This article will review the development of public-school services for blind and visually impaired children and their parents, and discuss the pediatrician's role. Public Law 94-124, the "Education for All Handicapped Children Act,"will also be briefly discussed as it is interpreted and articulated in the Vision Services Program in Montgomery (Md.) County public schools.
Blind children once were far more common in society than they are today. The incidence of blindness in children dropped dramatically after the turn of the century as effective preventive and corrective measures were found for ophthalmia neonatorum and other major causes of visual impairment in infants and children. As a result, the role of residential schools for the blind, which once had provided education for this population, underwent a period of change. As their enrollments shrank, children were admitted who were not completely blind but had partial sight and could read print.
This trend was suddenly reversed in 1942, when retrolental fibroplasia was reported for the first time. Before the cause administration of high oxygen concentrations to prematurely born infants) was discovered, the incidence of visually handicapped children had risen sharply.1 In the decade between 1 943 and 1 953 , some 7,000 infants were blinded by retrolental fibroplasia.2
Following the end of World War II, the known number of visually handicapped children increased significantly, owing both to the rising birth rate and to improvements in early identification of visual problems. This had three important effects on the quality and direction of education for the visually impaired: residential schools were expanded, admission criteria were changed so that partially sighted children could be admitted, and public-school vision programs were established.
In 1956 the 77-year-old Federal Act "To Promote the Education of the Blind" was amended by the 84th Congress to include visually handicapped children enrolled in regular classrooms as well as those in special schools and special classes. This act provides special books (braille and large-print) and educational aids manufactured by the American Printing House for the Blind3 on a yearly quota-funding basis.
PHILOSOPHICAL CHANGES IN EDUCATIONAL PROGRAMS
The belief that each blind child should be educated according to his individual needs, in his home community, was expressed in the Pine Brook Report, published by the American Foundation for the Blind in 1957.
The education of blind with sighted children in public and private schools is predicated upon the basic philosophy that all children have a right to remain with their families and in their communities during the course of their education; that a blind child has a right to be counted as one of the children of the family and of the community; and that both the family and the community have an obligation to provide for the blind child, as a minimum, the equivalent of what he might have had if sighted.4 It was once an accepted belief that most children with subnormal vision would damage what little vision remained if they used it too much. Many children with partial sight were, therefore, routinely educated as blind children and required to learn to read braille whether or not they could see to read print. But as Eleanor Faye, M. D.,5 the ophthalmologist and attending surgeon at Manhattan Eye, Ear, and Throat Hospital and medical director of the New York Lighthouse Low Vision Services, has noted, the concept of "sight- sa v ing" is no longer valid either in medicine or education.
"Residual vision should be used to the maximum capacity of the child," she states.
Barraga6 studied the effects of specialized instruction with appropriate materials on the visual behavior of children educated as though they had no vision. She undertook to determine if the visual functioning of children could be significantly increased in an eight-week period of intensive teaching. She concluded that (1) short-term intensive teaching procedures would significantly increase the visual efficiency of low-vision children (not the acuity) and (2) objective evidence showed the value of vision-stimulation programs for blind children with residual vision. It should be noted that Barraga's teaching procedures and those in my Vision Stimulation curriculum7 based on that research are educational and not optometric strategies.
PROVISIONS OF P.L. 94-142 Public Law 94-142, known as the Educationfor- All- Handicapped-Children Act, was enacted by Congress on November 29, 1975. It mandates that all handicapped children have available to them a free appropriate public education in the "least restrictive enviroment." This must include special education and related services that may be required to meet the child's unique needs. The law further provides that all services (1) be furnished at public expense, under public supervision and direction, without charge; (2) meet the standards of the state education agency; (3) include preschool, elementary, and secondary education; and (4) be instructionally implemented by use of an Individualized Educational Plan for each student.8
The "least restrictive environment" provision requires that school-aged handicapped children be educated with children who are not handicapped and that special classes, separate schooling, or other removal of handicapped children from the regular educational environment may occur only when the nature or the severity of the impairment is such that education in regular classes cannot be satisfactorily achieved.9
A wide range of services is thus provided visually impaired children under the law, including:
1. Transportation and the developmental, corrective, and supportive services required to assist a handicapped child to benefit from special education.
