July 19, 2016
Neurological sight loss highlights the need for a personalised approach to learning support for children with visual impairment, writes Richard Ellis
It is widely accepted that approximately 80 per cent of a child’s learning in the classroom is achieved through their visual system – by what they see. Physical presentations by the teacher, interactive white boards, tablets and computer screens all communicate an array of visual images, created to convey information and ideas. In addition to these formalised channels of communication, learning takes place through less obvious means – through the interpretation of non-visual social cues and body language. It is easy to underestimate the extent to which access to the visual world enables comprehension of our environment and the interactive learning that takes place within it.
By way of illustration, consider a fully sighted person walking into an unfamiliar room for the first time; in an instant they are able to ascertain the general layout of the room, who is in that room and potentially identify any hazards that may be present. For a blind or significantly visually impaired person to determine information about the room and its contents they will need to explore the room, employing their haptic sense (touch) and auditory skills. It is inevitable that this alternative approach to room familiarisation will take longer and may, certainly for younger children, require support and guidance to ensure the use of appropriate and efficient strategies.
Any significant reduction in functional vision is likely to have a profound effect on how children access and understand their environment. For many children with reduced vision their experience of the physical world can be as confusing and disorientating as it is for those who have no vision at all.
An individual experience
Every child with a visual impairment is a distinct individual and their experience of learning with a visual impairment will be equally unique. It is quite possible for two children to have the same visual diagnosis and possibly even the same clinical presentation, yet their visual ability and functioning may vary considerably. A child’s visual functioning will be determined not just by clinical presentation, or the level to which their visual condition affects them, but will also crucially depend on other factors, such as their personality, life experience and how they view themselves as an individual. Therefore, there cannot be a one-size-fits-all approach to meeting the educational support needs of this group of learners.
An individualised response
There are, of course, generic principles and strategies to employ when assessing the needs of children with a visual impairment. There are typical characteristics to consider when looking at particular types of sight loss or visual conditions. However, when planning supportive interventions it is essential to have a good understanding of the individual and an appreciation of their particular experience of visual impairment. Support interventions need to be tailored accordingly if they are going to be appropriate and effective. It is quite conceivable, for example, that the strategies used to access text may be completely opposite for two different visually impaired children. One child may benefit from having printed text increased to a particular font size, while for the other child increasing the size of text would actually compound their visual difficulties rather than resolve them. It is essential that support for children with a visual impairment is specifically targeted and delivered on an individualised and bespoke basis.
A different type of vision loss
This need for an individualised and well informed support service has never been more evident than with regard to visual impairment that occurs as a consequence of neurological sight loss. Good vision is dependent on the health and efficient working of the eye and ocular motor muscles working together with the brain to interpret and make sense of what the eyes are “seeing”. Neurological visual impairment is essentially impairment to vision caused by damage or disturbance to the visual pathways and/or processing areas of the brain. This type of visual impairment is referred to as cortical or cerebral visual impairment, depending on the specific location of the damage or obstruction in the brain. Children and young people with this condition may experience a significant visual impairment although from a clinical point of view there is “nothing wrong with their eyes”. This type of sight loss is becoming increasingly recognised as the largest categorisation of visual impairment in children and young people in the developed world.
Characteristics of neurological visual impairment
Children with this type of visual impairment may demonstrate a range of characteristics that are typical of the condition. They may present with having difficulty with distance viewing, exhibit a preference for particular colours, experience difficulty dealing with visual complexity or need movement to elicit or sustain visual attention. Some children may exhibit significant difficulties in certain characteristic areas and cope very well with other areas; individual children will demonstrate an individual profile of characteristics and how these characteristics impact on their functional vision.
One of the factors that will almost certainly be evident for this entire group is that of visual fatigue. The learning environment and the world in general can be a very confusing place for a child with such a complex visual condition. For these children, the process of making sense of their environment and using their vision for learning will be a significant challenge in terms of the additional time required and the degree of concerted effort required as the eyes and brain work together to learn through vision. Children will need opportunities to rest or take a break from sustained visual tasks.
As our awareness of neurological visual impairment increases, a number of issues of concern are highlighted. A significant area of concern is with regard to the potential number of children and young people who, due to acquired brain injury or neurological conditions, may have this condition but have not been recognised or identified as such. A growing number of children are being diagnosed with cortical or cerebral visual impairment (CVI) but it is suspected that many more children with brain damage or neurological conditions, such as those with cerebral palsy, have not had their visual needs clearly identified, and are certainly not accessing the support of an informed visual impairment specialist.
It is possible that these children have other disabilities or presenting difficulties which are more evident and attract greater priority. There may be physical or behavioural difficulties that present as having a more pressing need. A more cynical view may conclude that within local authorities with stretched and overburdened services there is a reluctance to identify an area of need which is unlikely to be able to be met with the limited resources available. However, for these young people, the impact on their learning and potentially their lives may be going unidentified or at least not fully appreciated. A child or young person who has a neurological condition or who has had a traumatic brain injury and presents with inconsistent, confusing visual functioning should be considered as potentially requiring an assessment for CVI.
A further concern related to this group of children and young people is for those who have been identified or even diagnosed as having a neurological visual impairment but for whom little or nothing has been done to meet these specific needs. As awareness and experience grows in this particular area of sensory loss it can only be hoped that there will be an increase in the availability of appropriate services for these children and their families. Early intervention is critical as it has been shown that, with targeted interventions and support, it is possible to anticipate an improvement in the functional vision of these children.
A different approach
It is apparent that the number of children with a neurological visual impairment is growing. It is encouraging that an increasing number of these children are being identified and diagnosed with a CVI but many children and their families are still being left in the dark with regard to what the implications of this condition are and how to best support their needs.
Vision specialists and advisory teachers working in schools do not always feel confident or equipped to respond to the needs of this type of sight loss and so parents who resort to internet investigations become frustrated in the knowledge that there is growing expertise in this area and that appropriate interventions have been shown to make significant improvements to the functional vision of children and young people with this type of condition.
Children who are identified as potentially having a neurological element to their visual difficulties should always be seen by an ophthalmic specialist for further consultation and possibly to obtain a diagnosis of their condition. An assessment of their individual needs and characteristics should also be carried out by an experienced visual impairment specialist, in order to develop an individual profile of how the child specifically experiences their visual condition. An individualised profile of visual abilities and challenges can then be developed. A bespoke programme of interventions and adaptations to the child’s living and learning environment can then be recommended with the aim of supporting them to use their vision more efficiently and effectively.
As the awareness of CVI increases and the number of children with this particular type of visual difficulty becomes more evident, educational support services will need to respond with specific, targeted strategies for understanding and supporting their needs. This requirement for an individualised approach to this particularly complex visual condition really serves to highlight and remind us that all children with SEN in our schools and colleges are individuals first and foremost. They will each demonstrate their own particular and specific physical or sensory strengths and challenges and their responses to those challenges will inevitably vary depending on a range of personal factors. It therefore follows that effective support for these children should be based on thorough, holistic and comprehensive assessments which lead to personalised and targeted support for learning.
Richard Ellis is Head of Visual Impairment Services at WESC Foundation, a specialist centre for visual impairment in Devon:
As written for SEN Magazine