Vision is an integral part to standardized learning. Students who lack visual abilities often feel lost in a confusing educational maze. Although the U.S. Department of Education reported that less than 1% of U.S. students had visual impairments in 2004, the actual number of children with visual impairments is higher. The consequences of visual impairment can range from missed opportunities in learning to obstacles to gaining independence.
At one point the term visual impairment referred to an eye disorder at the tissue level, but subsequently, visual impairments took on a broader meaning to include the consequence of a functional loss of vision caused by a number of eye disorders.
The definition of visual impairment includes a range of vision loss, including low vision. Specifically, it is defined as “an impairment in vision that, even with correction, adversely affects a child's educational performance. The term includes both partial sight and blindness” (Pierangelo, 2007, p. 331). In the educational context, three terms describe levels of visual impairment.
The fist level, partially sighted, refers to a visual problem that has resulted in the need for special education.
Low vision is used generally to refer to a severe visual impairment. The impairment is not necessarily limited to distance vision, but includes students with sight who are unable to read a newspaper at normal viewing distance, even with the aid of contacts, eyeglasses, or electronic devices. Students with low vision use a combination of vision and other senses to learn; they may require adaptations to lighting, print size, or provision of written materials in Braille.
Legal blindness is defined by vision of 20/200 or less in the better eye after correction, or limited field of vision (measuring 20 degrees at its widest point). Limited field of vision results in some confusion for students. Legal blindness also includes total blindness, or a person with “no vision or only light perception.” These are students who must receive instruction via aural methods, Braille, or other nonvisual media.
Visual impairments are caused by a number of eye disorders, including albinism, cataracts, retinal degeneration, diabetic retinopathy, glaucoma, corneal disorders, congenital disorders, and infection. Although the Department of Education listed fewer than 26,000 students age 6 to 21 as receiving special education services under the visual impairment category in 2004, the actual number is likely higher. Many students with visual impairments have other disabilities as well and are listed in those categories. Visual impairments actually occur at a rate of 12.2 per 1,000 people under age 18. Legal blindness occurs at a rate of .06 per 1,000 people under age 18.
Early assessment is key to helping a student benefit from appropriate intervention programs. Severe visual impairments are more easily identified in schools than milder vision losses. However, there are warning signs of visual impairment, such as lack of coordination in the eyes or excessive eye movement and blinking. Children who rub their eyes or who have frequent watering and signs of eye infections may need assessment for visual impairment. If children confuse colors, complain of headaches, or have poor posture when reading or writing, they may have vision impairment. More obvious signs include squinting, sitting very close to the chalkboard or screens, messy work, or complaining of difficulty seeing things clearly.
Among the goals set forth in the National Agenda for the Education of Children and Youths with Visual Impairments, Including Those with Multiple Disabilities, is Goal 6. It reads: “Assessment of students will be conducted, in collaboration with parents, by personnel having expertise in the education of students with visual impairments” (American Foundation for the Blind, 2005, p.1). Because the National Agenda emphasizes providing timely, quality educational services for children with visual impairments, initial and ongoing assessments are critical.
Students are assessed by a certified teacher of students with visual impairments (TVI). A functional visual assessment helps to determine how the children currently use any partial or low vision and what visual skills need further development or assistance. The TVI observes each child performing routine tasks and speaks with parents, teachers, and others involved in the child's care about how the child uses vision. The child's eye doctor also provides important clinical information on visual acuity, visual field, and diagnosis. A child with visual impairments may be examined by an ophthalmologist, who specializes in diagnosis and treatment of medical and surgical problems of the eye; an optometrist, who specializes in vision problems and treating vision conditions; and other providers such as an optician, who dispenses eyeglasses and other optical aids, or a low vision specialist.
The TVI will review the eye doctor's findings of visual acuity and summarize them on the report. The teacher also includes notes from observers and observes the child's visual skills from near and far distances. The teacher also observes how well the child sees objects that are to the sides, above or below the eye level to assess visual field, and notes other visual functions such as ability to localize, fixate, scan, track, and shift gaze. Eye preference and eye-hand coordination, as well as color vision, are additional concerns. The TVI observes the child in different settings and assesses visual abilities in relation to environmental considerations such as lighting, object size, and additional time to complete tasks. A team that consists of the TVI, parent or guardian, a general classroom teacher for the child, and other education professionals such as a school counselor or school psychologist, generally meet to make final recommendations and discuss the child's potential placement. The evaluation should include recommendations for services, adaptations, and instructional skills that will help the student learn.
If a child has no vision, he or she still needs a functional visual assessment to confirm medical information and blindness, as well as noting recommendations for instruction modification.
