# Vision for Doing

## Assessing Functional Vision of Learners who are Multiply Disabled

Chapter 7 Assessing Vision for Doing

Section 10 Responses to Reflected Light

## Aims of Section 10

In this section we begin to use real objects, which reflect light very well. Begin by using reflecting objects that are not too far removed from the intensity of illumination you used in Section 9. You are trying to discover whether the learner responds to real objects at different distances but still within the central part of their field of view. At the same time you will gain some understanding as to how quickly the learner is able to change her direction of attention.

(If you find that this is successful with highly reflecting surfaces, then you can move on to use large objects that are highly Contrasted. However, you don't have to as Section 15 deals specifically with differences in Size).

How to use Section 10

The kind of surfaces which are highly reflective include a mirror or revolving mirrors, glass, Christmas tree baubles (begin by using large ones and ensure they are unbreakable), empty foil bag from a wine box or tinsel. To make the surface reflect more light a bright torch can be shone from behind the learner's head onto the reflecting surface. Try shining it at different angles.

## What to observe

Turn to the diagram. For your observations of the learner you will be using that part of the diagram which is above the dotted line. You will see part o! it is numbered from 1 to 15. These numbers correspond to the (approximate) distance and direction from the learner at which you will be presenting reflecting surfaces. This should be done around head height. Still above the dotted line, and to the right hand side, you can read off the approximate distances from the learner's face corresponding to these numbers. It looks confusing, but the diagram is simply to give you a guide - you don't need to be highly accurate.

To record the results of your observations, use a system that you find convenient. For example, use:-

ticktick to indicate Consistently;

tick to indicate Occasionally;

0 to indicate Never.

Example: When presenting a reflecting surface at Position Number 9, the learner responds Consistently, so you ticktick at Number 9.

## Cautionary note

As we stressed before, remember not to allow previous items to influence subsequent items.

In this section it is difficult to separate out a response by the learner to the presenter from a response to the stimulus (reflected light). If you are unsure, observe whether the learner's response is different when the presenter is in the same position, but without the stimulus of reflected light. Other techniques include suspending the reflecting object on strong thread; presenting the stimulus at the end of a rod at arm's length with presenter to the side, or any combination.

Transferring results to Section 18

Refer back to the checklist at the start of this section. Now you have to decide what the results of your observations mean for the Summary Chart in Section 18. In that Summary Chart, you will find that in the row for Section 10 there is only space to tick under Aware and Attend. The other three boxes are filled in. This is because any general response by the learner by reflected light cannot tell us more than this.

If, however, the learner makes a very specific response (eg; reaching out accurately to a mirror) this would tell you that the learner could Localise. If the learner could also name it then that in turn would tell you even more. Naming would mean he could Recognise through vision. As in the previous section, additional information will be needed if you are to tell that the learner is doing more than Attending. If you have that kind of extra information by all means tick boxes in the filled areas as appropriate.

## No response to reflected light?

If the learner Never shows any visual response to any of the items in this section, you may also not be able to observe any visual responses to any of the subsequent sections in this Chapter. However, you should at least try Section 11, 13, 14 and, if she can walk or guide a wheelchair, Section 17. If these too result in Never you should refer back to the curriculum suggestions contained in Section 9. If you are in any doubt, come back another day and try again. In doing so, you will be sure of using different Settings.

## OR score Attend if:

You have ticked Consistent responses by the learner to all of the numbers. In this case go to the Summary Chart, find the row for Section 10 and tick in the box for Attend. (Again if there is extra information like accurate reaching, tick in filled boxes as appropriate). Then move on to Section 11.

## AND score Attend if:

A pattern in your results indicates that a distance has been reached beyond which responses become inconsistent (some are ticked Consistently, others ticked Occasionally or ticked Never). Note this distance for future work and, when introducing anything new or unfamiliar, be sure to keep the 'best distance'.

Perhaps there is a specific direction which is better for the learner (look at your diagram and see if this is the case. Some locations might be ticked Consistently and others ticked Never or ticked Occasionally.) In this case too, tick Attend in the Summary Chart. Move on to Section 11. (You can also try some of the strategies listed below in order to try to improve responses to the poorer directions. At other times you will want to be sure to avoid presenting objects in that direction.)

## OR score Aware if:

The learner shows no Consistent responses, but some are ticked Occasionally, then tick Aware in the Summary Chart. Then move on to Section 11. In this case you may well want to return and use the curriculum suggestions given in Sections 9 and 10.

## Where to go now?

Having noted the results of your observations and transferred these to the Summary Chart, you are then ready to make a choice. The choice you make will depend on the results you obtained.

## EITHER

You can skip the remainder of this section and proceed directly to Section 11 dealing with assessment of vision. By doing this you will continue your assessment of the learner's use of vision.

