This is aresearch paper I wrote for my music therapy course. I have learned a lot when researching and even want to help. If anyone you know needs any help, please let me know. We’ll work something out. (Also, sorry for the technical error. This article used to be http://snehith.com/?p=285 but is now http://snehith.com/?p=215. As far as I know, at least one site, linked to this article. Apologies.) All rights reserved. Snehith Chittavajhula.
Vision Loss and Blindness
In America alone, more than 3 million (2.7 percent) people aged 40 or older are reported as either blind or visually impaired (U.S. Department of, 2008). How these people go about their daily lives should be of high interest to the rest of us, because it allows us to know more about ourselves, too. Definitions for terms, different types and degrees of vision loss, possible deficit areas, possible etiologies, common prognosis methods, and common settings where the population live or are served have all been covered. An idea for a music therapy activity for use with the blind has also been described.
Definitions of Terms
To better understand what constitutes vision loss or blindness, it is important to know the definitions of some of the words commonly used when referring to this population. The term ‘blind’ is used to indicate that a person has no functional vision; 20/200 or lower is considered legally blind. 20/200 vision means that this person can only see at 20 feet, what those with normal vision can see at 200 feet. Low vision is when a person has partial sight. Residual vision indicates any remaining vision considered “useful.” Functional vision, on the other hand, is any residual vision sufficient for carrying out essential daily tasks (e.g. eating, hygiene, etc.). Visual efficiency is how well a person uses their residual vision. Visual acuity refers to the clarity in one’s vision, and the ability to distinguish details. The term “visual impairment,” according to the Centers for Disease Control and Prevention (CDC) (U.S. Department of, 2004), when referring to a state of vision loss, is used when an individual’s eyesight cannot be corrected to “normal,” through any treatments or interventions. A person’s visual field is the range of visual perception possible without moving the eyes. Total blindness implies that a person is incapable of seeing anything through either eye (“Key definition of,” 2008).
Types and Degrees of Vision Loss
The type and degree of vision loss will influence a person’s educational and environmental choices, as some may require more assistance for everyday tasks, while some may just need to make some minor adjustments. Levels of vision loss include low vision (or partial vision), functionally blind, and blind. People with low vision may use optical devices to enlarge print. If a person is functionally blind, this person can generally use functional vision for daily tasks, such as cooking, mobility, and dressing, while using Braille for reading and writing. Someone who is blind receives nothing useful through their vision, and relies solely upon their tactile and auditory senses for most things. Another type of vision loss is a restricted field of vision. For some, a form of this may be tunnel vision, or the lack of focus for objects not near the center of vision. For others, it might be somewhat of an opposite, with poor central vision. This is lack of clarity towards the center of the visual field. The person’s whole lifestyle– including their career, plans, and even social life– has to fit around what they are or aren’t capable of (Davis, Gfeller, & Thaut, 2008, 391).
The age of onset1 of vision loss can prove to be a very key aspect in how the person lives through, or adjusts to, a certain way of life. Whether the condition is congenital (present at birth) or acquired, there are a few advantages and disadvantages to both. If the vision loss is congenital, the person has grown so used to it that they don’t know what they are missing. This can be viewed as a good thing, since they might not feel like they are missing out on anything special. Another advantage to them is that they learn, from very early on, to use their other senses (such as hearing, and touch) relatively extensively, thereby developing those skills even more, and possibly more than a person with normal vision can. One downside to a congenital vision loss, though, is that they have nothing visual that is reliable enough to relate with any of the words or concepts they come across. They may have a very difficult, not to mention straining, time trying to understand more abstract ideas that depend upon vision to share. An example of this might be a child trying to understand what a “blue sky” might look like, or why an “ocean sunset” is considered beautiful. There are many things a “normal” person comes across like this, yet has never broken it down and thought about it, taking colors and light for granted. This is one of the biggest drawbacks for those with congenital vision loss.
