2.1. in the third column there are figures in brackets. One of these is 6/60. Two figures separated by an oblique mean in this case that the learner can see at 6 feet that which a person with normal vision can see at 60 feet.If, however, a learner notices people coming in through the door, turns to them and appears to be looking at them, this kind of ability to see at a distance would be where a child used 'Distance Vision'. For certain learning activities - such as looking at blackboards - or other activities in life, it is very useful to be able to see things at a distance. You would probably be able to think of many examples. In between these two is 'middle distance' and again at school quite a few activities take place at that distance. For example, the learner seeing dinner approaching, or identifying another person seated alongside.

In our chart, we offer two ways of reporting information already known on a learner's near and distance visual acuity. These are With Correction and Without Correction. These terms simply allow you to record VA with and without glasses or contact lenses.

It is often the case that the reports on learners who have multiple disability show no information as to visual acuity.

Often known as 'peripheral vision' this is the area of vision which helps us become aware of our surroundings and is used when we move around. We cannot see detail with our peripheral vision, but it is extremely useful to us in avoiding obstacles. If our attention is attracted by some thing in our peripheral field of vision, we tend to "look" at it with our central vision. In order to understand if there are limitations on peripheral vision, we measure the learner's Visual field.

Only occasionally will you find a reference to 'visual field' within the records contained in the school or other centre. Visual field is the width, height and depth of the area in front and to the side of a learner that can be seen without moving his eyes in any direction. Limitations on the field of vision may be so severe as to result in the person being limited to seeing only the equivalent of the width of just one word at a distance of two feet. Later on we will be offering you ways by which you can get your own idea as to the size of a learner's visual field. At that point we will have more to say about the learner's visual field.

Refractive errors..

What we see of our world is contained in the light that passes through the lens of each eye to the retina at the back of the eye. As the light passes through the eye, it is bent or refracted in a certain way. If the eye is not a 'normal' shape, then the light that is bent will not fall sharply on the retina. Just as in a camera, if the lens is not adjusted properly, the image can be blurred. The greater the degree the eye curves from a normal shape, the more blurring will result. As a result of this abnormal curvature, the learner may be long sighted, short sighted or can have astigmatism. Figure 5.2.1. shows how these errors of refraction can occur.

fig 5.2.1

Long sightedness (Fig 5.2.1 a)

A learner who is described as long sighted (or hypermetropic) will see things at a distance more clearly. This is familiar to us all when seen in a relative or friend who is beyond middle age. The person may hold a newspaper at or even beyond arm's length. Closer than this the image appears blurred. Where this is present from an early age, the acquisition of fine motor control or pincer grasping may be affected. (In the older person there is a reduction in the elasticity of the lens and muscles holding the lens. This is called Presbyopia).

Normal eye

(Fig 5.2.1 b)

Illustrates the normal eye with light entering the eye and focussing on the retina. This may be recorded in medical records as emmetropia.

Short sightedness (Fig. 5.2.1.c)

Of the three it is most common to encounter short sightedness (myopia) in younger people. If so details are seen best when they are up close, to within 2 to 3 feet (and often even closer). It may explain why a learner does not seem to notice facial expressions at the far side of the room, or even at distances which are usually associated with normal communication. As a result he may be deemed surly or uncommunicative, unable to detect non-verbal communication. You will be able to explore this further through the sections of this chapter.

Astigmatism (not illustrated)

This occurs when there are distortions in the light entering the eye. The result can make straight edges (such as lamp- posts) appear distorted.

Combinations (not illustrated)

Astigmatism can occur in conjunction with either short or long sightedness. And of course one eye may have a different refraction from the other.

If glasses are prescribed but not worn, find out whether there are good reasons for them not being worn. Often glasses are not prescribed for those who have multiple disability. Some times, all things being equal, glasses would have been prescribed for that visual impairment had the learner been without additional disability. Why should this be so?

For some it can be an unfortunate case of the stigma associated with having severe disability. In terms of our distinction in terminology cited at the beginning of this book, this would deservedly be called a 'handicapped learner'. There may nevertheless be very good reasons for a learner with multiple disability, who has refractive error, not being given glasses or contact lenses.

It may be that the learner constantly pulls them off his face. In such cases it may be possible to set up, and keep to, a rigid timetable of gradually building up to having them worn. Try starting with a few seconds and, if necessary, offer some sort of reward so that wearing glasses equals "good stuff"!

Another good reason would be where injury could result (perhaps from "head-banging"), but do not be too passive in accepting an explanation. Where the explanation smacks of an excuse, be prepared to press on.

