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Introduction
Since the early part of this century the benefits of magnification for persons with low vision have been described in the literature. In 1924 telescopic lenses were first demonstrated at a meeting of the American Medical Association. Although there were cautions expressed by some professionals that people with low vision would not want to be seen in public using such devices, it was Ann Sullivan Macy, Helen Keller's teacher, who stated, "You may be as enthusiastic as you please for me in endorsing the telescopic lenses—I never knew there was so much in the world to see." (Koestler, 1976, p. 368). Today, the comments we hear from children resound with the enthusiasm of Ms. Macy who would, no doubt, be amazed at the miniaturized telescopic devices currently available. Researchers, especially in the last decade, have found advantages in the use of optical devices with standard print rather than the use of large print for children with low vision. The literature also suggests that students who use only large print may plateau in reading speeds and reading levels. Nevertheless, ophthalmologists, parents, and teachers of children with visual impairments have not fully embraced the use of optical devices as a primary option for students with low vision who are readers of print.
The Project
Providing Access to the Visual Environment (Project PAVE) offers comprehensive low vision services to children and youth, ages 4-19. These students have been unable to see, or were uncomfortable with, standard print. In most cases they were using large print that only addressed their textbook needs. Other standard print materials, such as newspapers, maps, and menus were inaccessible as were chalkboards, street signs, other detailed visual information at a distance, and scenery. Some children have visual field restrictions, others have photophobia, lowered contrast sensitivity, or other visual effects alone, or along with, low visual acuity. Most of the children are considered legally blind by U.S. standards. In this presentation, I will share the unique components of Project PAVE, describe successes and challenges we've experienced, and discuss the need to implement similar programs for providing access to the visual environment for children with low vision.
The children in Project PAVE come from urban as well as rural areas; some have a visiting teacher of students with visual impairments and others live in areas where no teacher with knowledge of visual impairments is available. To date, fifty of the children have come from local school districts while thirteen attend the Tennessee School for the Blind.
Project PAVE incorporates many of the components of more traditional low vision programs, including a review of previous ophthalmological reports, a request for the visual demands of the classroom, an evaluation and prescription for optical devices, and communication with the children's parents as well as with teachers of children with visual impairments. Project PAVE, however, incorporates additional components which we believe are, in part, reasons for the many successes we have achieved.
We strongly believe that there must be a partnership of the family and the professionals involved in the provision of low vision services. The services must be child-centered and part of an overall learning program. Optical devices aren't just for reading; they are individualized learning tools which extend the children's visual environment, and which promote options for visual independence during and after school hours.
Objectives of Project PAVE are shared with all adults and children as appropriate. They include increasing—
access to standard print
and distance information
visual environmental awareness
control over the visual
environment
visual independence
literacy skills
parent's, student's, and
teacher's knowledge of visual impairments, and
establishing realistic expectations
for future visual functioning
Phase One: Preliminary Information
Information Pertaining to the Child's Vision. We begin gathering information related to the children's vision and visual functioning. Teachers recommend children based on specific criteria and this provides a general idea of the child's potential to benefit from optical devices. Criteria for participation in Project PAVE includes but is not limited to:
identified as a print reader
or pre-reader of print (this includes children who are using both print
and braille)
uses or is expected to use
large print (18 pt. or larger)
has visual fields of 20
degrees or greater
able to recognize people
at 5 feet
is uncomfortable with, or
unable to read standard print texts (12 point)
is unable to read chalkboards
from a preferential seat
generally moves closer to
objects to see them better
We review the children's medical eye reports, their functional vision assessments, and their orientation and mobility assessments when available. These documents tell us about the children's clinical measures and how well they use vision at near and at distance. We also consider any written goals pertaining to the development of visual function which are included in the Individualized Educational Program plan, a form required by our federal law for children receiving special education services.
