Vision for Doing
Assessing Functional Vision of Learners who are Multiply Disabled
Chapter 7 Assessing Vision for Doing
Section 17: Learner's Mobility
Aims of section 17
In this section we will examine how well the learner uses her vision for moving around her world. We propose to define mobility as: "Going where you want to go. Leaving when you want to leave.">
Such a definition does not restrict us to consider only those who can walk or run. It also encompasses those who are independently mobile but in a wheelchair: that is they themselves control the wheelchair. The items all bear upon some aspect of visual functioning. For instance bumping into obstacles may suggest an impairment to one or more areas of the visual field. Where obstacles are not avoided below knee height this may suggest a lower visual field defect. Refer to Section 13 to find out any other observations you made which support your conclusion.
Similarly if objects to one side are collided with this may suggest a field defect to that side. Again more information will be gained from the results of your observations contained in Section 13.
Confident easy negotiation of both familiar and unfamiliar settings requires the ability to detect contrast changes, fairly well functioning visual fields (though as seen in Section 13, even quite large 'blind spots' may not have a noticeable effect on functioning), as well as some ability to resolve detail (visual acuity).
How to usesection 17
Refer to the diagram at the beginning of Section 17. You are offered the by now familiar scheme of Consistently, Occasionally, Never .
Settings to use
Early in this book (in Chapter 2 where we explored the 'cycle of assessment, we emphasised the need for you to make observations across different Settings. And peppered throughout the sections in this chapter and Chapter 6, we have provided examples of the use of Settings. In the present section, it is especially important to observe mobility in both familiar and in unfamiliar surroundings. Try different lighting conditions - outdoors, indoors, dim light, bright light. Try surroundings that are cluttered with obstacles, and those that are clear of obstacles (of course, you must be cautious that you do not present hazards unnecessarily). It is up to you which Settings you use - the more the merrier.
Try to discover any difference between the learner's mobility in familiar versus unfamiliar surroundings. We offer you a choice from one of two broad categories for making your observations. Both may be regarded as independent mobility. The first is unaided mobility. Alternatively, if she has access to a self-controlled wheelchair, you would observe aided mobility.
Only read the section below that is appropriate to your learner (aided or unaided).
Transferring results to Section 18:
As with the other sections, you now have to decide what the results of your observations mean in terms of the Summary Chart in Section 18. In that Summary Chart, you will find that in the row for Section 17 there is space to tick under a variety of boxes. It depends on which particular responses you observe. Note that you should do either Unaided mobility or Aided mobility, not both.
EITHER unaided mobility
Score recognise if:
you observe responses Consistently to most of the items. In order to score Recognise, you must observe Consistent responses to the items "Goes to Preferred Places" and "Avoids places disliked and hazards". Ensure that you have made your observations in a variety of Settings &emdash; both unfamiliar as well as familiar. If so, go to the Summary Chart (Section 18) and tick Recognise.
OR score localise if:
there are Occasionally or Never responses for "Goes to Preferred Places" or "Avoids dislikes and hazards". Also two or more of the other items should be ticked Consistently.
OR score attend if:
there are less than two items ticked Consistently.
OR aided mobility
Score recognise if:
you observe Consistent responses to the items"Goes to Preferred Places" and "Avoids places disliked and hazards". Also the learner should Consistently avoid obstacles. Ensure that you have made your observations in a variety of Settings - both unfamiliar as well as familiar. If so, go to the Summary Chart (Section 18) and tick Recognise.
OR score localise if:
there are Occasionally or Never responses to "Goes to Preferred Places" or "Avoids dislikes and hazards". Also the other two items should be ticked Consistently.
OR score attend if:
there are less than two items ticked Consistently.
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.
you can skip the suggestions offered for developing the curriculum, and move on to read Section 18. You have completed your observations.
read the remainder of this section. In it we suggest activities for curriculum development.
