Refer this article as: Sumrana, Y., Minto, H., Demystifying the cognitive and functional vision assessment for children with low vision, Points de Vue, International Review of Ophthalmic Optics, N66, Spring 2012
Demystifying the cognitive and functional vision assessment for children with low vision
Despite overall increases in school participation over the past decade, some groups of children continue to be left behind, particularly children with disabilities. One-third of the 72 million children currently out of school have at least one disability, and 90 per cent of children with disabilities in developing countries do not go to school.  Disability has more impact on participation in education than gender, rural residence or household economic status.  Research in southern Africa suggests access to education is particularly limited for children with sensory disabilities, including those with visual impairments. Making education more responsive to the needs of children with disabilities is now one of the most pressing concerns if the MDG 2 of universal primary education by 2015 and the Dakar Declaration of Education for All (EFA) by 2015 are to be met.
The education of children with disabilities is also an essential driver for poverty alleviation and human development. People with disabilities constitute an estimated 20% of the world’s poorest.  Exclusion from education is a significant factor in the high levels of poverty often experienced by people with disabilities and their families. Denying children with disabilities access to a quality education greatly constrains their opportunities to gain independence and skills, often leaving them isolated and unable to contribute to their own self-fulfilment or their communities’ drive for development. Yet, with access to education, children with disabilities have the chance to become active and engaged citizens.
Globally, there are 124 million people with low vision. Approximately 65 million of these people have irreversible low vision and require low vision services. Most of those with low vision are older people and the numbers will double over the next 20-30 years because of the aging population. Whilst the number of children is small, the burden in life years with low vision is significant.
Children learn most about the world by what they see. Vision is an organizing sense that allows us to perceive objects at a distance and to make connections between these objects. When a child is vision impaired the amount of visual information they receive can be limited and it can often be interpreted inaccurately. Because of this, it is important for children with visual impairment to directly experience as much of their world as possible and to receive augmented instruction in making connections between objects and processes.
In very young (pre-school) children, it is often difficult and sometime impossible to assess and quantify the various visual functions through the conventional testing methods. Although special tests exist for the quantitative assessment of vision in children, these are often difficult to administer and require certain set of advanced skills which most clinician don’t practice as a matter of routine. There is also growing evidence that visual acuity score cannot accurately predict the function performance of an individual which relates more closely to the levels of visual efficiency including the ability to fixate, scanning and tracking.
Children with Special Educational Needs can be difficult to assess in the clinical setting. A satisfactory result is particularly hard to achieve when a child has significant learning and communication issues. Many children can associate the hospital clinic with previous unpleasant experiences. Many children with learning disabilities are unable to manage the standardised vision tests used to test visual acuity and other vision assessments.
Another issue is the translation of the results of the clinical findings by the education and rehabilitation into their planning for the individual children. For example a visual acuity score of 20/200 does really help a teacher understand how far the child needs to sit from the writing board.
There have been a number of attempt to develop a standardized methodology and testing materials for the functional vision assessment. The first significant attempt to standardize the procedure and develop a kit for functional vision assessment was developed by Natalie Barraga which was followed by the introduction of functional vision assessment kit developed by Prof. Jill E. Keffee for use in the developing countries. 
The functional vision assessment kit developed by us is an attempt to further streamline and standardize the functional vision assessment and make this available to professional working in the areas of vision rehabilitation at an affordable price through the V2020 Low Vision Resource Centre in Hong Kong. 
Functional Vision Assessment
Assessment for children with visual impairment includes comprehensive evaluations by members of a multidisciplinary team. Areas of assessment includes: ophthalmologic and optometric assessment, clinical low vision assessment, functional vision assessment, expanded core curriculum assessments, and learning media assessments.
The ophthalmologist completes the ophthalmologic evaluation of the child to diagnose the eye conditions and examine the health of the eye, as well as to give a prognosis of the visual impairment. Use of functional vision is not emphasized. The optometric assessment by an optometrist verifies the need for refractive correction and prescribes spectacles to improve acuity loss to the greatest extent possible. The optometrist also performs the clinical low vision assessment which assesses whether or not the child will benefit from low vision devices. One of the most beneficial results of the low vision assessment is the link made between medical and functional aspects of vision loss.
