Introduction

Sighted people take seeing for granted.  They don't need to think about it, plan to do it, or adjust the environment in any way (except possibly switching on a light or putting on glasses or inserting contact lenses).  They just do it!  Because seeing is usually an automatic activity few of us have ever had to consider what sight is, and how it is used.

This factsheet (one of a series) has been written to help staff and carers develop a better understanding of the role of sight and how a visual impairment can affect an individual.  Whilst each person is unique, many blind and partially sighted people with learning disabilities are isolated, anxious and afraid.  The effects of their visual impairment may not be understood because they have not received the support they so desperately need.  This may result in their quality of life being undermined.  Some people ‘give up’, becoming passive and compliant because they cannot control their environment.  Others develop behaviours which others may find hard to understand.

Staff and family carers can help visually impaired people with learning disabilities cope better with their world and gain more benefit from the opportunities available.  Sensitive help can make poor sight, which can spoil some of the good things in life seem less of a handicap.  There is no shortage of ways to overcome poor sight.  For example, the use of existing vision can be encouraged and changes made to the person's immediate environment.  A supportive relationship with staff or a carer can help.  Visually impaired people need this help; they have a right to it.

Seeing

Seeing involves the eye, the optic nerve and the brain.  Damage to any or all of these may reduce someone's ability to see.  This means that some people are blind or have poor sight because

• their eyes do not function successfully for a variety of reasons, or
• information is not reaching the brain via the optic nerve, which acts like a telephone wire, or
• the brain cannot make sense of the messages coming to it.

The process of seeing may be compared with taking a still photograph.  The eye is like a camera, the brain similar to the company that develops and prints the film, and the optic nerve is the person who took the film to the shop to be printed.  If a camera's lens is scratched or there is something in front of the lens that obscures the view, the quality of the picture is affected.  Alternatively the film within the camera (which would be the retina at the back of the eye) may be damaged.  In addition, a good photograph might be spoilt by poor processing - and the final product might be so bad that a person looking at it could only guess at how the picture might have been.

People with a visual impairment (regardless of its cause) are more likely to need glasses than the ‘general population’.  While glasses do not correct a visual impairment, they do help people who are short sighted or longsighted.  Many people with learning disabilities need help to become comfortable wearing glasses.

In the past it was wrongly believed that glasses would never help people whose sight problems were caused by damage in the brain.

What blind people see

The term 'blind' is not a medical one.  Only a minority of blind people are totally blind or just see light and dark.  The majority have some sight, which they can use in their daily lives.

Some people see the world as a blur - like a series of abstract pictures in muted colours.

Other people may only see a small part of the whole.

Limited visual field can cause tunnel vision, or result in people only seeing objects on one side or other,

or the upper or lower fields of vision.

When the brain receives unclear messages it will take time to work out what it is seeing - and how to respond.  If a person sees only part of the whole, it may take them time and effort to move their eyes or turn their heads to 'scan' an area.

But even having searched, they may find it hard to piece the sections together and interpret a complete visual picture of a large object, such as a house.

People who once had 'ordinary' sight often retain a 'visual memory'.  It usually helps them make sense of the bewildering sounds, smells and tactile clues in the world around them and to make informed judgements.

Building on previous knowledge, people may still need help to develop a visual picture in their mind from information gathered from a range of sources.  However, memory may be selective or fade in time, sometimes providing distorted images.

How poor sight can affect people with learning disabilities

Children and adults with learning disabilities who also have a visual impairment may have difficulty interpreting what they are seeing.  They may find it hard to make sense of information and to respond appropriately.  In addition, a physical disability may restrict the ability to use their sight successfully, due to an inability to turn their heads or change their position.

People who are blind from childhood, who do not have other severe disabilities, are taught to minimise or compensate for their visual impairment in a variety of ways.  These skills are seldom taught to people with severe learning disabilities, whose learning and/or physical problems prevent them from developing a range of ways to cope.  It is, therefore, necessary for their vision to be assessed as accurately as possible and for individual programmes to be devised to help them use their existing vision in the best possible way.

Uses of sight

People use their sight in a variety of ways throughout the day.  We have listed some key areas, but each person will be affected by his/her visual impairment in different ways, according to

• the person’s eye condition
• their other impairments or difficulties
• the support available
• environmental issues such as lighting

• and a wide range of other factors.