## OR

Postpone further assessment and read the remainder of this section. In it we suggest activities for curriculum development. These are to do with the use of reflected light.

## Improving Awareness

To have an interest in this subject you will have found from the completed Summary Chart that the learner is only Aware. Vision will be limited to perception of reflected light. Similarly the learner's use of 'The Other Senses' will be functioning at the level of Awareness. Those most interested in this part of Section 4 will be working with people who have very severe difficulties in learning about the world. Responses to information through sound, touch, smell and taste will, like those to visual information, seem to be inconsistent. They will only occur at this fairly gross level. Of course you would not only be interested in carrying out the activities of this section. You might also want to include some of the techniques mentioned in Chapter 6 which deals with non-visual information. Here we deal with aspects relevant to making use of only very limited vision.

## Why reflective surfaces?

The essence of providing reflecting surfaces, rather than shining low levels of illumination is to increase the informational content of the events in the learner's world. We are thereby facilitating the active stimulation that we are anxious to promote. Directed reaching is encouraged if real objects are present, rather than the purely sensory stimulation offered by levels of light.

## Santa's here

With the learner in a small darkened room, line the walls with cooking foil. Then hang Christmas lights (some of them blinking).

## Little room

A variation on the use of gold reflective paper is to introduce it at one side of a 'Little Room'. Lilli Nielsen, whose work we report on several times introduced the idea of a "Little Room". (See Figure 7.10.1)

## Figure 7.10.1 Schematic diagram of Little Room

Textured surface can be used for one side. Objects, toys can be easily attached. Wooden frame allows flexible use and can be erected in a variety of different ways. After Lilli Nielsen, Refnaesskolen, Denmark.

## Moving mirrors

Mirrored surfaces, empty silver foil covered wine-bags, and other reflective surfaces may be tilted rapidly backwards and forwards producing accentuated changes in reflection. Avoid rotating objects at speeds which may, in some children with epilepsy, possibly induce fitting1.

## Rubbish

Where swiping is occurring a different strategy can be used. The inside of a wastepaper bucket can be altered so that one half has a reflective surface. The learner's hand or arm is placed in the centre of the bucket. As a result any movement made by that arm will result in contact with the two different surfaces. During this try to encourage looking towards this area. Should this prove successful, a variety of different materials can be adhered to the surface of the bin. This can enhance the chances of the learner exploring new areas. After some success the container may be turned so that new orientations are experienced. (This strategy can then be used in the paragraphs below on Attending and Localising).

## Associating

Pair a light stimulus or reflecting light source with a stimulus to which the learner has shown a response. Using, for example, a pen torch or larger torch, present the light source while the learner is attending. Some examples would be tapping a drum while the light is on. Stop the tapping, and switch off the torch. You can do this kind of activity while the learner is carrying out activities such as rolling over a large ball. What you are trying to do is to help her to become more aware of, and attend to, the light. It is addressing the problem of the learner who seems to have very limited awareness of a relationship between what she does and something happening in the world (so-called cause-and-effect).

## Use of computer

For suggestions as to the use of computers refer to Section 9.

## Use of dark room2

For suggestions as to the use of a dark room, refer to Section 9.

## Improving attending

You will be interested in this topic of Section 10 if the learner showed a little more consistency in her responses to reflective surfaces. In addition the results of items in Chapter 6 will have pointed to this as being the appropriate "level" of intervention.

## Two surfaces

The learner who is multiply disabled has more than one potential source of difficulty in beginning to attend to reflecting surfaces. Not only might she have difficulty seeing the object, she may have problems in organising a response - due to physical and/or cognitive impairment - as well as in coordinating seeing with moving. To assist in attending, use two reflecting surfaces found to have resulted in some awareness. Shine a light from behind the learner first on one surface, switching the light on and off slowly. Then do the same with the other surface. Try introducing a sound with the first surface while shining the light, then introduce a different sound with the second reflecting surface. Experiment with the learner in different positions, and with the surfaces at different distances.

## Use of echoes

The use of surfaces which provide echoes is a much neglected area when working with low vision and totally blind children. For instance, the flat footed pattern of walking often observed with blind people may indicate not only negative but also positive features. A foot placed flat and heavily on surfaces such as wood, plastic, linoleum, vinyl and concrete can provide a rich source of information on the person's surroundings. There have been several reports of unusual sounds being emitted by young blind babies. Usually these have been discouraged by parents, being regarded as rather anti-social. Some of these unusual sounds may be attempts by the baby to obtain information about distance, direction, and size of objects. Echoes would reflect back the sound emitted by the baby to give information on these characteristics.