2. Speech pathology and audiology.
3. Psychological services.
4. Physical and occupational therapy.
6. Early identification and assessment of disabilities.
7. Counseling services.
8. Medical services for diagnostic or evaluative purposes.
9. School health services.
10. Social-work services in schools.
11. Parental counseling.
To qualify for funds under the act, state education agencies and local school districts must prepare plans detailing exactly how they intend to locate children with special needs. Learner10 has noted:
Each annual program plan must include in detail che policies and procedures which the state will undertake or has undertaken to insure that (1) all children who are handicapped, regardless of the severity of their handicap and who are in need of special education and related services are identified, located and evaluated, and (2) a practical method is developed and implemented to determine which children are currently receiving needed special education and related services and which children are not.
RIGHTS OF CHILDREN, PARENTS, TEACHERS UNDER RL. 94-142
Children have the right to a free and appropriate public education if they are under the age of 21 and the following criteria are met: evaluation in a language that they can understand, with tests designed for the purpose for which they are being used; service program recommendations based on more than one evaluation criterion; an individualized education program (IEP) and an annual review of services and placement based on the IEP; the same variety of programs available to regular pupils; placement in the least restrictive learning environment, when possible with nonhandicapped children and at the pupil's home school; placement elsewhere at the state's expense if local schools do not have an appropriate program; continuation in present placement during any administrative or judicial proceedings; privacy and confidentiality of all personal records; and a school environment free of architectural barriers.
Rights of parents and of teachers are also specified. Parents have the right to be consulted before child evaluation; obtain independent evaluations at parental expense; participate in the planning and review of the child's IEP; demand that meetings be held in the parent's primary language or with an interpreter; receive written notification of approval, denial, or any change in an IEP; see, review, and, if necessary, challenge the child's record in accordance with the Family Educational Rights and Privacy Act of 1974; receive a full explanation of procedural safeguards and a description of and justification for any proposed action regarding the child; and request an impartial hearing within 45 days on any change in the identification, evaluation, or placement of the child if the parent disagrees with it.
Educators have the right to evaluate pupils with parental consent; participate in group decision making with persons knowledgeable about the pupil; have ready access to pupil records; use interpreters or translators; be given sufficient advance notice of meetings to allow for proper preparation; and request in writing that an impartial examiner review a case when the parents have denied pupil evaluation, refused to approve an IEP, or refused placement or services.
EDUCATIONAL SERVICES IN MONTGOMERY COUNTY SCHOOLS
Montgomery County, Md, initiated itinerantteacher consultant service for visually impaired children in 1954, Total school enrollment was 50,546, and one special teacher consultant was employed to serve the three identified children. Previously, children with seriously impaired vision attended Maryland School for the Blind. This type of residential placement continues to be needed by some children: e.g., those with multiple handicaps for whom no local school placement ts available and those whose family circumstances are not conducive to solid support at a given time.
Visually impaired children may be found at every continuum-service level. Those whose needs are monitored periodically through the teachers, counselors, parents, or the students themselves are at level 1 . This includes children who enjoy maximal utilization of their residual vision and adequate academic success and social adjustment and who prefer to cope with minimal attention or assistance in the general education program. Intervention may be limited to provision of standardized tests and college-board tests in large print and /or the removal of time limits for taking tests. At the opposite extreme are severely handicapped children at level 6 who need several services and who attend Maryland School for the Blind or another nonpublic facility.
GOALS OF THE VISION-SERVICES PROGRAM
The goals of this program are to provide individual support services for blind and visually impaired students, their parents, and classroom teachers - services that will facilitate the development of the students' cognitive and compensatory skills, social and emotional adjustment, and other competencies needed to cope successfully in the community. Individualized services for children include diagnostic assessment and prescriptive program planning consistent with the kind and amount of assistance needed by each student. Social services for families include assessment of needs, personal and family counseling, and training seminars in (1) child development, (2) implications of severe visual impairment, (3) behavior management, and (4) communication skills.