While on the subject of wearing lenses, a couple of hoary old chestnuts need to be dispensed with. It is not true that every visual disability is amenable to wearing glasses. Many of the visual disabilities you encounter will not be alleviated by the wearing of glasses.

The second common misunderstanding that needs to be dispensed with is that by wearing glasses perfect sight will be restored. Wearing them may help but not in every case.

Glasses v contact lenses

You may wonder why it is that some learners wear glasses and others contact lenses. Although there may be many other reasons for one being chosen over the other, a reason that often occurs is that contact lenses may be prescribed for more severe refractive errors. This is because a spectacle lens would be very thick and thereby reduce the field of vision. Contact lenses, being worn closer to the eye, allow a greater field of view.

Low vision aids..

Where refractive errors do occur, glasses may be prescribed. You might even find a low vision aid (LVA) useful. Glasses and low vision aids are no more than different kinds of lenses. Often the child with multiple impairments does not have glasses prescribed even though there is a significant refractive error. Where glasses, contact lenses or low vision aids have been prescribed, you might never have seen them since the child has been at school. It is important to find out if they have been used in the past and you may well have to ask the parents or guardians about this. You may find that the reply is "Oh yes, they did have a pair of glasses", and it is the first you have known about it.

Any other information..

Under 'Any Other Information' you would include other impairing conditions; if there is any indication that the child's vision is likely to deteriorate; or other information you yourself find useful.

Transferring results to section 18:

This is the first opportunity for using the results you obtained in the assessment to inform suggestions for curriculum development. To do this you need to summarise your results and carry this summary across to the Summary Chart (Section 18). The Summary Chart. This relates to the model we set out in Chapter 3, in which we described our use of the terms Awareness, Attending, Localising, Recognising and Understanding.

For the present section, we could in theory determine that the learner functions at the "level" of Understanding. You would be able to do this if you have Background information that the learner has measurable visual acuity. You could then transfer this in summary form directly across to the Summary Chart. To do this you would simply go to Section 18, find the row for Section 2, go along and tick Understand.

In practice, however, the problem is that you have to be absolutely certain that you are confident in this measure of visual acuity. If you are not confident in the result, or (more likely) you do not have any information on visual acuity, you should not transfer any information across to the Summary Chart. Leave blank the row for Section 2.

Should you be quite happy with any visual acuity measure you have found from Background information, you should still carry out Section 3 in this chapter, as well as the sections in Chapter 6. In your assessment of vision you should concentrate on Sections 12, 13, 14, 16 and 17.

Carrying out Section 3

The items contained on the checklist beginning this section represent the first stage in taking an active role in observation of the learner. Tick the box appropriate to each item or, where appropriate, write in the space provided.

You will notice this is the first use of three categories - Consistently, Occasionally and Never. You will be using these throughout the assessment.

We wanted to recognise that learners who have multiple disability might not be consistent when they respond. We do this by recording:-

  • Consistently where the learner is consistent in showing a change in behaviour OR
  • Occasionally where the learner sometimes shows a change in behaviour OR
  • Never where there appears to be no change in the learner's behaviour.

You will probably be able to think of many times when you were not sure whether a response occurred by chance. Where there is doubt as to whether to put down Occasionally versus Never, then the rule is to give the benefit of the doubt and include the Occasionally. The very nature of this kind of assessment is that you can come back another day and try again.

Notice, too, that we do not ask you to describe the nature of that response. It is not difficult to understand why it would have been pointless for us to indicate specific behaviours to be recorded. Suppose we had specified that you record if the learner 'turns her head to a moving object'. If her head just happens to be held rigid in an orthopaedic chair then you would not obtain that response! The box would go unmarked, even though you might have seen her make some other response. It is not, therefore, helpful to specify responses.

Instead what is looked for is whether a change has occurred. In later sections you will use this same scheme to find out if the learner's behaviour changes in any way whilst carrying out each of the items.

No response present

What happens if you have carried out all of the sections, that is you have completed the whole assessment, and you have found that the learner does not respond at all? Or perhaps you know already that it is pointless to carry out the assessment. You think the learner does not respond in any way. What can you do? (You should only use the technique that is described next if you have found it difficult to obtain any response. Otherwise carry on with Vision for Doing).

When working with learners who have the most severe multiple learning difficulties, it can be difficult to determine whether any response is being made to an object or event. Sometimes a technique may be needed for refining our observation. One variety of tools does assist in this process. They are simply additional methods for structuring your observation. As you may not have come across these methods we thought we would include an example.

