VI healthcare professionals: Who does what.

If you have a concern about a child or young person’s vision the first step is to arrange a visit to their local optician.  If a visual impairment is identified they may go on to have a number of eye care medical professionals involved in their care – for more information about who the professionals may be and what they do please see below:

  • A General Practitioner (GP) doctor – The doctor is often the first point of contact for many families. He/she can carry out a basic visual screening.  They may then refer onto another professional if appropriate.
  • Paediatrician – Medically qualified doctor who specialises in working with babies and children. They check the overall health of the patient.  They can refer the child/young person to other specialists.
  • Dispensing optician – Dispensing opticians fit glasses and contact lenses working from a prescription written by an ophthalmic practitioner or ophthalmologist. They also fit and dispense low vision aids.  They do not test eyes.
  • Optometrist – Optometrists are trained to recognise, treat and manage abnormalities and signs of some, but not all, eye diseases. They can examine the internal and external structure of your eyes to detect diseases.  They may also test a person’s ability to focus and coordinate they eyes and see depth and colours accurately. Optometrists can prescribe and fit glasses, contact lenses and low vision aids.
  • Ophthalmologist or Ophthalmic Surgeon – Medically qualified doctor, based in a hospital, who specialises in examining and diagnosing eye conditions. They provide treatment for defects/diseases/injuries of the eye.  They can perform surgery and prescribe and administer medication.
  • Orthoptists – Orthoptists usually work with Ophthalmologists in the investigation and treatment of various abnormalities of the eye function relating to the development of the visual system, such as squints and double vision. They provide functional instruction on therapies to help improve eye movements – they cannot prescribe medication.

For further information, the following may be helpful:

Eye conditions

If you have a child who has been diagnosed with a condition and you’re struggling to find practical information on it, the linked  fact sheets below (in PDF format) –  may be of use.

The conditions

Introduction to “Orientation” and “Mobility”

Many people hear words orientation or mobility training, but aren’t quite sure what they mean. We explain.

  • Orientation refers to knowing where you are by using landmarks and clues around the environment.
  • Mobility means moving safely from one place to the other in a safe and independent manner.

Orientation and Mobility training involves teaching a young person with a visual impairment how to move around their environment safely and efficiently.  Specific skills are taught by a qualified Habilitation/Mobility Specialist, so that the student knows where they are and how to get there.  This can be indoors (such as a new school, or new home) as well as outdoors (the route from home to school).  Training is usually undertaken on an individual basis and is often repeated until the young person is able to travel safely and independently and has gained more confidence.

Some of the training may involve:

  • concept development
  • spatial awareness
  • self-protection techniques by using the natural extension of the arm and hand
  • route travel
  • use of android phone including apps to assist with independent travel
  • Using a monocular to utilise remaining vision.

Independent travel helps build self-esteem and self-confidence as the student learns to move.

Often as part of the training (usually at the start of the Orientation and Mobility programme) the young person will be shown Sighted Guide.  This is where a person who has been trained in the Sighted Guide technique, guides a visually impaired person and so that they can walk together safely and comfortably.



For information on Sighted Guide, download the Joseph Clarke Service’s booklet ‘How to Guide a VI child


An introduction to canes

You do not have to be severely sight impaired (blind) to benefit from the use of a cane.  There are different types of canes available that can help you become a more safe, confident and independent traveller.  Here are some of the canes that are commonly available:

Symbol canes

A symbol cane is not long enough to reach the ground, because its function is to inform members of the public that the person carrying it has a visual impairment.  It is light to carry and can be folded up so it can be carried in a bag and used as and when it is needed.

Guide canes

These are sturdier and longer than a symbol cane and are used to locate kerbs and steps.  Guide canes can be fitted with a tip that is straight (pencil tip) or one that rolls along the ground.  Learning to use the guide cane requires minimal training in order for you to start moving independently.

Long cane

When used in a scanning technique, one-or-two-point-touch (tapping technique) the long cane can help you to find obstacles in your pathway.  Like the guide cane, you will also be able to find kerbs and steps.  Depending on your vision, you may only need to use the long cane on a part time basis (for example, if your vision reduces when conditions are dim).  In order to use the long cane effectively, you will be required to undergo a long cane training programme.