Developing a curriculum
Exploration of the topic of mobility is important because:-
it reinforces the investigation of Settings as an essential part of the cycle of assessment;
- mobility is highly motivating;
- it places emphasis on continuity existing across the "levels" of responsiveness;
- mobility is a fine demonstration of our commandment Thou shalt think of tomorrow;
- mobility implies movement.
Let us spend a little time developing these points.
In Chapter 2 we presented details of a cycle of assessment, part of which required investigation of the different surroundings or Settings in which the learner found himself. In the various Sections of Chapter 6 (and of Chapter 7) there is a temptation to forget to carry out an investigation of Settings.
By its very nature mobility forces us to look at the learner in different surroundings. For instance what happens in familiar versus unfamiliar surroundings? What does the learner do when confronted with a flight of stairs?
In many places in this book we have identified the need to consider abilities as well as disabilities. One of our earliest items asked you to investigate the learner's interests and likes. Mobility - in, or out, of a wheelchair - has potential for imaginative use as a motivator.
Later we will present some interesting results of work carried out with learners in electric wheelchairs - showing the sheer fun of being offered the chance to negotiate the world independently.
We stressed in the Introduction to this chapter that there is a need for continuity in our intervention. By continuity we mean that you don't take up one new activity one month only to jump off to some completely different activity the next month. However we accept that it is easy to forget the need for continuity. In fact the strategy used for identifying where to begin intervention seems to steer away from continuity.
Topics under Awareness, Attending, Localising, Recognising and Understanding suggest breaks in development between these topics. This kind of model is suggestive of stages or jumps &emdash; that is discontinuity. So to redress this imbalance we intend to use mobility as one example of continuity in approach. In the other sections there are usually strong links between individual suggestions, although less time is spent on making these links explicit. To have done so in each and every section for each and every suggestion would have made this book even longer.
The stress we lay on the need for continuity does of course reflect one of our Ten Commandments (see Chapter 4). The importance of planning for tomorrow when thinking of what to do today cannot be over-emphasised. We will use Mobility as one example of planning for tomorrow.
Mobility means movement - of oneself in relation to the world. A great deal of valuable visual information relies upon the detection of movement. Movement attracts attention, accentuating the relation between foreground and background through shearing at the edges, lighting and shadow changes, perspective cues and in other ways. An example of how important movement can be in supplying visual information was demonstrated in the Figure 7.14.1.
No doubt you will question how it is possible to consider Mobility if the learner is only at the level of being Aware of the world. Surely, all of the items listed at the beginning of this section correspond at the very least to an ability to Localise? In a strict sense you would be right, the learner would at least need to be able to Localise (whether by sight, hearing, touch or smell). You would also be right that none of the items to be recorded relate to Awareness.
However, recall our definition of Mobility given at the beginning of this section. We chose a broad definition to enable us to highlight the need for continuity in intervention - from Awareness through Understanding. Let us now consider the threads which can run through effective development of the curriculum.
Familiarity or trust
There are many examples contained in this book of ways to establish trust
with the learner. Formalised approaches also exist. These include Intensive
Interaction (or Education) , Movement Therapy and Resonance.
Appropriate use of Massage Therapy, Aromatherapy, Snoezelen, Music
Therapy and Facilitative or Child-oriented play can all be used to
help build up a close trusting relationship1. Of course formal approaches are not necessary. The essence of any of
these approaches is consistent and meaningful responsiveness to the learner.
Any slight movement of the learner is "given back" contingently
to the learner. (And if Thou valuest the learner, you will not
restrict your responsiveness to specific times of the day given over to
an activity. To do so would not comply with the commandment Thou shalt
not compartmentalise). Unless you have established familiarity and trust with the learner it
is extremely difficult to proceed. After all in the future you could be
asking her to step out into the unknown.
Of course formal approaches are not necessary. The essence of any of these approaches is consistent and meaningful responsiveness to the learner. Any slight movement of the learner is "given back" contingently to the learner. (And if Thou valuest the learner, you will not restrict your responsiveness to specific times of the day given over to an activity. To do so would not comply with the commandment Thou shalt not compartmentalise).