Note that this is a technique which does not fit comfortably with many caring and committed people. The reason it seems alien has to do with us wanting to be doing things with the learner, rather than sitting watching. Yet much may be gained by taking time out to observe. In the real example shown in Figure 5.3.1. we see three different observation periods. You may be able to do all three in one session. If not, select a similar situation at the next opportunity. There are after all many other aspects of teaching and physical caring in which you will have to be engaged. So do not despair if you have to break, but carry on where you left off.

fig 5.3.1

Each of the three periods of 10 minutes (you might choose 5 minutes) is spent closely observing the learner. Record any movement (note that in our example one of these is a vocalisation) the learner makes in the appropriate appropriate time slot. This will take practice. Any difference between Parts b) and c) will help you to distinguish the effect of a person's presence on the learner versus that of the specific stimulus you wish to investigate.

Structured observations of this type begin with a measure of baseline performance (see 5.3.1.a). In this you record what the learner does when no-one is present. Conceal yourself behind a screen or by other means. Record behaviour over a 10 minute slot, at 30 second intervals.

The next thing to record is thelearner's response when an adult (yourself or a helper) approaches and interacts (Figure 5.3.1.(b)). Note that we need a comparison between a) and b). It would be erroneous to take as a baseline the learner's behaviour only in b). You need to know what hap pens when ostensibly no person is around (Figure 5.3.1. a above). And compare this with what happens when a teacher/carer is present.

In this example our comparison reveals interesting results. Comparing a) with b), it can be seen that the learner does indeed respond differently with an adult present as opposed to being isolated. You might then want to go on to explore a whole range of communication issues.

After these are recorded, that is the time to note whether there is any response to a specific event of your choice (as in Figure 5.3.1. (c)).

From 5.3.1 .(c) we surmise that the particular visual stimulus did indeed have an effect. You are then ready to proceed to discover whether this will be the only type of visual or other form of stimulus which will be effective in eliciting a response.

Response present

Having set out what to do if you are finding it difficult to record any response, we can now return to the remainder of Section 3 and indeed the other sections of the book.

In Section 3 you will record behaviours that are apparently not related to vision. In the text that follows we show why these items have been included. We use the same headings as the items included in the checklist at the beginning of Section 3. You will be most interested in discussion points under these headings should you have ticked Consistently.

Transferring results to

Section 18:

Before you read about the discussion on each of the items, you should transfer a summary of the results of your observations to the Summary Chart in Section 18.

Score attend if:

the learner has Consistent preferences and Consistent Challenging behaviour. If so, go to Section 18, find the row for Section 3 and tick Attend. Then move on to Section 4.

OR score aware if

: the learner Consistently shows unusual mannerisms. If so, go to Section 18, find the row for Section 3, and tick Aware. Then go to Section 4.

Learner has likes..

In accordance with our Commandment on 'abilities' (see Chapter 4), we begin by recording if the learner has any 'likes'. Later on you will be able to capitalise on these. Examples of likes might be situations, places, certain people, music, particular toys, activities and even foods or drinks. The learner may only give a vague indication of these 'likes'.

You may be in the position of being aware of the learner liking any one of these suggestions (or indeed any others not listed), but you are finding it very difficult to complete the remaining sections of the assessment. If so, ask yourself this question. How do I know he has likes?

For to indicate a liking the learner must, in some small way, be moving, making a response or being vaguely consistent - to a smell, a taste, a feature. Try to clarify this for yourself. This should help you to complete some of the later assessment items.

Learner adopts unusual postures..

Positioning

Supported positioning is of significant importance for learners who have sitting or hand control difficulties1. If they are using all their energy in maintaining balance, the visual target might be lost involuntarily. When securely supported energy can be put to the activity of seeing.

Positioning and seeing

There is some evidence to show that learners - especially children - who have multiple disability have optimum positions for seeing (and for other activities). If you are not already aware of information on optimum positioning, then consult with a physiotherapist or occupational therapist. Gross physical positioning should be investigated as it may be that in a side-lying, or supine position, or indeed some other position that visual tasks are facilitated.

You should also note that it is not always the case that the best position for seeing coincides with optimum physical positioning. You may have to take a consensus decision. In this way it may be possible to devote short periods of a day to achieving positioning for seeing optimally, at the expense of optimum physical positioning. That is why we emphasise consulting with occupational and/or physiotherapists.