BASIC COMPETENCIES NEEDED BY VISION TEACHERS
It is generally agreed that the following basic competencies are needed by vision teachers: (1) Skills required by regular teachers of sighted children in addition to specialized course work in education of the blind; (2) Knowledge of child development and of the anatomy and physiology of the eye and implications for functioning; (3) ability to teach compensatory skills: braille, typing, Optacon, visual stimulation, pre-cane, listening, daily living, and basic concepts; (4) skill in diagnostic assessment and prescriptive intervention; 5} knowledge of curriculum and program adaptations; and (6) public-relations skills.11
Our program utilizes basically the same organizational patterns defined in the Pine Brook Repon12 in 1957. Program components are (1) Itinerant Services (including Orientation and Mobility), (2) Vision /Special Needs Class (elementary), (3) Vision /Learning Disabilities Class (middle school), (4) Early Childhood Services for children, birth to school readiness (or eight years), and their parents, ( 5 ) Counseling and Social Worker services, (6) Vocational /Career exploration and practicum. The Vision Services Center houses vision staff, resources, and equipment and provides a training site for parents and staff. These plans and their continuum- service levels, age/grades of students, and dates of implementation are described briefly below.
Itinerant-teacher plan - levels 1 and 2. The itinerant vision teacher or consultant serves an assigned student caseload. Each student attends his neighborhood school or a special class placement. Objectives include direct teaching of students, consulting with regular school personnel, and transcribing materials. Infants receive home teaching.
One orientation and mobility specialist provides individual training in safe and efficient travel techniques in both indoor and outdoor environments. Objectives include training in body image, spatial orientation, basic concepts, daily living skills, map skills, pre-cane skills, and cane travel. This plan has served students from the kindergarten through the 12th grade since the program's inception, and in 1971 it was extended to infants. Resource-room plan - level 2. Children are enrolled in regular classes in a school provided with a full-time vision teacher and a resource room. This is indicated for children in grades 1 through 6 who need more direct one-to-one teaching than they can receive from an itinerant teaching staff; the plan includes some remedial teaching. Vision /special-needs class - grades 2-5. Local school services have been strengthened with the advent of P. L. 94-142 and its mandate for the "least restrictive environment." There is no reason now to bus a child miles away from his neighborhood school if he is to remain in a regular classroom for all instruction except for three to four hours per week of direct teaching by a vision specialist. Children recently referred to the visionresource room in our system have had additional needs or problems. Although these are not direct correlates of visual impairment, they are related.
Compounding the negative effects of the lack of visual efficiency available to most children are slower rates of reading and writing, delayed maturation, lack of adequate compensatory skills development, and critical symptomatic high levels of anxiety - shown in frustration, failure to achieve, increased loss of vision, blocks to learning, manipulative behavior, etc.
A teacher certified in vision and learning disability implements an individualized program, with "mainstreaming" for related arts and physical education and gradual re-entry into regular classes in subject areas in which these children can succeed. The focus is on the child and his achievement of objectives and skills expected of all children in grades 2 through 5 and on the development of independent work habits and study skills and an improved self-concept. In order to provide this level of service, restructuring of the vision-resourceroom program was necessary.
Vision-learning-disabilities class - levels 3 and 4. This is a class for visually impaired children in grades 6 through 8 whose achievements have fallen two years below grade level and who demonstrate significant neurologic and /or learning problems, with resulting anxiety and emotional problems. This was initially planned as a level 4 class, with "mainstreaming" only for related arts and physical education. But now children are mainstreamed for one-third up to one-half of every day, depending on the individual pupil's readiness for Success at grade level.
Early-childhood services - level 4. These include infant-parent home teaching, classes for toddlers, preacademic training, and classes for multihandicapped children.
Infant-parent home teaching objectives include parent counseling and (itinerant) home demonstration teaching for infants up to the age of two.