Many factors determine how visual impairments affect a child's learning experience. Age of onset and severity of vision loss, as well as presence of multiple disabilities, are some of the factors that make each child's situation unique. The U.S. Department of Education reported in 2004 that more boys than girls had visual impairment. As more and more infants are born prematurely, the incidence of visual impairments is expected to rise.
The cause of visual impairment and overall functioning level of a child also determine how the visual impairment affects a child's development. In general, visual impairments have cognitive, academic, social and emotional, and behavioral effects.
Restricted movement within the environment, particularly for children with congenital visual impairment, can affect a child's development. Children with visual impairments often have limited interactions with their environments, less reason to explore interesting objects, and as a result missed opportunities to learn. This lack of exploration may continue until some sort of intervention begins to motivate learning.
Academic performance may suffer for children with visual impairments, particularly in reading and writing. Alternative media and tools may help, such as Braille or an alternative form of print.
Children learn much about social behavior by observing others, so those with visual impairment may not understand nonverbal cues and other nuances of social behavior normally learned through imitation. The functional limitations caused by visual impairments may create obstacles to a child's independence as he or she ages. Studies have shown that some children with visual impairments can display social immaturity, more isolation, and less assertiveness than their peers.
Many myths surround children with low vision. In addition to later discovery of their visual impairment in some cases, those with low vision may not receive the adaptations and services they need as compared with their peers who are declared legally blind. Yet students who have low vision have unique social and emotional needs, such as identity issues, and they may need help with developing communication and self-advocacy skills.
Overall, children with visual impairments require assistance with technology, special print, auditory, or Braille materials. Other specialized needs depend on the functional visual assessment and ongoing assessments concerning the child's development.
More than 30 specific diseases and conditions are associated with visual impairments. An ophthalmologist can make the definitive diagnosis as to the cause of the visual impairment based on a physical examination and associated tests. According to a report from the U.S. Preventive Services Task Force, the most common causes of visual impairment in children under age 5 years are amblyopia and its risk factors and refractive error not associated with amblyopia. The common name for amblyopia is lazy eye. It develops in early childhood and involves one eye not working well with the brain, resulting in reduced vision in the affected eye. Amblyopia affects about two to three out of every 100 children.
Amblyopia may be due to effects of other conditions that interfere with normal binocular vision, such as strabismus (ocular misalignment), anisometropia (a large difference in refractive power between the eyes), cataract (lens opacity), and ptosis (eyelid drooping). In anisometropic amblyopia, the two eyes have different refractive powers; one can be nearsighted, while the other is farsighted. The misalignment of the eyes in strabismic amblyopia causes one eye to be used less than the other. The nonpreferred eye does not receive adequate simulation, and the visual brain cells do not develop normally.
Refractive error not associated with amblyopia primarily includes myopia (nearsightedness) and hyperopia (farsightedness). These problems are correctable regardless of the child's age at detection.
Retinopathy of prematurity can blind a child. It generally develops in premature infants with low birth weights or less than 31 weeks of gestation. It is classified in five stages, from mild to severe. Diabetic retinopathy is a complication of diabetes, brought about by damage to tiny blood vessels in the retina. It is the leading cause of blindness in the United States. Retinoblastoma is a malignant tumor of the eye. Although it can occur at any age, it most often occurs in children younger than age five. The tumors may be present in one or both eyes.
Nystagmus is an involuntary movement of the eye that reduces vision. Typically, the movement is from side to side, but it can be up and down or circular. There are several forms of nystagmus. The condition may be hereditary and can result in severe reduction in vision. Students may need extra time for reading to scan text.
Strabismus is the misalignment of one eye and comes in several forms, such as esotropia, the inward turning of the eye, and exotropia, or outward deviation of the eye. Hypertropia refers to vertical deviation of the eye. Strabismus also can occur intermittently. The cause of strabismus generally is unknown. Other disorders often are associated with strabismus, including retinopathy of prematurity, ret-inoblastoma, traumatic brain injury, hemangioma near the eye, Apert syndrome, Noonan syndrome, Prader-Willi syndrome, and others.
At one time, students with visual impairments were taught only in residential schools for blind children. Early in the 20th century, local school districts began educating students with visual impairments, but primarily in special classrooms. In the early 2000s, itinerant teachers, resource rooms, general education classes, and special schools all may be used in the education of students with visual impairments. By 2004 the U.S. Department of Education reported that about 90 percent of children with visual impairments spent at least some time in regular classrooms with peers.