This is one area where if the vision loss is adventitious, or acquired, there is a major advantage of having experienced vision before. This person now has a memory bank, a storage space, full of images to associate with words and concepts. This same point can also be viewed as a huge disadvantage. These people are accustomed to having proper vision, or any vision, for that matter. They must now learn to adapt to their new condition. This includes any necessary changes to their lifestyle, their environment, their way of communicating, and even their career and work. An example of this might be a middle-aged man living alone, and now has acquired vision loss due to an accident. He had been working as a bank teller and cashier for quite some time now, and with this unexpected turn of events, it is no longer in his capacity to do the job. He now, most probably, has to live with some degree of assistance. He can no longer check the caller ID as easily when the phone rings, or just play a video game for fun. He has to adapt to his new environment. Another important drawback for this part of the population is that once they have experienced vision before, any intervention or treatment (that does not exactly correct the problem to “normal”) does not meet their expectations. They know what it should be like. This can get really frustrating for the person. This can also lead to a feeling of losing control, a drop in self-esteem, isolation, and maybe even depression.
These conditions can also be acute or chronic. Acute can be understood as rapid, sudden, onset. An example of an acute vision loss might be an accident resulting in damage to the eye, such as caused by accidents. Chronic, in this context, works as the opposite of acute, with the regression being a long-term effect. An example of this may be increased vision loss accompanying the aging process.
The Different Affected Areas
Key areas of development to consider are cognition, behavioral/emotional response, communication, physical aspects, social interactions, and also academics and education. Each of these has it’s own advantages and disadvantages. For cognition, a disadvantage for people with vision loss is the lack of visual observations and illustrations that help with easier understanding of the topic. Since, they have little to no reliable sources, they may score lower in tests that measure intellect. Although there is an ever-present difficulty in understanding, on a more positive note, visual disability does not impair intellectual capacity, and many people with visual impairments have scored similar to (or, sometimes even higher than) people with normal vision, provided the tests do not involve and depend so much on vision.
When it comes to emotional and behavioral responses, the attitudes of other people toward the person with blindness is a very important factor, possibly having an affect on self-esteem and confidence. Socially, since the person cannot see their peers or the other person, there may be much fewer opportunities available to socialize. People with normal vision “automatically” look for social cues of interaction, such as gestures (body language) and facial expressions. Persons with visual loss, cannot fully observe these forms of nonverbal communication, and cannot make eye contact, which is generally perceived to be an integral part of socialization. They must learn to listen for these social opportunities, such as pauses in speech or tone of the other person (“Did they finish?”), and present their own speech appropriately. Fortunately, it is possible to teach a person with visual difficulties the use of nonverbal communication themselves, usually through other senses (generally tactual). This can improve social skills as well as develop ways of communication. Yet another disadvantage is the presence of (common or uncommon) stereotypical behaviors, which can also prove to be a physical aspect.
Vision loss or blindness does not have an intrinsic affect on physical development, per se, yet having no vision can still have an impact on many different areas. Physically, normal young children (with vision) look around at the world they are in, and are motivated to explore their environment. Young children with no vision, however, generally do not have this motivation, resulting in the high possibility of delayed locomotion and motor skills. There is no “typical” childhood experience, and they may have developmental delays in other areas as well. More often than not, this includes skipping over basic steps in the developmental process. Also, mobility and orientation are highly important. Mobility is the ability to move safely and efficiently from one point to another, whereas orientation is a sense of one’s own present location and position relative to the surrounding environment (Davis, Gfeller, & Thaut, 2008, 395). Stereotypical behaviors should also be considered. These are more often caused by the lack of observation of what is “normal” and appropriate behavior from childhood. Behaviors such as body rocking or repetitive movements may also prove to be a detriment socially. For example, other “normal” peers might find a blind child’s continuous rocking to be strange or even repulsive, and therefore avoid the child altogether. One advantage is the possibility to train the person, therapeutically or otherwise, to replace these stereotypic behaviors with more appropriate ones.