Toddlers (two to three years) are given diagnostic assessment and prescriptive programming in self-contained classes.
Preacademic services are provided for children between the age of three and the time they start school.
Multihandicapped children between the ages of three and seven are provided the early childhood services at this level.
Itinerant teaching is provided those children placed in private nurseries or special schools.
Ongoing assessment is made in each of these programs, with available medical and other formal diagnostic reports, developmental checklists, and standardized measurements that assess both strengths and deficits. Prescriptive program plans are then based on this information.
The benefits of this program for the blind child and his family are obvious, but it is equally important to the development of the child with residual vision. We have learned that we cannot assume that these children will develop visual concepts incidentally; we must bring everything into their range of vision, identify it and its properties, and classify it. The child does not have to have perfection of a visual image to get information from it.
As a search for meaning develops, an object becomes located within a spatial field; it stands out from its background, the beginning of the perception of figure ground. Some details are perceived, and it begins to behave in a certain way. Because of this final perceptual constancy, predictions and probabilities may be assigned to the image. When the child can combine his visual percepts with information from the other senses, he will be able to think for himself and generate ideas.
Bishop13 states that the preschooler with any vision problem must have more emphasis on readiness than his normally sighted peers in the areas of motor, language, discrimination, and perception. In agreement with Barraga, she has observed that vision plays an important role in the development of discriminative perceptual skills, and these skills are probably the most important prerequisite factors in reading. It is essential that they be stressed in the preschool readiness program(s), since, as she notes, "the future scholastic achievement of both blind and partially sighted children may depend on the foundation in discrimination and perception laid in the preschool years."13
An intensive readiness program suitable for all children is provided daily with special attention to needed compensatory skills- i.e., visual /motor training, braille (tactile) readiness, vision stimulation, listening, orientation, premobility, basic concepts, and daily living skills. In keeping with the P. L. 94-142 mandate for education with the nonhandicapped, fully sighted children are enrolled on a space-available basis. The Early Childhood Learning Center is housed in an elementary school so that children may attend regular music, art, library, and physical-education classes. They are enrolled in kindergarten for some portion of their day during their last semester there.
EDUCATIONAL DEFINITION OF VISUAL IMPAIRMENT
Entrance and exit criteria for the Montgomery County Public Schools' Vision Services programs are shown in Table 1. Visual acuity is only one factor, among many others of equal importance, that should be considered in making appropriate educational diagnosis and placement. The child's ability to use the vision he has, his motivation and interests, his intelligence, his personality, his physical and/or mental problems, and his degree of vision must be considered. A meaningful definition of a visually impaired child must be in behavioral and functional terms, rather than in terms of arbitrary indices of visual acuity. Faye14 states that acuities should be regarded as limited pieces of information. These figures do define legal categories of handicap; they do not indicate efficiency or reading medium needed. Acuity level and performance are, in fact, not related.
In Montgomery County public schools, a visually impaired child is defined as one whose visual limitations interfere with his learning efficiency to such an extent that he requires teacher consultation, special teaching services, and/or special educational aids if he is to attain appropriate performance standards and realize achievement in keeping with his potential.
THE PEDIATRICIAN'S ROLE
Today, as never before, the pediatrician must function as a member of the interdisciplinary team or teams making decisions and plans for handicapped children. His role will be supportive if he:
1. Refers children who have temporary or longterm special needs arising from physical, cognitive, or emotional factors or whose parents demonstrate unusual anxiety about an identified impairment or observed developmental delay.
2. Prepares a thorough report of his findings to be sent to the local education agency.
3. Demonstrates a willingness to discuss the functional implications of physical problems with the child's teachers or other educational personnel, including any needed clarification of his written report.
ENTRANCE AND EXIT CRITERIA
Physicians occupy a unique position in American society. No other occupation is so besieged with demands to be all things to all people. Requests for advice range from medical concerns to marriage and family problems and include pleas for help in educational decisions. This places an unfair burden on any individual and is one that doctors should not accept.
