Photographs: Image Bank; Stone
Additional research: Sarah Jenkins
Next week: Sanctions and rewards
In the 19th century, blind children were considered "God's punishment" and sometimes put on the streets to beg for money. Thankfully, things have moved on. In this hi-tech age, increasing numbers of visually impaired children are being taught in mainstream schools. But an end to routine eye tests for children means many specialists fear that common sight conditions are going undiagnosed, with knock-on effects for health, behaviour and achievement.
A common problem
Research published in 2001 by Dr David Thomson, of City University, London, found that around one in five schoolchildren has undiagnosed sight problems. Usually these conditions - such as short or long sight or astigmatism - can easily be corrected by glasses or contact lenses. More serious problems are usually picked up before school age.
"Children are not very good at self-diagnosis," says Dr Thomson. "Sometimes vision changes slowly over a long period of time, so they don't always realise it's happening." Those who might be worried about their vision are often put off getting help by the fear of standing out from the crowd by wearing glasses.
See better, work better
Vision requires a complicated combination of sensory, cognitive and physical skills, all co-ordinated by the brain. In fact, research by the American Foundation for Vision Awareness found that seeing uses more of the brain than any other single activity. "We know of cases where children are diagnosed as having special educational needs, when actually all they need is a pair of glasses," says Anita Lightstone, head of eye health at the Royal National Institute for the Blind (RNIB).
Myopia, or short-sightedness, makes it difficult to see clearly over longer distances. Children can struggle to read from a whiteboard, might not see the ball in games, or find it difficult to look at coloured diagrams. With long-sightedness, eye muscles tire quickly when reading close to a book or computer screen; as children get older, and the print size they use gets smaller, the problem worsens.
Those who find it hard to read class material are more likely to give up and become disruptive, or to feel less socially confident than their 20/20 peers. "If you get a headache after five minutes of trying to read, you're going to give up pretty quickly," says Dr Thomson.
The good old days
School eye tests started more than a century ago. Although primitive - featuring the familiar board of diminishing letters - they were effective at picking up common problems. Until 2003, government guidelines recommended pre-school vision screening for all children at three or four, with further tests at five, seven and 11. Vision continues to develop until the age of seven, and these tests were particularly good for diagnosing conditions such as lazy eye - where the muscles in one eye do not develop properly - which respond more effectively to treatment when the patient is young.
Free for all
Since 2003, however, schools have only been expected to test at the primary entry stage. After that it's up to parents to take their children for tests, which are free until the age of 16, or until 19 for those in full-time education. But many parents aren't aware that the guidelines have changed. "They are far more likely to take their children for a dental check-up than an eye-test," says Dr Thomson, who would like to see school screening reintroduced.
These days it is often teachers who spot vision problems. Symptoms include: children frequently peering, narrowing or rubbing their eyes; struggling to concentrate on written material; or copying from the person sat next to them, rather than straight from the board. "If a teacher has suspicions that a pupil might be suffering eye problems, they should suggest to the parents that they take the child for a test, and they should make sure parents know that it's free," says Anita Lightstone.
A question of degrees
While common eye conditions can have a range of knock-on effects in school, a significant minority of children suffer more serious vision problems.
Research by the RNIB in 2003 estimated that as many as 24,000 British children under 16 are blind or partially sighted, although figures from the Department of Health show that far fewer are actually registered as having a visual impairment: officially, there were only around 4,000 blind and 4,000 partially sighted children in 2000.
The lack of precise figures reflects the confusion about defining visual impairment and the range of criteria used by different health professionals. In particular, children don't always match definitions designed for adults. To register a child as blind or partially sighted, an ophthalmologist must determine whether the child is likely to grow up to meet strict generic definitions: blind is defined as "unable to perform any work for which eyesight is essential", while partially sighted is "substantially and permanently handicapped by congenitally defective vision". Because it is difficult to fit young children into such categories, ophthalmologists have to apply their discretion.
Registering children is often not considered as important as registering adults, and parents are often unaware of the process or its financial or practical benefits.
In the main
Around half of all children with visual impairments attend mainstream schools and about a third go to special schools. Half of all visually impaired children have another physical or learning difficulty, and around a third have profound and multiple disabilities. As the numbers in mainstream education have risen, so those attending special schools for children with visual impairment have fallen, from 22 per cent in 1988 to only 5 per cent in 2003.
Most visually impaired children in mainstream schools are supported by classroom assistants, usually on a one-to-one basis; there are more than 12,000 TAs in the UK working with visually impaired children.
There's little consensus, however, on whether a mainstream education is a better than a specialist one, especially when it comes to life beyond the classroom. "Academically, visually impaired children often do well in mainstream schooling," says Dr Olga Miller, of the school of psychology and human development at London University's Institute of Education. "A to Cs at GCSE is something you can measure. But the social and emotional side still gets overlooked."
For example, while TAs can make lessons more accessible, they can also get in the way. "If you spend all day with an adult by your side, other children will see you as being different. It will certainly affect the way they react to you," says Rory Cobb, the RNIB's children's officer. In an RNIB survey, nearly 60 per cent of visually impaired children at secondary level reported being bullied by classmates.
Even with the best support, loneliness is often a major concern. Mr Cobb remembers one school where a rota system assigned a different class member to look after a blind child each day. "It was well meant," he says, "but it was misguided. Spending time with the visually impaired child became seen as a chore." Mr Cobb recommends that visually impaired children in mainstream schools take time out occasionally to join other children with visual impairment.