Compensatory head postures

Less obviously, orientation of the head in a certain direction may help a learner to see objects. For some learners with impaired sight, only certain parts of their eye can detect information. It may mean that in order to see more effectively, the learner has to adopt an unusual head posture.

You may be trying very hard to encourage looking in a midline direction, while the learner sees best by turning her head in an apparently unusual manner. Observe whether there is any consistency to unusual positions adopted by the child. For example, she might strain parts of the face or neck, or adjust her body into certain positions. Does this happen only with certain objects; or only when things are presented visually?  

You can increase your confidence in deciding between an unusual posture being a purely visual response or a more general response. Try comparing your observations to visual information (Chapter 7) with those gained with non-visual information (from Chapter 6).

Learner shows unusual mannerisms..

What are mannerisms?2

Blind children often exhibit mannerisms or apparently unusual and repetitive or stereotypic behaviours. Some times known as 'blindisms', these have been known to include eye poking, hand waving, unusual head movements, rocking of the whole body and others. The younger the child and the more additional impairments there are present, the more likely it is that one will observe one or even several mannerisms. Generally these do reduce with age.

What causes mannerisms?

Although several authors have wanted to ascribe the cause of mannerisms to one single thing: maternal deprivation, cross- cultural differences in child rearing practices, sensory deprivation and so on - it would seem that there is in fact no single cause. Eye poking may indicate an irritation of the retina, and further medical advice should be sought.Some other mannerisms may, however, have their origins in attempts at communication which were successful early in life. There may be other reasons.

This last point shows that it can be hard to draw the line between what is and what is not a mannerism. For example a lack of awareness of facial expressions of adults could apparently be manifested by a learner avoiding eye contact. Is this a good thing or a bad thing? It may be that what appears as a pathological sign is in fact the learner attempting to catch sight of a hair line offering good contrast against the background: in other words attempting to interact - the very opposite reason. These unusual patterns of interaction may well represent useful responses for that learner in particular situations. Which takes us to possible remedies.

What to do about them?3

Having followed the discussion above you will realise that a single 'treatment' for mannerisms is out of the question. So behaviour modification and other simplistic approaches should be re-considered. In some instances that approach may be right, but there is no educational aspirin which applies to all instances of mannerisms.

The first thing to do is to record instances. Is there a pattern that emerges over a couple of weeks? Look at different settings, when different people are present, at different times of the day. Glean information from home. Depending on the results of your observations, you may want to consider some of the following approaches:-

  • giving substitute means of initiating interactions with staff;
  • engaging the learner in motivating activities;
  • try saying no - just because a child is blind does not mean mannerisms follow automatically.

Remember though that there is also a place for the learner with multiple disability to have the same range of normal neurotic responses as the rest of us. Where these do spill over and become the ritualistic mannerisms, or stereotyped behaviours, then one needs to ask the kind of searching questions mentioned above.

A confusion in terms..

A significant number of those who have multiple disability including visual impairment exhibit challenging behaviour. In fact the term 'Challenging Behaviour' has several different meanings. In the USA it is now often applied to behaviours seen in a range of learners who in this country are seen as having 'severe and profound learning difficulties'. Whereas in the UK it is usually applied to those who exhibit severely antisocial behaviours. These could include a variety of forms of self-mutilation and aggression to others. We use it to refer to learners who exhibit anti-social behaviours.

The term shifts the focus away from thinking that there is something wrong inside the learner's head and towards there being something wrong with what she does, and with the structures we have put in place to deal with it. The broader use of the term places an onus upon those working with the learner. It is the professionals who are challenged, NOT the learner who is challenging.

A definition..

We are happy to use the definition as introduced by Gordon Phillips that it is

"of such intensity, frequency or duration as to affect the physical safety of the learner or others">4

As with many of the other topics touched on in this book the issue of Challenging Behaviour is deserving of more in- depth treatment than our cursory glance.

Challenging behaviour and severe visual disability

You may wonder why this is common with people who are blind and multiply disabled. A few obvious causes which may spring to mind are that the behaviour could be:-

  • merely one aspect of being blind. If this were indeed true then it would be a cause for great pessimism, for it would indicate that very little could be done to alleviate the problem - short of restoring vision;
  • blindness could be just one form of damage to the brain. Challenging behaviour would then be just another form of brain damage - just as the learner's other disabilities would be;
  • because of the level of sensory deprivation, the learner has to provide his own stimulation. After all, this may be the only one over which he has some control;
  • a problem of communication. In this view the blindness causes problems in communicating. The Challenging Behaviour then becomes either a way of communicating or a way of withdrawing from communication;
  • one specific example of the above point would be that this offers a consistent way of getting attention;
  • a consequence of the structures put in place by various forms of local or central government. There are many examples of how this may happen. For instance, many parents will report anxiety at an impending long summer vacation.