This means that assumptions about the likely problems need testing on a regular basis.

Communication

Sight is used in conversation with others.  Eye contact helps in 'taking turns' to talk.  Sight enables people to understand facial expressions, body language and individual gestures.

The inability to see can affect the early bonding process between blind children with severe learning disabilities and their parents.  In the past, they were at particular risk of being rejected by their families - especially if the family did not receive professional help.

Poor sight obviously does not stop children from loving their parents, but sometimes families have difficulty understanding their severely disabled blind child's body language or early attempts to respond to them.  All people - regardless of ability or disability - communicate in a variety of ways, including gesture, mime, facial expression, body language, and making different noises.  People need to learn to 'listen' and act on what that person is telling us.

Many blind children were often admitted to long stay mental handicap hospitals, spending their childhood in large impersonal surroundings.  Often they had no 'special person' to take an interest in them.  Research has shown that blind children with severe learning disabilities in institutions received less attention than sighted institutionalised children - the ability to make eye contact is an important way of attracting staff.

Sight helps people to see sign language.  People with visual impairments may be able to see some signs.  However they may not be able to see the whole of a sign.  Programmes to teach signs to people need to take account of a person’s visual impairment or they may fail to learn to develop communication skills.  When people cannot express their needs, those around them have to make informed guesses, leading to frustration for all concerned.  An individual's inability to be understood and have his/her needs met can easily result in challenging behaviour.

Nearly everyone can learn to communicate using a system called 'objects of reference'.

Motivation

Sight helps to create motivation - for example, blind children often need to be encouraged to reach out for things.  If they are unable to see desirable objects across the room, they may not be motivated to discover and touch those things.  They may not be bothered about learning to walk, and may lack the confidence to move in an unknown environment.

Blind children and adults with learning disabilities often seem to be lacking in 'drive'.  A common complaint is that 'they just sit and wait for things to happen - they don't do anything'.

People who have not learned that they have the power to control their environment may appear compliant or passive.  However, their whole personalities may appear to change when they receive appropriate help to develop communication, mobility and self-help skills.  Finding ways to motivate blind people with learning disabilities may not be easy - particularly when they have discovered that staff and carers expect them to fail.

While different people are motivated by different things, many blind people with severe learning disabilities are most likely to need rewards other than just visual ones.  It is, therefore, important to break tasks down into tiny steps and to make activities fun and rewarding for an individual, giving him/her plenty of encouragement and praise.

Learning and development

Sight plays an important part in learning and personal development - both through planned, structured teaching (in schools and individual programmes), and informal learning from looking at pictures, watching television and copying others.

Blind and partially sighted people who have learning disabilities have to learn in a more structured way than sighted people and they usually take longer to learn.  They are more dependent upon being taught about their world and are less able to learn informally - such as observing or watching others.  They need special help to make sense of things and to understand what is being asked of them.  Supporters often need to explain tasks carefully, breaking the activity down into small, achievable stages.

Opportunities for learning need to be ‘real’ and experiential (not theoretical or abstract) and most people need more time to learn.

Often staff and families have been over-protective, so the person's natural curiosity has been stifled.  It is not uncommon to find relatives or staff so anxious about an individual hurting him/herself, that the person has actually been stopped from moving about alone.

To help learning and personal development, people with visual and learning disabilities constantly need the world explained to them.  Every possible opportunity should be exploited to give people information and ways of learning so that they are not deprived of 'visual things'.

Assessing people, places and situations

A sighted person may enter a room and instantly be aware of who is present, what is going on and, without thinking, may be conscious of details such as carpets, furniture and lighting.  A blind person may gather this information - but it would probably take them very much longer, and the information might be incomplete.  This can be remedied by providing clear explanations, perhaps supported by clues - such as noises, floor textures, etc.

People with severe disabilities need plenty of time to discover things for themselves so they can make their own decisions based on knowledge they have gained.  They need to learn to assess if situations are safe or if risks are worth taking.

Co-ordination

It is a fallacy that all blind people have good hearing and a highly developed sense of touch and smell.  This simply is not true - although some blind people are able to develop these skills.  A high percentage of people with visual and learning disabilities also have unidentified hearing problems, often caused by impacted earwax.