The Hoople is a pear-shaped device which achieves a similar function to a white cane, but is designed for use in conditions where using a long cane can be difficult, such as over rough terrain or in a rural environment.  It can also be used by young children as a pre-cane aid or by people with limited hand movements.  The Hoople is moved along the ground as opposed to being moved from side to side like a long cane.

Does the cane need to be white?

Traditionally canes are white because they are easily recognisable by members of the public.  But there are more colours that are now becoming available for long canes.

At what age should a child start long cane training?

It depends on the needs, maturity and abilities of the child.  That being said, some mobility specialists introduce a cane to a visually impaired child as soon as they can walk.


For more information…

If you want to find out more about canes and cane training, contact the Mobility Officer at SENDsuccess

Or you may find these resources useful

All about environmental audits

Our Habilitation Specialist can undertake an ‘Environmental Audit’ within educational settings. As part of this process information and practical advice is given to make the school environment less confusing and more accessible to students, staff and visitors who have a visual impairment.  Additionally, for the students, physical adaptations can assist in; promoting inclusion, independent travel and making their surroundings safer.


Painting doors in strong contrasting colours can help navigation

Recommendations may include painting the edge of steps and stairs in a strong contrasting colour to the background.  Doing so will assist some people with a visual impairment to negotiate each step more safely and assist with depth perception.

As most visually impaired people have some useful vision, colour contrast is commonly referred to in the audit, which will help them to separate the foreground from the background, assist with orientation and avoid obstacles.


A step with contrast-painted edges,

Consideration will also be given to areas such as: signage, lighting, storage and outdoor areas (playground).


Finding your way around your hearing aid

Getting to grips with the buttons and fitting it can seem daunting at first. This video takes you through the different elements step-by-step.

Points covered

  • The different parts of the hearing aid
  • What the buttons do
  • How to fit it to a child’s ear
  • Troubleshooting – whistling sounds.

Changing hearing aid batteries

Changing the batteries in a hearing aid can be a bit fiddly, but isn’t hard. The video below shows how it is done. Be a bit careful listening to this one – there are a couple of loud feedback noises on the video which are part of the demonstration.

Hand-under-hand exploration

If a child has a visual or a multi-sensory impairment, their hands are the means by which they obtain information. Often the people working with these children need to bring the world in the form of objects.  The sense of touch is an essential source of information.


When using hand under hand if possible work from behind your child so that your hands and his/hers will be moving in the same direction. If they are little and it is appropriate, sit them on your lap. When older, sit behind them or next to them and reach your arms around theirs.

Before you show the child how to do something using this method, it is really good practice to try it yourself with your eyes closed. Pay attention to the steps you are taking to do the activity, you will then be able to describe it better to the child.

Most children need multiple demonstrations of a new task to learn it. Since the child may not be able to see another person doing a task clearly or at all, the only demonstration they may receive is the one they feel through the use of hand under hand. Be patient and give many opportunities to practice this new skill. The child with physical difficulties is still able to place their hands upon yours and with practice will be able to maintain this position for longer periods of time

Why use this technique

Some children are resistant to trying new activities. They’ll pull their hands away and won’t want to touch. Respect the message your child is giving you consider this, would you want to place or put your hands on/in something you can’t see, your eyes allow you to discriminate and choose?

However, if they are never encouraged to try new things they may not ever expand their understanding and interest in the world around them

Hand under Hand

When you use the hand under hand technique, your hands perform the activity while your child’s hands rest on top of yours—in this way the child can feel what your hands are doing. If the activity is new to your child and they are hesitant to try it, they may feel more secure touching your hands rather than the unknown object or activity. Also, because their palms are on your hands, the child will be able to focus their energy on feeling the movements of your hands. Research has shown that children still receive much tactile feedback in this way The child may also feel more comfortable and in control because they can freely remove their hands if that is what they want to do. As you perform the activity, verbally describe what you are doing with your hands.


  • Place the child’s hand on top of yours when stirring a bowl of ingredients
  • When forming new signs – model it by placing their hand on yours
  • When manipulating playdoh, plasticine etc
  • When exploring different textures
  • When ripping things – experience the physical movement pulling tearing without having to touch

Using ‘visual cues’ with your child

Providing your child with visual supports can be a very effective way to help them learn and develop their understanding.   ‘Visuals’ can mean objects, photographs, symbols or text.  It is important to know your child’s level of understanding when choosing which type of visual to use. Your school will be able to help you with this.