Unless you have established familiarity and trust with the learner it is extremely difficult to proceed. After all in the future you could be asking her to step out into the unknown.
The major feature of being able to attend that is relevant to Mobility is the beginning of a distinction between self and the world. There are many play techniques which can aid this process. These include the use of:-
- resonance boards to lay down the foundations for developing concepts of up/down, in/out and so on.
- action songs (see Section 4)
Each of these is far easier to progress with if you have first of all established a relationship of trust with the learner.
One very special instance of the learner discriminating self from the world is that of Aided Mobility. We have chosen to separate aided from unaided mobility for one very important reason. There have been many instances where a learner, diagnosed as totally blind and unable to walk has, as a result of that diagnosis, not been given the chance to control his own mobility. He would be placed in a wheelchair and, because the diagnosis is one of total blindness, would be pushed by another person, going to places to which he has no wish to go, and leaving at times he does not want to leave.
A variety of research has shown that where children (and adults) are given appropriate control over the movement of an electrically operated wheelchair, they may demonstrate use of vision and a route finding capability which goes far beyond any label of "profound multiple disability". An important point to note is that many of the people who were given this opportunity to exert control over their mobility had to wait for that opportunity until they were adults.
The notion of using independently controlled wheelchairs at this stage of Attending seems to fly in the face of logic. Doesn't a learner have to first be able to understand things like near/far; right/left; back/forward before being offered the chance of independent control of an electric wheelchair?
Some very interesting work suggests that this is not true. Different studies in the UK, Australia and Sweden have shown that independent mobility - given by an electric wheelchair - can be a cause of progress in development (rather than being dependent on a stage having being reached)2. Learners with very severe cognitive impairment have shown themselves to be able to learn to operate an electric wheelchair. The activity is fun, highly motivating, exploratory and not at all abstract, but based in real experience.
A story about mobility
In terms of the learner's visual disability independent mobility through an electric wheelchair has another distinct advantages. It encourages full use of functional vision. The story in the caption illustrates the effect this can have.
Does aided inhibit unaided mobility?
For those who are concerned that a wheelchair might discourage any further attempts at unaided mobility there is no need to worry. There is every reason to continue with both aided and unaided mobility. Indeed some writers have reported that the use of a self-controlled wheelchair may give renewed interest in all forms of mobility3.
Intuition tells us to take the learner to objects outwith his grasp. The problem in doing this is that it is still relatively passive - it is not the learner who has initiated the movement. By using well contrasted materials and textures, exploration is encouraged.
Find a quiet area (or room if you are fortunate enough to have one). Place a favourite object beside the learner - especially one that has a 'cue to distance'. These could include one with a pleasant smell, a sound or light. Try to make it a game to reach out towards the object. You will have to help in leaning towards the object, showing her how to support herself through resonating with her own movements.
Once success has been achieved you can gradually introduce additional objects to serve as distractions. You will probably have to repeat the exercise once the learner is able to stand.
Pram or rollator
Movement to the unfamiliar can be helped by having to push around a rollator or trolley. This enables independent (but aided) control over her visual surroundings while offering a degree of security. In the process she is beginning to distinguish what was once unfamiliar. Thereby you are moving into the territory of Recognising.
Touch as a prompt
Being led by even one finger is a long way away from complete independence in mobility. To help make the transition it may be worthwhile to lightly touch the learner after each step. Gradually increase the time between you making contact, always being prepared to return to short intervals if needed.
You don't need to carry out any of these for long periods at one time. Up to 10 minutes means the fun can be retained while learning still takes place.