School Information. School information is also obtained. We ask for academic and nonacademic information which relates to the use of functional vision; this information helps us to set goals and applications of optical devices in the children's programs. Specifically, we ask for the reading levels and reading speeds (oral and silent), handwriting samples, and the types of special education services provided. Some of the children have additional disabilities. For example, are there learning disabilities, neuromuscular difficulties, or emotional problems?
Teacher Interview. Teachers are asked to complete two forms titled, Expectations for Visual Functioning. This is a likert-type scale which asks the extent to which a person with or without optical devices will be able to perform 20 adult-oriented visual tasks, items include, will the person be able to read a standard newspaper, a street sign across a street, or read for an hour at a time. Teachers first complete this scale for a hypothetical individual with an uncomplicated visual impairment; this provides us with an understanding of each teacher's expectations for visual functioning and we can compare it to that of other teachers. Then, we ask the teacher to complete the same form for their student or students who are participating in Project PAVE.
We review the children's visual information and goals established for visual functioning. Teachers are asked to share their hopes and concerns about the future visual needs of their students and their impressions of how their students and their families will .
Further, we ask about the teacher's knowledge of visual impairments, lenses, optical devices, and accommodations for students with low vision. For some teachers, even those with preparation as teachers of students with visual impairments, additional readings, demonstrations, and/or instruction can be provided.
Parent Interview. We begin parent interviews by asking about their child's visual impairment. Oftentimes, parents know the name of the condition but do not understand what part of the eye or visual system is affected or what the clinical measures such as visual acuity mean. This year we found that only 79% knew the name of their children's conditions, 53% knew the meaning of the diagnosis, and 37% could explain visual acuity measures. This level of knowledge did not change as children's ages increased.
With additional questions we learn about the parents' understanding of how their child uses functional vision, what concerns they have for future visual needs, and how they anticipate optical devices will impact their child's present and future learning. We also ask parents to complete a visual expectations form. This tells us of the parents' expectations but also lets us compare expectations with those of their child's teacher. In other words, we learn whether the messages being given to children by their parents and teachers are similar or whether each has a very different picture of what the child can learn to do with his or her vision.
Parents are an integral part of the project. Their support of their children's use of vision and optical devices is critical. Parents provide encouragement for the development of skills, provide opportunities for children to use their devices during family outings and at home. While some parents readily see themselves as partners in promoting the use of optical devices and see the devices as tools to help their children extend their visual functioning, others share concerns related to their children's or their own acceptance of optical devices. Some parents believe their children appear "normal" until they use a device in public and they fear a stigma. Others worry that if their children use optical devices special education services will be reduced or withdrawn. While Project PAVE staff cannot allay all concerns, parents know that they are partners in the process by which their children gain visual independence. They can call project staff at any time and are often present during follow-up visits with their children. Parents receive instruction in the use of the devices and are involved in determining the effectiveness of the devices for their children. Explaining this process during the initial parent interview lays the groundwork for the project year.
Child Interview. Children are also interviewed and again we ask about their knowledge of their own visual impairments. We are still amazed when 16 or 17 year old students have little understanding of their medical conditions or when they have not had an opportunity to review their own functional vision assessments. We ask students a variety of questions related to what helps or hinders their visual function, what they hope to be able to see with optical devices, and how they feel about events and rituals related to having low vision. We have developed a short scale for students which alerts us to special challenges they may be facing with their identity as a person with low vision or with regard to their social experiences of having low vision.
Phase Two: Clinical Evaluations
The Department of Ophthalmology and Visual Sciences of Vanderbilt University Medical Center provides the clinical low vision evaluations for Project PAVE. In addition, they provide, at parents' request, pediatric ophthalmological examinations. Drs. Regina Elkins and Sean Donahue are the low vision optometrist and pediatric ophthalmologist, respectively.
During this phase, parents and the children's teachers attend the clinical low vision evaluations. Children are encouraged to bring school materials and a wish list of activities in which they would like to participate during or after school hours. We are introduced as problem solvers, people who are there to help them figure out ways to become more actively involved in doing what they want to do. From marching band, to skateboarding, to reading from the chalkboard, or seeing teenage magazines, we respond to the visual needs of the children.
