The Provision of Low Vision Rehabilitation Services for Children, Youths, and Adolescents: An Initial Discussion

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Professor Emerita Department of Special Education, Ophthalmology and Visual Sciences, Vanderbilt University
Nov 22 2010
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Only 86 years have passed since Anne Sullivan Macy was shown a pair of telescopic lenses and stated, “I never knew there was so much in the world to see” (Koestler, 1976).1 Only 57 years have passed since the first low vision clinics were established in New York City.2 And, it has been only 53 years since the Veterans Administration included low vision devices as an appropriate part of rehabilitation services for veterans.2 And, nearly 50 years have passed since Barraga’s dissertation study was published on increasing a child’s visual efficiency through specific activities; because of her work children who had been treated as if they were blind were beginning to be taught how to use their functional vision.3 So, why in 2010 are we still struggling to ensure that children and youths receive comprehensive low vision services?

 

Both special education and medical services (including ophthalmology and optometry) for infants, toddlers, children, and youths with low vision (hereafter referred to as children with low vision) are charged with caring for a child’s sight and vision. This charge covers the health of the eye and medical treatments, prescription of lenses, assessments for functional use of vision, and work toward improvement of functional vision with and without prescribed low vision devices (optical, non optical, and electronic). Based on assessed needs a child’s educational goals and objectives are determined; this is part of the Individuals with Disabilities Education Improvement Act of 2004(IDEIA).4 Whether teaching a child to improve visual functioning without devices, e.g., learning to attend to objects at a distance, to scan an environment, to become more aware of objects in the periphery, to use non optical devices, e.g., bold writing paper, or to use prescribed devices, professionals are compelled to understand that these services are among the most basic services for children with low vision. They allow children with low vision to “extend their visual reach” and to become visually independent (to the extent possible), to gain better control over their visual environment, and to need fewer accommodations, adaptations, and assistance in school, community, home and work environments. Some students with low vision may find minimal improvements in their use of vision while others find they are able to become visually independent. Those students who have learned to efficiently and comfortably use optical devices (and their parents) report higher levels of self-esteem and participation in typical childhood activities.

 

Further, children can derive benefits from the use of prescribed devices in all areas of the Expanded Core Curriculum for Students with Visual Impairments, first discussed by Hatlen, 1996.5 This curricular framework includes the areas of: compensatory skills, orientation and mobility skills, independent living skills, sensory efficiency, career education, self determination, technology, recreation and leisure skills, and social interaction skills. In each of these curricular areas learning to efficiently use available vision can be found, e.g., for safe crossing of streets, for reading with fluency and stamina, for literacy skills for near and distant tasks, to derive pleasure from scenery, and so forth.  A presumption should be made that these services are needed whether a child is, based on assessed needs, a print only reader, a dual media reader (braille and print) or a braille reader (who has low vision). With these services, a child and his or her family will be able to make choices, based on functionality, whether to use vision and/or to choose non visual approaches, also known as “blind skills” for specific tasks.

 

The intent of this paper is to provoke a discussion on the provision of:

 

  1. clinical low vision evaluations for which optical devices (e.g., contact lenses, spectacle corrections, hand held and mounted magnifiers) and electronic devices (e.g., desktop or handheld video magnifiers) are prescribed for access to visual information at near, intermediate- and at far distances (using central vision) and to extend the possibility for accessing information in the periphery (for those with and without central visual disorders). They also include light absorptive lenses (e.g. contacts) and lenses with low light transmission of various colors. 
  2. the provision of these individualized prescribed devices for use in the school, home, and community settings, and  
  3. instruction in the use of the devices in school (e.g., classroom), home, and community settings (e.g., orientation and mobility)
  4. instruction in the use of functional vision within the realm of school learning

and to raise selected issues that must be addressed as to why these services have not become fully embraced by eye care professionals, teachers of students with visual impairments, orientation and mobility specialists and other professionals who have a command of the literature, research, and promising practices of the field and their discipline.

 

Currently, low vision services and resources seem to be provisional rather than programmatic; they are based on zealous efforts of individuals, specific organizations, or groups of professionals who advocate for children with low vision in specific states, special schools, local education agencies, individuals or groups of eye care professionals. To date, there are no data indicating the proportion of children with low vision who have received a functional vision assessment, a clinical low vision evaluation, prescribed optical or electronic devices, and instruction in the use of unaided vision and device-aided vision.

 

Promising practices in the education of children and youths with low vision include these services. This point has been discussed in several documents and texts.6-11 
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Promising practices in the education of children and youths with low vision include these services. This point has been discussed in several documents and texts.6-11

 

Within ophthalmology and optometry programs, low vision seems to be addressed in different ways. Although there are residency programs for ophthalmologists and the low vision Diplomat Program for optometrists, in my experience I have met general and clinical low vision specialists who report that during their training they had little or no participation in a low vision clinic where pediatric services were a focus. They had mostly worked with adults and older adults who were experiencing acquired low vision and saw a small number of children. They also had little or no experience with children with low vision and multiple disabilities. One pediatric ophthalmologist accompanied me to see children in schools using optical devices; in one class at a special school he saw them finding nouns in newspaper articles, copying from white boards, and so forth. As we were leaving he remarked that he had told parents that their children could benefit from optical devices but he had never seen a child using one!

 

The primary responsibility is, in my opinion, a shared one for both medicine and education with other disciplines having specific roles in ensuring that services are available, e.g. How many general eye care professionals can say that every child they have seen who has low vision has been referred to a clinical low vision evaluation (if he or she is not an ophthalmologist or optometrist with a low vision specialty)? How many teachers of students with visual impairments or educational administrators of programs for children with visual disabilities can say that all of their students with low vision have had clinical low vision evaluations, prescribed devices and instruction in their use? 

 

We cannot continue in this fashion where a child with low vision must be extremely fortunate to be seen by the “right” eye care professional or be in the “right” school system to receive services! Or, must a child have the “right” parents who seek information from consumer groups such as the National Association for Albinism and Hypopigmentation, go on online searches, and seek information through other sources, to learn about the benefits of these services?

 

If we are to move forward in ensuring comprehensive low vision services for children I propose that six areas of inquiry be addressed. These are within the disciplines of sociology, public policy, medicine, education, economics, and research.

 

To stimulate discussion, under each discipline I pose three questions and a personal commentary about the current situation. I understand my comments come from my own biases and experiences as both a professional and as a person with low vision.

 

The editors invite you to add your comments at the end of each discipline or you can write a comment on the whole article at the end of Final Thoughts.



Table of Contents:

 

Sociology

 

Public Policy

 

Medicine

 

Education

 

Economics

 

Research

 

Final Thoughts

 

References


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