You could encourage use of echoes while increasing visual feedback. Do this using reflective surfaces covering a hard flat object. This gives the clearest echoes. If the learner is not producing sounds, position yourself behind the learner but slightly above. This way you will be able to produce sounds (eg; singing) which will bounce back off the hard surface. Encourage reaching too by bringing his or her hand up to locate the hard surface.

The use of hard surfaces for producing echoes can often be associated with reflecting surfaces such as a mirror, wine bag or gold coloured reflective paper. There is then an increase in the variety of opportunities to explore with both auditory and visual stimuli. You should note, however, that for a learner with a severe hearing impairment, some of these opportunities may be counter productive.

## Movement

When this degree of visual loss is coupled with severe physical disability, strengthening of hand movement may help in leading to crawling, and free standing. Use towels as props under the arms allowing the child to push up more freely. Large-size therapy balls may be used in conjunction with a floor covering which reflects light, or with an area of reflecting surface onto which a light may be shone at an angle. This is an example where limited sight is used as a motivating factor in movement.

## Flashing hands

Learners who have poor control of their hand movements can have highly reflective tape attached to their knuckles and wrist joints. A light, such as an angle-poise lamp can be shone onto the area of the back of the hand (position the light source from behind the learner). Any movements made will lead to interesting sequences of dancing lights. The light source can then be pointed slightly towards one side of the hand. In order for the twinkling lights to continue, the learner has to move this hand into the illuminated area. During this activity, an adult should be present so that the learner does not use her mouth on the tape.

For those learners who are in side-lying frames the reflective surface can be positioned at around a 30° angle. With this angle not only the learner's own face but objects around the body will change the pattern of reflection on the surface.

Iocalising:

You will be interested in following up this part of Section 10 if the responses to reflected light showed some consistency. As well as this the Summary Chart will have indicated the learner to be functioning at this "level".

## Sitting

In order to further encourage independent sitting, two shiny objects made from different materials may be presented to either side of the learner.

Introduce into one hand an object such as a drumstick, spoon, chopstick. Show the learner passively how to produce sounds with this object. It may be possible to then offer two different objects, one in each hand. For either single or both hands, sing in rhythm while placing the learner's hands to either side, tapping lightly on the surface. This may help establish sitting posture while not being exposed to the possible dangers lurking for the severely visually impaired learner.

## Contingency

A variety of toys and devices are available which make use of the kind of contingency detection or perception of relationships between cause and effect we have established elsewhere. As before you should try to have the duration of the stimulus approximate the time taken for the learner to carry out the movement. Avoid frequent interruptions of music which would be demotivating. A reflective mirror surface could be rotated dependent on the learner moving his leg, with the duration of the rotation being at first equal to the length of time for the learner to make the movement. (Refer to Chapter 4 for an explanation of Contingency in the Commandment Thou shalt follow the Learner's Lead. Further technical information is provided in Appendix I on 'Switches and Interfaces.

## Looking glasses

Children especially may often appear not to make eye contact but instead direct their gaze to a person's hairline. Sometimes this is interpreted mistakenly as indicating autism. (The argument goes something like:- learner is avoiding eye contact; eye contact is a form of non verbal communication; avoidance of communication and social interaction indicates autism: therefore the learner is autistic). An explanation relying on the presence of visual impairment should not, however, be discounted.

Often the same learner will look towards a person's eyes if glasses are being worn. It is therefore worth experimenting to see if a person may be identified in this way. The reflectance of the glass may be varied by moving towards and away from a light shining from behind the head of the learner. Where possible, the activity should be encouraged, interacting with the learner appropriately and, if the learner does look towards the Eyes + Glasses, then make a fuss of the learner.

This technique may also be used in reverse. If the learner does not seem to be attending to faces, but does seem to be attending to the reflective surface of glasses, then this can be paired with an activity that is liked by the learner. Suppose the learner likes being tickled. As soon as the learner looks at the glasses tickle him. After a time, tickle him while he is looking in that direction, even though there might be no glasses being worn at that time. (Section 16 discusses this in more detail.)

## Playmats

Playmats of several different types may be made from readily available materials. It is useful to have clearly distinguishable sides in order to give added clues to orientation. Contrasts offered through sight can also be given in conjunction with changes in texture. In this way, visual contrast is combined with tactile contrast. For example, a smooth reflective surface may be set against a rougher surface of a lighter colour. Sheets, quilts, or blankets can be decorated with crepe paper, small bean bags, bells, etc.

## Rolling play

If rolling a learner, it is helpful to provide a consistent light source as this encourages awareness of place in space. It can also be helped with additional sound sources such as washing machine, fridge, running water. Do not expect the learner to understand that which is occurring outside his visual sphere.