Visual acuities are always taken with a low vision chart. These help children and their parents receive a more specific visual acuity than they may have received with a standard Snellen chart. It also provides us determine whether there are improvements to which a Snellen chart may not be as sensitive. We also look at children's visual fields, contrast sensitivity, and need for light absorptive lenses. At times recommendations are made for changes in glasses or contact lens prescriptions. When complete optical systems are changed to accommodate some aspect of an optical device prescription or to improve visual functioning as when a field restriction is being accommodated, the project pays for the lenses in addition to the optical devices.
Typically, we recommend hand held devices for the children in the project. There are many functional as well as cosmetic reasons for this. At times, however, spectacle mounted lenses are needed as when specific tasks warrant having two hands free or when a teenager is preparing for tasks such as driving a car.
Phase Three: Follow-up in Schools
A clinical low vision evaluation report is written and when all of the prescriptions arrive, Project PAVE staff meet with parents, teachers, and children in the school setting. At that time all information in the report is shared and explanations are provided as needed. Initial instruction in the use of optical devices are provided using real chalkboards, texts, writing paper, and so forth. Parents also have opportunities to observe and receive instruction in the use of devices and learn about such skills as one-handed focusing of monoculars, or methods for spotting information on a chalkboard. For many of the children, attending and interpreting detailed information at a distance is a new experience and it is more complex a task when looking through a device with perhaps 6 or 7 degrees of visual field.
At this time project staff work with the teachers to set goals for optical device skills and for incorporating optical devices into the academic curricula and extracurricular activities. We recommend that children become skilled with optical devices before bringing them into class. In this way they are able to attend to their teachers' lessons rather than be concerned with manipulations of devices. During instruction speed and comfort are stressed. We want optical device users to see magnifiers or monoculars as extensions of their visual systems, as tools for accessing information, and as individualized approaches which allow for visual independence. For many children for whom assignments have been shortened or omitted, building visual stamina is an important goal.
We also recommend that children and/or their teachers and/or Project PAVE staff help introduce the optical devices into classes, especially where young children have concerns about classmates' reactions. At times children will decorate their devices or personalize them with brightly colored straps or carrying cases. Children learn how to care for their devices and to have a method for quick retrieval of the devices when needed.
Whenever possible, we request that the children's teachers continue with the instruction However, when a teacher is unable to do so, as when there is no teacher of students with visual impairments available, project staff make additional visits to provide instruction. For all children, project staff return periodically to monitor their efficiency with their optical devices and to discuss progress with other aspects of visual functioning. At the end of the school year, reading speeds, visual expectations, follow-up interviews, and other information is gathered and analyzed.
Successes and Challenges of the Project
At the time of this writing, we are still gathering data for the second year of Project PAVE (and we hope to share it with those in attendance at ICEVI). However, we are assured that we have seen, as in the first year, significant increases in reading speeds in many of the children (while maintaining comprehension). Children have access to a wider variety of visual information than they had previously. From reading newspapers, to seeing the small print in advertisements for cars, from reading baseball cards, to reading the Bible, children have told us about their uses for near vision magnification. We know many children are reading and copying notes from the chalkboards in their classrooms. They are using their monoculars to see sporting events, characters in plays in their school auditoriums, and scenery during field trips.
Teachers are telling us that they are changing their approaches to working with students with low vision. Rather than circumventing or compensating for poor vision, teachers are working to help students make the most of what vision they have. As one seventh grade regular class teacher said, "I used to not call on Jason in class; it was so hard for him to read. I also used to give him copies of what was on the blackboard. Now he's as fast as others in the class and I call on him to read."
We hear from parents that their children are using devices in a variety of settings. At baseball games, in church, during shopping trips, and while signing in at an after school job, students are finding that their devices give them options and independence. When asked about his experience with his 13 year old daughter's involvement in the Project PAVE, one father said, "I just want her to be able to see beauty. I want her to know trees, birds, mountains, and blades of grass...without a description from me...and now she can."