We educators urge pediatricians to suggest to parents of visually impaired children that they explore existing special programs and services that may be available in their communities. It may not be wise for the physician to recommend a particular school (just as one would not want the educator to prescribe a medical treatment), particularly if the child is of preschool age.15
Early identification and case-finding of the visually impaired is mandated both by P. L. 94-142 and by Title XIX of the amended Social Security Act. Thus the schools are now required to locate visually impaired preschoolers and identify their problem before they reach school age. Every school district must now maintain an active Child Find office.16 Physicians thus should refer parents to the administrative or special-education offices of the school district in which they reside. A telephone request to these offices will usually bring a supply of brochures containing program information and referral procedures that the physician can display in his waiting room.
Ever-increasing numbers of educators are joining the ranks of those subscribing to professional liability-insurance plans. Documented evidence of contraindicated management in the areas of advice, direction, placement, or intervention can result in malpractice litigation for physician and educator alike. So this is another impetus to establishing a team approach in the care of the visually impaired child.
The child's best interests will be served when the teacher and the physician exchange their own specialized knowledge for their mutual benefit as well as for that of the child and his parents. The child will best be managed by the teacher who knows pertinent facts about his physical impairments and by the physician who understands how poor vision, poor hearing, or other impairments are affecting his ability to learn and his overall school performance.
Physicians wishing further information on office screening procedures for visually impaired children are referred to the Physician's Handbook, edited by Peters et al.17
1. Lowenfeld. B. Our Blind Children. Springfield, III.: Charles C Thomas, Publisher, 1964, pp. 8-9.
2. Newell, F. Ophthalmology: Principles and Concepts. St. Louis: C. V. Mosby Company, 1969, p. 258.
3. Jones, J. W. Blind Children. Degree of Vision- Mode of Reading. Washington, D. C.: U.S. Department of Health, Education, and Welfare, 1961, p. 45.
4. Pine Brook Report. National Work Session on the Education of the Blind -with the Sighted. New York: American Foundation for the Blind, 1954, revised 1957, p. 13.
5. Faye, E. E. The Loia Vision Patient. Clinical Experience with Adults and Children. New York: Crune & Stratton, 1970, p. 141.
6. Barraga, N. Increased Visual Behavior in Low Vision Children. New York: American Foundation for the Blind, 1964, p. 32.
7. O'Brien, R. (ed.): Alive . - - Aware ... A Person. Rockville, Md.: Montgomery County Public Schools, 1975, p. 240.
8. Education for All Handicapped Children Act: P.L. 94-142. School Law Register. Washington, D.C.: Capitol Publications, December, 1975.
9. Barbacovi, D. R., and Clelland, R. W. Public Law 94-142; Special Education in Transition. Arlington, Va.: American Association of School Administrators, 1977, E-4.
10. Learner, S. NEA Research Repon, P.L. 94-142: Related Federal Legislation for Handicapped Children and Implications for Coordination. Washington, D. C.: National Education Association, 1978, p. 10.
11. Spungin, S. J. Competency Based Curriculum for Teachers of the Visually Handicapped. New York: American Foundation for the Blind, 1977, pp. 7-8.
12. Pine Brook Report. National Work Session on the Education of the Blind With the Sighted, New York: American Foundation tor the Blind, 1954, Revised 1957, pp. 16-17.
13. Bishop, V.E. Teaching the Visually Limited Child. Springfield, Ql.: Charles C Thomas, Publisher, 1971, p. 61.
14. Fave, E. E. The Low Vision Patient. Clinical Experience with Adults and Children. New York: Grime fc Stratton, 1970, p. 147.
15. Faye, E. E., supra, p. 150.
16. Learner, S. NEA Research Report. P.L. 94-142. Related Federal Legislation for Handicapped Children and Implications for Coordination. Washington, D. C.: National Education Association, 1978, p. 19.
17. Peters, J.R., et al. Physician's Handbook: Screening for MBD. Little Rock, Ark.: QBA Medical Horizons, 1973.
ENTRANCE AND EXIT CRITERIA