The children affected by vision loss are greatly impacted when it comes to language development and communication. Although words relying on vision (such as adjectives like colors, etc.) are hard to understand, it is possible to develop normal vocabulary and skills if the child is in an environment rich in language. Alternative forms of communication can prove useful, and are encouraged. One common form of alternative communication for the blind is Braille, developed in 1821 by a blind Frenchman named Louis Braille (“Braille,” 2010). Braille is a system of raised “dots” as a tactile method used for reading and writing by many people with vision loss. Academically, Braille can be used as an educative tool by providing a medium of information, provided the material is in Braille format. Other mediums such as recorded audio can be used, although the lack of graphs and illustrations can make learning relatively more difficult. One interesting, yet shocking, fact is that, according to the National Foundation for the Blind (NFB) (“Nfb – braille.org,” 2010), ninety percent of children who are blind are not taught to read, although Braille can be accessible enough to teach it, and practical for the student to learn it. This is attributed to three primary reasons: (1) not having enough Braille teachers, (2) some teachers not having enough training in Braille for dealing with these children, and unfortunately (3) many educators and instructors believing that Braille and Braille instruction is not necessary. Before the Braille system was invented, there existed another form of reading for the blind, essentially raised letters (Kimbrough). Along with having limited access to reading material and activities, these student face testing procedures that are different from those administered to students with normal vision. Different testing conditions and changes in the evaluation and processing of scores are necessary and should be implemented.
Etiology of Vision Problems
As noted earlier, vision loss or blindness can be congenital or adventitious (acquired), acute or chronic, and can be influenced by the age of onset. Common etiologies (causes) of visual disabilities are infections, diseases, accidents, injuries, and prenatal/postnatal influences. Some of the common infections and diseases that bring about vision loss are glaucoma (internal pressure on the eye), diabetic retinopathy (damage to, and leaking of, the retina-supporting blood vessels; caused by long-term diabetes), macular degeneration (blurred vision due to damage to the retina), and even cataracts (clouding of the lens, blocking passage of light), retinitis pigmentosa (night blindness) and traumatic brain injuries, where there is a high possibility of damage to optic nerves or other vital connections (“What Causes low,” 2010). Accidents that may lead to vision problems include vehicular accidents, chemical accidents, and even an unsafe overexposure of light to the eyes for a longer period. Injuries include those that occurred while operating machinery, as well as any damage that may have occurred by not wearing adequate protective gear appropriate for the job. An example of this can be construction workers, who work extensively with wood and metal shavings and debris, requiring goggles most of the time as a safety measure. The most common prenatal incident influencing vision loss is hereditary; where the genes will predetermine that the child will be blind. One postnatal possibility is retinopathy of prematurity (ROP), a condition occurring in premature infants due to being exposed to very high oxygen levels in the neonatal incubators (“What Causes low,” 2010).
Yet another set of factors to classify a condition are stable versus progressive. Stable, as the name implies, is when a condition or disease does not increase, decrease, or fluctuate in the level of severity and symptoms. A progressive condition indicates that the problems are increasingly regressive, often at a steady pace.
Prognosis
Prognosis includes any treatment, interventions, aids, training, and assistance necessary to bring about the best possible result. One of the most common treatments for vision loss and blindness are surgeries, performed by an ophthalmologist. Surgeries in this category include laser eye surgery (sometimes also used in refractive surgery), the common cataract surgery (lens removed in severe cases, replaced with a plastic IOL2), glaucoma surgery (such as canaloplasty), corneal surgery [including most refractive surgeries (which in turn includes laser treatments)], vireo-retinal surgery, extraocular surgery, oculoplastic surgery (reconstruction of the eye and related structures) and even eye removal (“Eye Surgery,” 2010).