And, we are hearing from children. A six year old told us "Before I got my magnifier I could only scribble." While this may have been too much to attribute to receiving his optical devices, a question from a 15 year old was more telling of how they have impacted his school work. John asked his teacher, "Why did it take you so long to get it? First you gave me large print books that were big and bulky; then you gave me a cctv [closed circuit television] I had to roll from class to class. Finally, you gave me something that works. Why did it take you so long to get it?" John is now using an illuminated 10X magnifier and an 8 X 20 monocular. Four students recently commented that they were able to see with their monoculars, the comet, Hale Bop, which was visible in Central Tennessee this Spring!
We have also had some challenges, too. Some school systems without teachers of students with visual impairments have been reluctant to give up ordering large print books; they believed these were special and all children with low vision needed them. We have seen some children comfortable with using their devices in school but not at home or vice versa. Although some children have shown they can read standard print efficiently and comfortably, some parents have continued to read all printed materials for their children at home such as dials on ovens or directions on food packages.
The dearth of orientation and mobility instructors is a major concern. We find children not only in need of the service but children who need specific instruction in the use of distance vision that goes beyond our resources. We know an optical device alone will not solve their problems and fear that some school systems may think otherwise.
We have had questions regarding whether children can learn to use optical devices if they are readers of braille. Three youngsters in Project PAVE are braille and print readers! This does not present any problems and only provides additional options for these students to do spot reading or to determine which medium will be more efficient for specific tasks.
Current cost analysis shows that on average per child $245 was spent for prescriptions including: hand and stand magnifiers, monoculars, corrective lenses, and light absorptive lenses. Duplicates are purchased for young children to have at home; repairs and replacements are also included in this analysis.
Table 1
Costs Associated with the
Purchase of Prescribed Optical Devices and Systems
________________________________________________________________
Category Costs Per Student
Near Vision Optical Devices
$1,803.47 34.68
Distance Vision Devices
5,887.11 113.21
Corrective Lenses 4,069.40
78.26
Light Absorptive and Tinted
488.15 9.39
Repairs, replaced, duplicates
516.15 9.93
TOTAL 12,764.28 245.47
________________________________________________________________
The state of Tennessee currently does not have a figure indicating what the costs are per child for those using large print. However, Charles Mayo, of the Textbook Division of the Texas Education Agency (personal communication, May 29, 1997) indicated that for this academic year the typical large print text (2 volumes and 500 regular print pages in length) costs $120 for the state of Texas. One example is a seventh grade Social Studies book, Texas and Texans; it is 748 regular print pages and costs $177.43 in large print. Mr. Mayo also indicated that most students need several books each year. In a 1989 study by Corn and Ryser, it was found that in Texas 41% of the students using large print needed 5 or more books per year. If one student needs 5 books, with the average cost of $120 per book, that student's books would cost $600 for one year. Those books may or may not be used by other students in other years.
Conclusion
We wish to thank the Tennessee Department of Education for funding Project PAVE at the level where we have time and available personnel. Their commitment to getting comprehensive low vision services to children is appreciated. We know that Project PAVE will continue to have challenges but it is the successes that are most meaningful.
Providing access to the visual environment is one of the many responsibilities of educational programs for children with low vision. While not all children will attain reading speeds comparable to those with normal sight, be able to read for an hour at a time, or be able to see everything available in standard print, many of the children in Project PAVE do. We must extend this opportunity to all children for whom magnification or other types of optical solutions will increase their visual function.
Project PAVE a cost effective approach that provides access to the visual environment, increases visual environmental awareness, increases visual independence, improves literacy skills, and provides options for children to use their functional vision. Ultimately, the children will determine the extent to which using vision is a useful and efficient method for gaining information. We owe it to them to let them have this choice. I think Ann Sullivan Macy would have enjoyed knowing the children in Project PAVE.
Koestler, F. (1976). The unseen minority. New York: David McKay Company, Inc.