Sight is important in co-ordinating information gained by other senses.  It confirms what is heard, touched, tasted or smelled and helps to make a 'whole' of all the information.  When people have little or no sight, it is perfectly possible for them to learn to co-ordinate all available information, by staff giving them detailed descriptions, concentrating on the type and quality of information to be given, varying the tone of voice.

Memory

Another myth is that all blind people have good memories.  Some do, others don't!  Sight provides the memory with useful prompts and reminders.  Memory is based on the previous receipt of information, and the ability to 'file' knowledge.

If they have little or no sight, people may need specially created 'prompts' to jog their memory.

Knowledge of self and self-image

Without visual feedback, it may be difficult to develop a true picture of oneself.  People need to know where they begin and end, how much space their body occupies, how they look and what image they are presenting to the world.  Feedback helps people modify their behaviour, clothing, hairstyle, and so on, so they can 'blend with the crowd' or choose to look different from others.

There is much that can be done to help people discover how they look - using mirrors, clear photographs, videos and discussion.

Space, size and abstract concepts

Young sighted children have no difficulty in grasping quite abstract concepts such as size, direction, distance and space - even when they cannot touch the objects concerned.  Many blind children with learning disabilities find the concept of 'object permanence' difficult - that an object is still there when it cannot be seen, heard, touched, smelled or tasted.  When someone leaves the room are they gone forever, or will they return?

More abstract concepts such as love, anger and age-appropriateness may be even more difficult to grasp.

Balance, movement and mobility

Sight helps people maintain their balance.  Good balance allows people to move independently and safely without fear of falling.  People with little or no sight may be apprehensive about textures underfoot - for example, carpets, grass, and sand on the beach.  They may experience hills and slopes or changes in surface level more dramatically than people with 'ordinary vision'.  However, different surfaces provide people with useful clues about where they are.

Sight plays a key role in finding one's way around, travelling and learning routes and recognising one's destination when it has been reached.

Trust

Trust is based on previous knowledge of people, places and situations and an assessment of personal security.  So, sight plays an important part in the development of trust.  People who lived in large impersonal institutions and whose visual problems have not been acknowledged, may never have learned to trust others.  They may not have received help to understand what is going on around them, so they experience their lives as a series of random events, which makes them feel insecure.

To establish trust, it is always helpful for an individual to have a 'special person' who can understand his/her needs.  However, the best way to get people to trust other people is to help them communicate successfully with each other.

Concentration and attention-span

Most people find it easier to concentrate on an activity for long periods if they can see clearly and focus their attention on the process.  People with little or no sight may need help to develop their powers of concentration.  They need verbal feedback to tell them of their successes.  In this way, they know it is worth concentrating and finishing a task.  They may not feel motivated to persevere unless they are told about their progress and achievements.

Many tasks may seem to have little relevance or interest to them.  People happily concentrate on the things they find rewarding - sometimes to the point of obsession.  Staff need to see what an individual enjoys, and try to incorporate this into other things.

Autonomy and independence

Sight helps people to be totally independent when they want to be, enabling them to make a whole range of choices, based on first-hand knowledge.  Blind and partially sighted people with learning disabilities may need special help to become assertive and autonomous.  They may often be in situations where their individual preferences and special needs are overlooked, so they are forced to be dependent upon other people for basic information, explanations and interpretations of their surroundings.

Variations in sight

Each person's sight and the way he/she uses it is unique to that person.  He/she will not always see the same things in the same way.  A person's sight may alter considerably throughout a single day.  Indeed some people's sight can vary over very short periods; environmental factors and personal issues affect it.

Sighted people watching blind and partially sighted people are often confused because they wrongly believe that an individual's sight is static and unchanging.  They may say, quite incorrectly, “she can see when she wants to”.