The functional vision assessment includes a variety of evaluations that test the child's use of vision and visual efficiency in daily activities. The assessment determines how the child accesses his/her visual environment. A trained teacher, orthoptist, or low vision counselor completes the functional vision assessment. Based on the information collected through record review, interviews, observations, and assessment a report is generated that addresses the various issues. The assessment helps us understand exactly what the child can see in everyday life. The assessment findings:
- Help to explain how a child is functioning with his/her level of vision
- Provide strategies and ideas on how to make the best use of available vision or to make adaptations to make the visual world easier to understand
- Give us a comparison of levels of vision to other children of the same age
- Look at other related areas of vision such as depth perception and color vision where appropriate
- Give us information as to how vision is impacting on the child’s mobility and playing skills
- Give us ideas about how the child will best learn and what aids might be appropriate for schooling.
Functional vision assessment kit (FVAKit)
Functional vision most often assessed through observations rather than formal setting. Various assessment kits and checklists have been used to assess the functional vision worldwide; however, there is a visible lack in standardization, especially in the context of developing countries. Considering the paucity of uniformed tools to assess the functional vision, this kit has been developed to make the assessment procedure more systematic and consistent. The development of this kit and training guidelines were the first attempt towards the process. The purpose of FVAKit is to provide standardized tool for functional vision assessment to determine the recommendations for visual skills training, referrals, adaptations, and intervention based on information gathered during the observations.
The guidelines and assessment forms have been developed as part of FVAKit.
The trial of FVAKit were conducted in three different settings; i) special education schools, ii) mainstream schools, iii) low vision clinics. Optometrists, Teachers and Low Vision Counsellors were trained in the use of various tools and protocols to record the observations. The feedback from teachers and counselors have been encouraging and helped to make the FVAKit more effective based on complete and consistent data.
What happens during the assessment
The assessor considers the following steps while conducting the functional vision assessment. The emphasis is on making the experience enjoyable for child. A mutually convenient time is made for the assessment. Most assessments take at least an hour and half as many aspects of vision are covered. A written report follows the assessment, outlining and explaining the results. This includes recommendations for making the best use of visual abilities.
Tab. 1: The FVAKit consists of following fourteen tools (24 items) which have been specifically designed considering the various components of functional vision assessment procedure.
The following aspects are considered and information is included in the functional vision assessment report.
- Vision use in a variety of lighting situations - both indoors and out
- Reaction to change in lighting, such as going from a dim-lit room to a bright playground
- Ability to identify colors in the natural environment – including identifying objects and landmarks by color while walking
- Fluctuation in vision and any patterns in fluctuation • Usefulness of non-optical low vision devices
- Postural concerns: types of furniture and aids that provide comfortable posture
- Most beneficial type of learning media • Vision use compared to use of other senses when exploring objects, pictures or symbols, both near and distant.
During a functional vision assessment, the child is observed in his or her natural environments with a variety of visual challenges that he or she encounters in the daily routine. The successes and difficulties are observed to recommend ways in which the vision can be enhanced or, if it cannot be enhanced, to recommend task modifications that will help the child to be successful.
The findings are recorded on the “Functional Vision Assessment Record Form”. The first section of the form covers the basic social and medical history; second part provides details of general observations regarding environment in which functional assessment carried out as environment has a significant impact on assessment results. The third section comprises of assessment findings; parameters have been defined to record the results on the basis of various activities performed by child during the assessment. These parameters are , then, translated into the report which addresses that how the child's visual impairment will affect the child's functioning in the daily activities of life and how to make successful adaptations.
The identification of visual perception issues is particularly crucial when considering access to learning. A child with visual impairment will be at a significant disadvantage with visual learning generally, and especially when attempting to use a visual communication system. The right information from a functional vision assessment helps the educators to design an enabling environment, with appropriate teaching and learning mediums, to ensure that every child with visual impairment and/or any other disabilities have the very best access to learning.
The team philosophy in completing a FVA guides the direction and the outcome of the assessment. Parent involvement is crucial to ensure a partnership relationship that denotes the importance of working together as a team on behalf of the child. It is of paramount importance that team members work together in both assessment and programme implementation.