The Individuals with Disabilities Education Improvement Act (IDEA) was introduced in 1975 and passed in 1990. It was reauthorized in 1997 and 2004 and includes provisions for children with visual impairments as defined above. Students with visual impairments also may be eligible for accommodations for general classroom inclusion under Section 504 of the Vocational Rehabilitation Act, passed in 1973.
The National Agenda for the Education of Children and Youths with Visual Impairments, Including Those with Multiple Disabilities is a grassroots effort that has helped improve education for children with low vision and blindness. In 2003 the National Agenda was updated to include 10 goals. The goals range from ensuring referral to an appropriate education program within 30 days of identification of suspected visual impairment to recommending ongoing professional development for those providing services to students with visual impairments. The National Agenda also encourages implementation of policies that involve parents as equal partners in the education process, that local education programs ensure access to a full array of services, and that access to educational and developmental services include assurance that materials are available to students in the appropriate media and at the same time as their sighted peers. Educational goals should be based on the assessed need of students with visual impairments and goals and strategies should be set throughout the student's life continuum.
The TVI works with local and national professionals as needed to provide access to educational materials for students with visual impairments. Students who are blind may use raised maps and charts and other materials to facilitate tactile learning. Many rely on auditory information from books on tape or CD-ROMs, spoken output from a computer, or tape computers, in addition to large print or Braille materials. Each state has specific policies and practices for broad programming of curriculum. The National Agenda has an expanded core curriculum that describes the skill areas needed for students with visual impairments to prepare for a successful adult life. This curriculum goes beyond academic skills to include other considerations for the individualized education plan (IEP) team. Examples of expanded core curriculum areas are orientation and mobility, social interaction skills, career education, technology, independent living skills, and visual efficiency skills.
Students with visual impairment should be included in general education when possible through careful assessment, strategies, and use of assistive equipment and materials. A TVI coordinates the instructional program. As children get older, it often is advisable to introduce them to adults with visual impairments so that they can experience normal work situations.
As stated previously, children with visual impairments may have difficulty with reading and writing and some low vision problems simply require more time for students. These issues can be particularly trying during standard testing at schools. The No Child Left Behind (NCLB) Act was signed into law in 2002 by President George W. Bush. The act revised the Elementary and Secondary Education Act, which is the primary federal law in precollegiate education. NCLB requires annual testing of all students in reading and math proficiency.
A student's functional visual assessment may need to include adaptation of achievement and other standardized tests such as those administered to satisfy school and state requirements under NCLB. The test may be conducted in Braille, on a computer, with magnification, or in a number of other ways, depending on the child's visual impairment. Responses may be given orally or through word processors or Braille writers. Scheduling accommodations such as extended time also may be made for students with visual impairments who need them.
There are challenges particular to educating students with visual impairments. Teachers who specialize in educating students with blindness and low vision often are isolated from their colleagues in the field because they may be the only TVI in the school district. They should remain connected with the larger community of professionals serving students with visual impairments. Some of the assistive devices for students can be difficult to find or expensive, so careful assessment, proof of need, and at times assistance from specialized resources may be required. Educators and parents of students with visual impairments should try to provide assistance to students only when needed, within the guidelines of the assessment plan and IEP, and help students develop a sense of initiative and independence.
American Foundation for the Blind. (2005). A teacher perspective. National Agenda on the Education of Children and Youths with Visual Impairments, Including those with Multiple Disabilities. Retrieved April 11, 2008, from http://www.afb.org/Section.asp?DocumentID=2669&SectionID=56.
Baumberger, J. P., & Harper R. E. (2007). Assisting students with disabilities: A handbook for school counselors (2nd ed.). Thousand Oaks, CA: Corwin Press.
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Huebner, K. M. (2006). The expanded core curriculum: Finding the time. Retrieved April 11, 2008, from http://www.tsbvi.edu/agenda/core-ppt.htm.
National Dissemination Center for Children with Disabilities. (2004). Disability fact sheet no. 13: Visual Impairments. Retrieved April 11, 2008, from http://www.nichcy.org/pubs/factshe/fs13.pdf.
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Pierangelo, R., & Giuliani, G. (2007). The educator's manual of disabilities and disorders. San Francisco: John Wiley & Sons.
Riordan-Eva, P., & Whitcher, J. P. (2004). Vaughan and Asbury's general ophthalmology (16th ed.). New York: McGraw-Hill.
Topor, I. L. (n.d.) Fact sheet: Functional Vision Assessment. Retrieved April 11, 2008, from http://www.cde.state.co.us/cdesped/download/pdf/dbFuncVisionAssmt.pdf.
U.S. Preventive Services Task Force. (2005). Screening for visual impairment in children younger than five years: Recommendation statement. American Family Physician, 71, 333–336.
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