Solutions

• Glasses or contact lenses - when prescribed, need to be fitted by an optician or optometrist to maximise vision.  They need to be kept clean, and care needs to be taken not to damage them.  Many people with learning disabilities give the impression of being blind or partially sighted when they need glasses.  People diagnosed as having a visual impairment frequently need glasses.  When people are first prescribed glasses in adulthood, they usually need support to wear them.
• Support from Rehabilitation Officers for the visually impaired (usually based in the local social services/social work department or voluntary society for blind and partially sighted people), Rehabilitation Officers can offer advice on helping people use their sight better, environmental issues, and provide skills training. 
• Support from low vision clinics - these services, which are usually based in eye hospitals, help people to use their sight better. 
• Using low vision techniques:
• Big - most people see big things more easily than small objects.  People may need to sit very close to objects or hold them near to their faces to see.  Individuals who depend largely upon hearing, touch and smell may prefer close contact with other people and objects.
• Bold - objects need to stand out clearly from their background.  Colour contrast helps people to use their sight more successfully.  It enables children and adults with visual impairments to see and find things.  For example, a brown door against a white wall, a red cup on a white tablecloth will show up.  It is important to find out what colours a person sees and not assume that the most obvious colour contrasts are the most successful for that person.  ‘Visual clutter’ is to be avoided - trying to distinguish something against a busy background may prove difficult.  For example, trying to find a teaspoon on a crowded dinner table or a sweet on a multi coloured plate may be difficult.
• Bright - lighting is very important to people with poor sight.  Correct lighting levels help people see, but lighting needs vary according to eye conditions and the task in hand.  Most people see best in strong, clear and even light, while others function better with softer, dimmer lighting.  Rehabilitation officers for the visually impaired (usually employed in social services/social work departments or the local voluntary society for blind and partially sighted people) can advise on lighting.  But other workers need to make time to observe what works best with a particular person.  It is important to avoid ‘glare’, which literally ‘blinds’ people and causes pain.  Visually impaired people may experience glare when people with ‘ordinary vision’ do not consider the light to be particularly bright.  Glare can be caused by shiny surfaces, metal objects etc.
• Position - people need to be in the right position to make the best use of what sight they have.  They may have adopted unusual head positions to make the best use of their vision, or supporters need to ensure that a person’s wheelchair is ‘parked’ to enable people to take part in activities.
• Time - when the brain receives unclear messages it takes time for people to work out what they are seeing and how they should respond.  The person may experience their world as a series of blurred images, which may be confusing and hard to interpret - especially if they do not have a ‘visual memory’ and remember how things used to look.  If a person sees only part of the whole, it may take them time to move their eyes or turn their head to ‘scan’ an area.  But even after scanning carefully, the person might still find it hard to piece the sections together and interpret the complete visual image as a house.
• Prompts - some people may need to be told clearly what is expected of them, and reminded to do things.  They may be helped by being given tactile or tape recorded timetables.  Buildings with minor adaptations, such as markers placed underfoot or on doors remind people of routes.  Labels on doors - either visual or tactile, or different door handles to denote different rooms - all help people to remember where they are.
• Anticipation - people may find it easier to interpret what they are seeing if they know or are told what to expect.

Practicalities

There are some issues that are less obvious, and are by no means exclusive to people with a visual impairment.

• Obstructions - some people are prevented from using their sight by obstructions such as dirty, old or poor-fitting spectacles, or being unable to turn their heads to use their sight because their heads are held in a particular position by the restraints on their wheelchairs.
• Noise - quiet environments help people concentrate and use their sight and hearing to the maximum.  Many people find constant noise tiring or stressful - some places, for example, have the radio or television on constantly.
• Health - people function better when they are well or not distracted by pain.  Epilepsy, diabetes and sickle cell disease can make blind and partially sighted people or people with 'ordinary' vision see less clearly.
• Medication - some drugs may make people sleepy and less alert, and others produce side effects including visual distortion, blurred or even double vision.
• Time of day - most people see better when they are not tired.  Few people are at their brightest when they have just woken up!  Many people feel rather slow after a heavy meal.
• Emotional state - anxiety may cause people to overlook things, or raise their levels of stress to such a degree that they appear to become more disabled in their panic.
• Motivation - people see best when they are motivated and there are real rewards for making the effort!  Seeing and trying to make sense of what they have seen may be a tiring activity for some as they may have to concentrate harder than people with 'ordinary’ vision.  If they lead boring lives, it may just be too much like hard work.  It is only natural for people to 'switch off' if they are not interested.

Sight is for using!  It will not wear out.  Like everything else, seeing improves with practice.  The more people use, and are helped to use, their sight, the easier they will find it to see and interpret what they are seeing.

We hope that this Factsheet has been helpful - but a factsheet can only generalise and is no substitute for training.

The best results are obtained when staff who are trained in visual impairment ask a person what they can see, when and how best to improve the chances of using their sight - or take time to observe people, and plan carefully for the individual so their visual impairment is not a handicap, merely an inconvenience.

Look Up: Hints on Teaching Skills for Work

June 2008 

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