The Austin Assessment – A screening tool for identifying children with brain based visual difficulties
(Note: Brain based visual difficulties refers to impairment of vision based on injury or damage to the brain, as opposed to the eye).
Over the last 40 or so years, two major factors that have led to the significant increase in the numbers of children with visual issues collectively referred to as brain based visual impairment (BBVI), or cerebral visual impairment (CVI). Medical advancements in neonatal care for premature infants, mean that more and more children are surviving being born as young as 24 weeks gestation. Premature birth is the main cause of BBVI/CVI, with any child born before 32 weeks having an 86% chance of having visual issues based on injury or damage to the brain. Additionally, advancement in the understanding of how the brain works and the different areas of the brain involved in the process of seeing, which is around 40% of the brain. Further to this, the impact on seeing when any of these brain areas are injured or damaged, either prenatally or at any time during the lifespan.
While these two factors have helped in terms of increasing the awareness of these visual issues for the estimated 3.4% of children in mainstream classrooms, further work needs to be done around identifying these children and supporting them so that these visual issues do not impact on their education attainment. To put this prevalence rate of 3.4% into perspective, based on research out of the UK, potentially, there could be currently 1 child in every classroom in every school in New Zealand struggling with their learning due to visual issues that have not been identified or recognised. Also, as the numbers of children with BBVI/CVI are expected to continue to rise due to further advancements in neonatal care, the most important need right now is better identification and support for these children.
What are these visual issues?
BBVI/CVI is an umbrella term for a myriad of different visual issues. These issues can be divided into two distinct areas of visual functioning – the basic visual functions and the higher, or perceptual functions. The basic visual functions include visual acuity, contrast sensitivity, oculomotor control and visual fields and are all assessed as part of routine eye checks by optometrists or ophthalmologists. The higher visual functions, however, are not so easy to assess, resulting in most children with issues in this area going unrecognised. There are two main reasons for this. Firstly, many children with visual perceptual difficulties (VPD), have normal or near normal visual acuity, meaning they can read the eye chart easily and don’t get identified as even having a visual difficulty. The second reason is that VP abilities can appear differently in real world situations compared with clinical settings. So, children can show good or normal VP abilities in a quiet, uncluttered clinic, but may struggle in a cluttered and noisy classroom.
An assessment tool to detect visual perceptual difficulties (VPD)
Up until now, there has been no way of assessing these children in a real-world situation, giving rise to the need for a simple and effective tool for detecting VPD’s in children. With both personal and professional experience of VPD’s, I decided to take up this challenge and create an assessment tool to detect VPDs that could be used as a screening tool to identify the growing numbers of children around the world with BBVI/CVI. Based on an experience of working with a young boy with CVI, I developed the Austin Assessment and tested its effectiveness as part of my doctoral research. The Austin Assessment is a simple activity of matching playing cards over 5 levels, starting with 4 cards, 1 pair working up to 12 cards, 5 pairs. Although this activity seems easy and straight forward, the initial research showed that children with VPD took twice as long as children without visual issues to match the pairs at each level and often weren’t accurate in matching the pairs, especially when there were more cards to choose from. Moreover, the children with VPD’s showed significant rapid eye and head movement as they searched for the pairs, whereas the children without visual issues did not. The reason for these findings, is that clutter greatly impacts on anyone with VPDs, making it harder and harder for them to see a single card, as the numbers of cards increased at each level. Relating this back to how this would impact on learning and in the classroom, when there is a lot of information for children to visually process at the same time, it is difficult for them to focus their visual attention on any one thing at a time. This often leaves children feeling overwhelmed, and unable to focus on what is being taught. To a classroom teacher, it may appear that the child is easily distracted and not engaged with the classroom activity.
These results are so significant that I received funding from Massey Ventures to turn the Austin Assessment into an iPad app. As word has got out about the effectiveness of the Austin Assessment there has been significant international interest in the Austin Assessment and its potential uses. The Austin Assessment app is now being touted as a screening tool for BBVI/CVI that could be used by parents, teachers, and medical professionals around the world, which would make a significant difference in not only in how we identify children with these visual difficulties, but also in how we support children with BBVI/CVI in the classroom. Currently, children with VPD and BBVI/CVI often get identified with learning and/or behaviour difficulties at school, due to their visual difficulties going undetected. They are then supported based on their learning and behaviour needs, rather than the actual cause of these needs. If the Austin Assessment was used as a screening tool as part of the B4 school check for all children at age 4, for instance, support could be put into place as soon as they start school based on their visual needs, which would hopefully reduce any learning or behaviour needs developing during their school years.
To help support the use of the Austin Assessment, I have developed a database of time taken and accuracy in completing the Austin Assessment by age group for children without visual difficulties as a normative range database. For this, I assessed 450 children aged between 5-18 in three local schools. While developing this database, I identified 20 children with potential VPDs who had previously not been identified as having visual difficulties. However, when these findings were discussed with their parents and teachers, many reported that this made complete sense and helped them to understand their child’s learning and behaviour difficulties they had been experiencing. These findings support the potential use of the Austin Assessment as a screening tool and highlight how useful it could be for both parents and teachers in understanding children’s learning needs.
I am currently undertaking further validation research with the Austin Assessment on children already diagnosed with BBVI/CVI before making it available for wider use in both New Zealand and around the world – so watch this space!
Dr Nicola McDowell is a lecturer in the Institute of Education at Massey University, New Zealand. She is the Blind and Low Vision endorsement and Accessibility coordinator on the Specialist Teaching Programme. For her doctoral research, Nicola developed the CVI practice framework as an approach for supporting children with cerebral visual impairment (CVI) that can be used within an education or rehabilitation context. Nicola’s other research focuses include supporting students with learning needs to have equal access and equal opportunities for success within their educational environment. Also, issues related to empowerment of those with disabilities and their whānau / caregivers.