## Yes/No

If you have found that one surface elicits a fairly consistent orientation towards ("likes"), and another a fairly consistent orientation away from ("dislikes"), you then have an opportunity to introduce a rudimentary YES/NO. If the learner looks to the side with the surface "liked", shine the light on it. If to the other side, do not shine the light.

## Grasping

For young children, use objects of a size that may be grasped as opposed to simply being palmed or batted while reaching. Typically these might be non-breakable/shatterproof reflective Christmas tree baubles, tinsel, egg boxes, pieces of sandpaper, soft squeaky toys. These positioned within reach at first and the grasp rather than hit the objects. There should then be variety of touch information depending! the object contacted. Once success is obtained at this distance, the arrangement can be positioned elsewhere at different distances. Reflective tape may be attached to one of the objects and torchlight shone from behind the learner on this. So, too, can fluorescent glow-worm toys be used.

## Signing

See section 5 for a little more explanation of the use of signing. In similar ways to a sighted learner acquiring signing, the learner with visual disability may be able to come to understand that other people make consistent responses to movements made by the learner. Consider an example. The learner is swung in a blanket, an activity which all the staff agree is enjoyed by the learner. Staff could easily turn this around and look for the learner to make a movement. This movement is then associated with being swung in the blanket, a fun activity. Repeat the swinging if during the session he or she happens to vocalise or make an arm or a head movement. The link with this particular section is to accentuate the feeling of motion by having a reflected light at one end of the arc of the swing.

recognising:

You will be interested in following up this part of Section 10 if the responses to reflected light showed some consistency. As well as this the Summary Chart will have indicated the learner to function at the "level" of Recognising.

## Mixed messages

On many occasions, the learner who is multiply disabled will be confronted by several therapists, teaching and ancillary staff. How can you make use of this time so that one activity does not interfere with another? Here we would like to make a distinction between what goes on in a single area of interest versus that which may happen across several areas of interest. In fact it was so important that we introduced it in two of our principles underlying practice (Thou shalt not compartmentalise and Thou shalt think of tomorrow). It is the distinction between the micro and macro effects of what we do. For our purposes the micro effects are the surface levels of what we do. They are the stuff of a particular activity occurring in a specific situation at one time of the day or week. They constitute that which we believe to be our curriculum objectives. The macro effects of each isolated activity might be very different. It is important to try to bring together these areas of micro- and macro-teaching and learning. This helps to make sense within the world of the learner who has multiple impairments.

The macro view works towards linking together the individual events in which a learner is placed, in order to present a coherent whole. A day which is structured successfully for discovery tries to ensure that there is a relationships between parts, which brings coherence to the individual activities of the day or week. It sounds grand in theory but it is also simple in practice.

The point of this is that we can never be sure how a learner who is multiply disabled will perceive each possible occasion for learning. If we provide mixed messages across each of the weekly activities, as well as mixed messages for changing from one activity to the next, the learner's task of achieving meaning will be made much harder. Of course we could take this argument to an absurd level and, as caring people, lead ourselves into no end of depression. Turn this problem on its head, however, and consider it as looking for ways to glue each individual occasion for learning into a web with consistent features.

Here is one way of doing so.

## Tactile calendar

One way of easing this situation is to utilise a type of calendar to prompt the learner on the order of upcoming events. Section 5 provides a detailed discussion of Tactile calendars. For the present we concentrate on the use of reflective materials.

Reflective materials may be used to signify the different days of the week. Arrange the days of the week vertically and at a height the learner can reach. To represent each day use a bright colour or reflective surface. Use a different one for each day. It is fine to mix these with tactile material. For example:

Monday = gold reflective paper

Tuesday = Felt;

Wednesday = kitchen foil and so on.

You might wonder why we are not suggesting that reflective surfaces should be used to represent individual activities. This is because the relationship between such a surface and an activity would usually be too abstract. However, there are instances when the reflective surface could be very concrete and meaningful to the learner. A silver paper wine bag may have some very interesting and real connotations! A small mirror might be relevant to a learner who enjoys face painting. Attempts at augmenting communication are aided greatly when the thing to be communicated is intrinsically motivating to the learner.

understanding:

You will be interested in following up this part of Section 10 if the responses to reflected light showed some consistency. Also the Summary Chart will have indicated the learner to be at the "level" of Understanding.

## Shape recognition

Improvement in shape recognition is enhanced by using descriptive qualities of real objects. This is true not only for sighted more able learners but is even more desirable for those who are multiply disabled. The concept of a circle can be offered through glasses, cups, door knobs; that of a square by windows, milk cartons; a triangle by the roof of a toy house, the top of a milk carton; a rectangle by some styles of windows and doors. These can be looked for in toys. Again try to accentuate these cues by using reflective surfaces. Of course you do not want to confuse the learner by using the same reflective surface in association with different shapes.