External aids are more common than surgeries, due to factors such as the relative ease of use, the substantially lower costs, and a much lower risk factor. The most common aids are corrective lenses, such as eyeglasses and contact lenses (also called as glasses and contacts, respectively). Corrective lenses are prescribed by an optometrist (as opposed to ophthalmologist for surgeries). Eyeglasses may be more feasible for some than contact lenses, since a less complex method is involved in wearing them. Other types aids include the iconic walking canes for the blind and service dogs. Canes help support the blind by letting them feel around them as they move, protecting them from tripping over something so easily. The cane gained popularity among the blind after World War II, when some with eye problems were handed canes. The canes were immensely useful, since they allowed the blind much greater travel independence, while allowing them to go by foot (Zahl, 1950, 353-365). Some common things to watch out for when selecting a cane include being lightweight (to probe ahead constantly), being long enough (to reach ahead and work as a barrier, if necessary), and having a tip that is capable of sliding easily across the ground surface (Sauerburger, 2009). According to the same source, those who require a support cane, as well as a probing cane, may have to use both, with one in each hand. Service dogs are trained to assist the blind in daily activities, and to act as a lasting companion to the individual. Activities and training for service dogs (also known as guide dogs) include following a path, maneuvering, obeying commands, and occasionally disobeying to protect the person, if in danger (“The Guide dog,” 2010b). According to Guide Dog Foundation for the Blind, Inc.’s “Guide Dog Do’s and Don’ts” (“The Guide dog,” 2010a), a working service dog should be ignored and left alone to do its work properly, since distractions (including petting, abusing, or commands from someone other than the dog’s master) can jeopardize the safety of the dog and its master. The source also stresses the importance of not treating the dog as a pet, but rather a working dog deserving respect. Other forms of aids include printed Braille text alongside “regular” words, especially on signs and boards. A very common occurrence of this is the Braille text on the doors of restrooms, or next the buttons in an elevator. Other very nice devices for the blind are the Braille keyboard and the large print keyboard, such as those advertised by Hooleon Keyboards (“Large print computer,” 2010). These Braille keyboard are essentially the same as regular keyboards, but with raised Braille lettering on each key. Large print keyboards are also very similar in concept, but with large lettering on each key, with the lettering size often filling up the surface of each key.
Another part of prognosis could be personal training. In this personal training, areas such as adapting and functionality may be worked on. Helping the person to adapt includes helping them adjust to their new environment, new lifestyle, new schedule, and even the unfamiliar treatment procedures. Working on functional vision with the patient involves the assistance with and training for essential daily livings tasks, such as cooking, eating, mobility, and hygiene. These skills must be taught through senses other than vision, and through hands-on experiences. Social and physical skills must also be part of the training. Along with discouraging stereotypic behaviors, social aspects should be encouraged. These include learning how to take turns, looking for social cues and opportunities, and participating in conversations. An example of academic skill training might be teaching Braille. In this scenario, a music therapist might work with the child, starting off with teaching him/her the Braille alphabet. Songs, such as the ever-classic alphabet song, can be used here. Songs and melodies can also be used to teach facts and concepts by incorporating music, musical instruments, and musical activities. Songs such as “Wheels on the Bus” are perfect for this kind of activity, since they describe everyday things that happen in the world around them. Songs such as “The Itsy Bitsy Spider,” for example, also work better to encourage the use of the hands, and possibly reducing stereotypic behaviors, while the child is preoccupied in having fun with the gestures. Such activities might require the use of tactile senses as major part of the teaching process.
The Settings
Where people with blindness or vision live depends significantly upon the type and degree of the condition. For someone with only a minor vision problem, corrective lenses may be sufficient. Another person might require thick glasses and large print to read. Those with a severe form of vision loss might require Braille for reading and writing, and depend upon other external aids (such as canes, rails, etc.) to move around. This last group might need more assistance with daily life than the others. If the person is to live quite independently on his/her own, the house may be modified, both interiorly and/or exteriorly, for accessibility with the new impairment. Part of the treatment or therapy program here might be to accustom the blind person to, and familiarize him/her with the new layout of his home. This adjusting process can take quite some time, possibly weeks or even months. It is one of the therapist’s duties to assist the person and provide support at this crucial stage.
The visually impaired might live in community living centers (CLCs), or choose to live independently. Other settings where people of this population are most likely to be served are in hospitals, regular classrooms, special classrooms (such as those with assistive technologies), or even special institutions tailored to them. An excellent example of an institution like this is The Maryland School for the Blind.