A material difference
One way to help visually impaired children feel part of the class is to ensure they can follow the lesson. An RNIB survey in 2000 found one in four visually impaired children in mainstream schools was often given material in a format they couldn't read, while around a third said they had received test papers in an inaccessible format. Almost two-thirds said their GCSE choices were affected, with geography, science, PE and technology the subjects most likely to be avoided.
"Most teachers will only come across one or two children with visual impairments in the whole of their teaching career. So making adjustments is not likely to be a high priority," says Rory Cobb. "Some think the answer is to shove stuff on to the photocopier and blow it up, but it's often more complicated than that."
A change of style
But it may be worth the effort. The American Foundation for Vision Awareness says that around 85 per cent of classroom learning happens visually. Although this may be changing with increased understanding of different learning styles, technological innovations such as interactive whiteboards have put the emphasis even more firmly on visual approaches.
Basic techniques such as saying aloud what is shown on the board and always addressing a visually impaired child by name can help. So can getting the relationship with the teaching assistant right. "The most important thing is close liaison between the teacher and the assistant," says Lynda Hall, who supports a blind girl at Healing secondary school in Grimsby. "Turning materials into a braille format takes time. Planning is the key to making sure that a visually impaired child isn't disadvantaged."
Understanding the subtle relationships between child, TA and teacher can be just as important. "A child needs independence; they can end up feeling force-fed if they have a one-to-one assistant," says Dr Miller. "And a teacher shouldn't be tempted to leave everything to the teaching assistant and concentrate on the rest of the class. That pushes the assistant into the role of teacher, and can leave the child feeling isolated."
Cleaner, clearer, brighter
Under the 2001 Special Educational Needs and Disability Act, schools must make "reasonable adjustments" to ensure children with disabilities are not disadvantaged by their environment. With visual impairment, where the range of needs can be so broad, this means consulting with the child involved to find out what works best.
Because many visually impaired children rely heavily on hearing, rooms should have good acoustics. Touch, too, can be important. Fitting handrails is one obvious improvement, but installing surfaces with differing textures can also help a child build up a mental map.
Lighting can be brightened or dimmed. shiny surfaces should be avoided: reflected light can add to pupils' difficulties, as can areas of sunlight and shadow, flickering fluorescents, or energy-saving bulbs that are slow to warm up. Don't overlook colour schemes, either. Pale walls and ceilings with doors or cupboards in darker colours make it easier to identify routes around school.
"Supporting a blind child in the mainstream involves the whole school,"
says Lynda Hall. "From the caretaker who keeps the corridors clear, to the dinner ladies in the canteen."
All tech'd up
Integration is becoming easier thanks to improved technology. The range and quality of contemporary aids means there is something for most conditions.
For a non-specialist the choice can be baffling. But the children themselves, along with specialist organisations such as the RNIB, can offer advice. Only one in 20 children with a visual impairment, for example, uses braille. Braille technology, such as readers which "translate" what is on a computer screen and embossers which print documents straight into braille, is also relatively expensive. Braille readers cost around £4,000, and schools with devolved budgets might find it hard to justify investing that kind of money on one student.
Before flicking through the catalogues, it's worth putting in some groundwork. Because children with visual impairments are more dependent on ICT than others, it's particularly important to make sure that working conditions - such as the angle of the screen, chair height and keyboard position - are not going to cause long-term problems.
And it may be worth trying to negotiate individual contracts: some schools complain that if ICT is provided as part of an LEA-wide contract from a big supplier, it can be difficult to get customised equipment.
Help is at hand
For children with moderate sight difficulties, a portable video magnifier can be carried from lesson to lesson. It not only magnifies and zooms, but it can also change the colour of text and background to make reading easier, for example by switching to white print on a black background.
Most PCs can also be modified to show text against different backgrounds.
Textbook material can be scanned into a computer and manipulated by the student. Specialist software allows you to increase type size further, and even reformat web pages automatically to a preferred layout.
For those with more severe impairment, "speech output" software - such as the Jaws program used by Friday magazine columnist Nicole Dryburgh (see page 20) - means that written text on the screen can be reproduced by a synthesised voice.
Perhaps one of the most promising recent advances is Daisy (digital accessible information system). Rather like an MP3 player, Daisy is a CD-based portable technology which allows children to access specialised curriculum resources, and record notes.
Daisy is being piloted in 22 schools, colleges and universities in Scotland, where feedback so far has been positive. "It's easily navigable and children are very enthusiastic about using it," says Jamie Cuthbertson, development officer for RNIB Scotland's transcription service. "It presents material in an exciting and accessible way and has potential way beyond blind and partially sighted users."
Whatever good work is done with visually impaired children in schools, things can get tough as they get older. Proportionally more blind children go on to higher education than their sighted peers, but once they get to university they say materials are often inaccessible.
And according to Action for Blind People, 75 per cent of blind or partially sighted people are out of work, while nine out of 10 employers describe it as "difficult" or "impossible" to employ blind people. But this need not be the case. Blind in Business runs workshops for schools that emphasise the range of career possibilities for visually impaired children. "Most careers advisers do not know about visual impairment issues, so they can't fully advise," says Dan Mitchell, training leader for Blind in Business. "The majority of pupils are wrongly informed that they can't be a teacher or a lawyer or an accountant. We put them straight. With modern access technology almost any career is possible. You can't be an astronaut, perhaps, but you can work for Nasa. It's just a case of taking away barriers and thinking creatively."