Of these suggestions - to which more could be added - it is clear that the last four would be the most amenable to being changed by adopting changes in curriculum. For these explanations suggest that the maladaptive behaviour(s) have results to do with the learner's Settings. That is it is functional for the learner to engage in challenging behaviour.

Begin by describing

As with most of human behaviour there may be more than one cause and each cause may interact with other causes. That being so, it is important first of all to describe which behaviours occur; the occasions on which these are observed; the people with whom they happen; and what the learner might be getting out of performing these behaviours.

A useful source of help in this is to consult with a psychologist. He or she may draw up a list of behaviour categories for you to record such as ones that are:-

violent, aggressive to others - such as hitting, pushing people;

self-injurious - head banging, eye poking;

disruptive - tantrums, running away.

Styles of non-intervention

There are a host of ways of not dealing with the problems presented by challenging behaviour. Many have hidden from the problem, or blamed the victim, or passed the buck to someone else or permitted it to happen. In a thoroughly interesting and entertaining account, Phillips discusses these and others and shows how various administrations of government and local government have striven to build structures around these ways of not dealing with the problem.

Styles of intervention

We would like to describe four broad areas which you may encounter as suggested ways of guiding your intervention with those who exhibit challenging behaviour. These are Drug Treatment, Behaviour modification, Gentle Teaching and Cognitive Therapy.

Drug treatment

We think this is overdone. To give you some idea as to why we think this to be so let us tell you a true story. It concerns a young man of 14 years. He had been exhibiting a great deal of challenging behaviour, including wrecking rooms, breaking windows, assaulting staff and many more.

The school staff pressed for him to be put on a form of tranquilliser which they could administer. Soon after the drug had started reports were that he had calmed down. The drug treatment had worked. Or had it?

Unknown to the staff the boy's mother - who was unhappy at him taking the drug - struck a deal with the local chemist who supplied the drug. He mixed a placebo, coloured the mixture the same as the drug and in the same shape. The school used this happily for over a year, blissfully unaware of the true contents of the 'wonder drug'.

Too often drug treatment is used in place of changing administrative structures. Medication should be a last resort, only used when all else has failed and for as short a time as possible. In fact, many drugs used for this purpose have side-effects on concentration, on vision, and on mood.

Behaviour modification

You will no doubt be aware of this term used to describe the system of rewards and punishments to reduce challenging behaviour (as well as in other realms of the curriculum). Indeed its use is a severe challenge (no pun intended) itself to the commandment in Chapter 4 on allowing the learner to have control over his world. For challenging behaviour is in this view a sign that the learner already has too much control. The aim is to reduce the control the learner has over the world.

Behaviour modification can be very effective. However it has two main disadvantages. First there is difficulty in generalising. What is learned becomes extremely specific - to one member of staff, to one room, to one activity at one time of day. Transfer becomes difficult. The second difficulty with this method is that training in skills does little good without concurrent change in attitude.

Gentle teaching

This is only one of many forms of practice currently being used with learners who in general do not have visual disability. The technique can be applied to those who have visual disability.

A special form of this kind of approach has recently been discussed by Lilli Neilsen2.

Cognitive therapy

This technique, recently introduced into the field of Clinical Psychology is, as yet, almost entirely untried in the area of multiple disability with visual impairment. It is an area worthy of further investigation. Further discussion of this subject is beyond the scope of this book5.

General principles..

Here are some general points to consider when thinking of ways of handling challenging behaviour. However, you are also invited to refer to other sources which deal much more comprehensively with the subject:

  • begin with the learner's interests and likes;
  • establish security aiming for a key worker;
  • identify communication strategies that will indicate what is to come next rather than having the world continually happening to the learner;
  • allow some control over what happens in the life of the learner;
  • all staff must agree on ways of handling behaviour.

As can be seen these issues represent the broader area of how to work with the learner who is multiply disabled. These are discussed in Chapter 4. A final point on our brief discussion of challenging behaviour. It can be very difficult to work with a learner whose behaviour is challenging. In that position it can be very difficult to identify where you are 'going wrong.' As a committed professional you are likely to blame yourself. In that position, it is important to discuss with others. Consider what other kinds of resources are available - in the centre, at home, within the local authority, within the voluntary sector. Can they help and does their approach coincide with your knowledge of the 'Ten Commandments'.