Music Therapy Activity
A music therapy activity we can possibly use with children who are blind involves the use of different pitches to denote different numerical values. I would use a piano, with Braille stickers on each key. The stickers can read the note names (A, B, C, D, E, F, G, sharps, flats) along with specially assigned numbers (e.g. 0, 1, 2, 3, 4, etc.). Suppose the child needs help with remembering things, and we are starting out by getting him to memorize his telephone number3. Let us say it is 555-6438. Starting out on the C Major scale (easiest with all white keys), the sequence might be GGGAFEC, with the last C ending in the higher register. Once we work with the child to create ourselves a rhythm, we now have a little song (or jingle) that the boy can easily remember the number, should he ever need to dial it. Along with his very own, personalized tune, a part of this exercise might teach feeling for, and using the keys, as well as basic phone operations (such as picking up the phone4, or hanging up). Through these mnemonic devices, the child can learn to memorize not only phone numbers, but also addresses, passwords, names, or anything else he would come across in life.
Conclusion
Vision is something many of us, the able-eyed, take for granted. Once we can work toward understanding how the blind function and live through, we can understand ourselves better, and therefore show more empathy toward them. A little awareness can go a long way. Knowing what the possibilities are for vision loss, we can take the necessary precautions to protect others and ourselves. Simple measures, such as goggles or masks, should be practiced when working with potentially dangerous tools. Be being more prepared, we can hope to take care of those already in need, first.
References
Braille. (2010). Wikipedia, the free encyclopedia. Retrieved (2010, May 27) from http://en.wikipedia.org/wiki/Braille
Davis, W. B., Gfeller, K. E., & Thaut, M. H. (2008). An Introduction to music therapy: theory and practice. Silver Spring, MD: American Music Therapy Association, Inc..
Eye Surgery. (2010). Wikipedia, the free encyclopedia. Retrieved (2010, May 27) from http://en.wikipedia.org/wiki/Eye_surgery
Key definition of statistical terms – american foundation for the blind. (2008, September). Retrieved from http://www.afb.org/Section.asp?SectionID=15&DocumentID=1280
Kimbrough, P. (n.d.). Braille history. Retrieved from http://www.brailler.com/braillehx.htm
Large print computer keyboard,braille keyboard,large print keyboard sticker labels. (2010). Retrieved from http://www.hooleon.com/menu-vision.htm
Nfb – braille.org. (2010). Retrieved from http://www.nfb.org/nfb/Braille_Initiative.asp
Sauerburger, D. (2009). What Type of cane should i choose? | visionaware. Retrieved from http://www.visionaware.org/what_type_of_cane_should_i_use
The Guide dog foundation for the blind inc – etiquette and guide dogs. (2010). Retrieved from http://www.guidedog.org/Content.aspx?id=1416
The Guide dog foundation for the blind inc – frequently asked questions. (2010). Retrieved from http://www.guidedog.org/Content.aspx?id=564
U.S. Department of Health and Human Services, Centers for Disease Control and Protection. (2004). Vision impairment 2, dd, ncbddd, cdc Atlanta, GA: Retrieved from http://www.cdc.gov/ncbddd/dd/vision2.htm
U.S. Department of Health and Human Services, National Eye Institute, National Institutes of Health. (2008). Prevalence of blindness data Bethesda, Maryland: Retrieved from http://www.nih.gov/about/index.html
What Causes low vision?. (2010). Retrieved from http://www.aoa.org/x5241.xml
Zahl, P. A. (1950). Blindness: modern approaches to the unseen environment. New York, NY: Hafner Press.
Footnotes
1 The age of onset is the age in which a person first started showing or experiencing symptoms of a condition or disease.
2 Intraocular Lens
3 Another observable fact is that all telephones have a little “bump” on the 5 key. This is so that anyone familiar with the layout of a phone should be able to dial a number, without fumbling in the dark, or because of vision. This works since all other numbers are arranged around the center key. This is also true for computer keyboards, where on QWERTY keyboards, for example, similar “bumps” are on letter F and J.
4 Another thing to consider when teaching this is that most modern cordless phones don’t connect by “picking up”; rather a “Talk” button (generally green) needs to be pressed. The same can be said about “hanging up” and the “End” button (often red).