Look for any specific problems which may occur out of doors. Often we confine tasks indoors to those which occur on one level, and this is not possible when outside. In unfamiliar settings, especially when outdoors, the learner will have to negotiate many different surfaces. Use available conditions of bright sunlight, cloudy sky, shade and various times of the day. Under these conditions, give the learner practice in negotiating drop-offs at kerbs and stairs, encouraging lateral head movements to increase cues from motion parallax (see Glossary). Some learners who are affected by glare may benefit from use of sun glasses, visors or caps. Try placing the learner in a variety of positions in relation to the direction of the sun. Compare her preferences under these various conditions.
This is one technique commonly used in mobility training with those who have the single impairment of vision. For any chance of success with those who are additionally disabled, a lot more work has to go into the technique.
Again make use of objects which are found to be of interest to the learner. Attach these to the wall, making it interesting to trail along. Instead of having only the fingers trailing, you will probably need to encourage the learner to use his whole body. Egg cartons, felt, paper, shiny or crinkly paper, polystyrene might be useful.
If the learner is able to recognise symbols or everyday signs, then try to discover the conditions out of doors which are best suited to this function. This can be done using billboards, identifying objects and relating these back to activities at school.
Note that many learners who have visual impairment are likely to seem to perform poorly outdoors after snow has fallen. The glare may impair their sight severely. A similar effect may occur from bright sunshiine after showers of rain, and with low sun in winter. Allow time to explore the playground at school, or other surroundings. Help him to discover the presence of swings and other play areas, plants and flowers.
Compare abilities under familiar (if you get the chance see him in the area around his home), and unfamiliar routes where the learner is able to move independently. Look again at unfamiliar routes under different lighting conditions of sun, shade, cloud.
Just to give you some idea of how difficult it can be to get around the world if you are visually disabled here is a story. It is based on a real learner. But it is written as if the learner is himself telling his story. In brackets are some comments to help you to identify what is wrong. If you like you could follow these up in the relevant sections.
Hello my name is Andy and I'm 9 years old. I was born with Rubella so I've got a lot of problems with my vision and as if that wasn't enough I've got a hearing impairment and a few physical problems. Here is what it is like for me to get around in the world.
What about my sight?
I'm not totally blind, no sir. But the area I can see without moving my eyes is cut down (restricted visual field). This makes it difficult to walk outdoors especially in unfamiliar surroundings. Even in familiar surroundings, I am easily caught out by objects and people - they seem to appear as if by magic. They tried to give me an eye test (Snellen, E-test, finger counting). They didn't seem in the least bit relevant to how my sight affected my walking. And the doctors say I cannot cooperate with them to do a proper visual field test. Why don't they just open their eyes and look at me?
You might think I'm better off on a bright day. But outside there is a lot of glare. That can make it even more difficult to see objects. (Andy had congenital cataracts). Outdoors is where the biggest hazards are, you know, cars and stuff like that.
Soon after I was born I had my cataracts removed (early surgery is most effective for congenital cataract). But now my eyes don't focus very well at different distances and I have to wear glasses (difficulties in accommodation). Its alright for older folks who get that op. They can compensate for these problems in focussing - they have got a lot of knowledge from their past when they could see OK about the things to expect to see in the world. I don't.
This is a really important point that a lot of people miss. And I'm worse off than others. I cannot compensate by using my hearing to get clues about my surroundings and approach of traffic. I can't use echoes to indicate presence of significant landmarks. I cannot use those everyday sounds which a person who is 'only' blind takes for granted.
What about my hearing?
If it's quiet I can make out clear, even speech, so long as people don't shout. But this isn't much good for getting about outside. The average level of noise makes it really difficult to understand speech and all other sounds. This is really dangerous, so one of my parents has to supervise me whenever I'm near a road.
Other effects of Rubella
I'm also not so good at the motor control. This makes it difficult with balance. This too means I need supervised when out of doors. Some folks say I'm impulsive and wilful. I don't like to follow instructions. I tend to go off and do my own thing, whereas I'm supposed to be doing something constructive: such as crossing the road. But if I just did what other people wanted me to do all the time, I'd never learn , would I!