Using ‘First and Then’ boards

Sometimes called ‘Now and Next’, these simple boards are used to introduce your child to the idea of doing things in a sequence of two.  These can be very helpful to motivate your child to complete a less preferred task by showing them (and reminding them) that a more desirable activity will follow shortly.

First & Then board

First and  Then board

You can find out more about First and Then boards at

Even older children can benefit from this approach by receiving something they really crave once they have completed that thing they have been putting off!  For example, going to the cinema at the weekend if they have arrived at school on time all week, or time on the computer after homework has been completed.

Visual timetables and schedules

Children with learning difficulties or disabilities may find it hard to understand what is happening and can feel very anxious because they don’t know what to expect next. By showing them, using a timetable or schedule, you will be helping to take away their fear of the unknown.

Visual timetable

A visual timetable

Schedules can also be used to help your child learn tasks which can be broken down into small steps such as brushing teeth, getting dressed, going to the toilet etc.

You can find out more about visual timetables at




Free visuals can be found at the following Web sites

Other visual resource for parents can be found at  View2do

A guide to the different kinds of hearing loss

There are different types of hearing loss you may come across, we’ve produced this handy guide to help you understand them

There are two types of hearing loss, with different underlying causes :

  • Conductive
  • sensori-neural.

These can cause different levels of hearing loss:

  • mild
  • moderate
  • severe
  • profound

We take you through these terms below

The Types

Conductive hearing loss

Conductive hearing loss is the result of sounds not being able to pass freely to the inner ear. This usually results from a blockage in the outer or middle ear, such as a build-up of excess ear wax or fluid from an ear infection (especially common in children). It can also happen as a result of some abnormality in the structure of the outer ear, ear canal or middle ear – or be due to a ruptured eardrum.

The result of this type of hearing loss is that sounds become quieter, although not usually distorted. Depending on its cause, a conductive hearing loss can either be temporary or permanent.

Conductive hearing losses can often be corrected with medical management, or minor surgery.

 Sensori-neural hearing loss

This type of hearing loss occurs within the inner ear.

A permanent sensorineural hearing loss is the result of damage to the hair cells within the cochlea or the hearing nerve (or both). Damage to the cochlea occurs naturally as part of the ageing process or babies can be born without fully developed hair cells resulting in a sensori-neural loss. –  there are also many other things that cause sensorineural hearing loss, or add to it, such as:

  • Regular and prolonged exposure to loud sounds. These sounds do not necessarily have to be unpleasant – for example, exposure to loud music can be just as harmful as exposure to loud machinery. Even short term exposure to loud sound can cause temporary deafness.
  • Ototoxic drugs – some medicines are harmful to the cochlea and/or hearing nerve. These include drugs that are used in the treatment of serious diseases such as cancer but also include certain types of antibiotics
  • Certain infectious diseases, including Rubella
  • Complications at birth
  • Injury to the head
  • Benign tumours on the auditory nerve – although rare, these can cause hearing loss
  • Genetic predisposition – some people are especially prone to hearing loss.

Sensorineural hearing loss not only changes our ability to hear quiet sounds, but it also reduces the quality of the sound that is heard, meaning that individuals with this type of hearing loss will often struggle to understand speech. Once the cochlea hair cells become damaged, they will remain damaged for the rest of a person’s life. Therefore sensorineural hearing loss is irreversible and cannot be cured – at least at the present time.

The levels

Hearing loss can be categorised in to 4 main levels of deafness – mild, moderate, severe or profound. These levels are determined according to the quietest sound, measured in decibels, which you can hear without the aid of a hearing device, such as, hearing aids. (learn more)

Mild hearing loss

The quietest sounds people with mild hearing loss can hear are 25-39 decibels. If you have a mild hearing loss you will find it difficult following speech in noisy environments.

Moderate hearing loss

The quietest sounds people with a moderate hearing loss can hear are 40-69 decibels. If you have a moderate hearing loss you may need to use hearing aids in order to be able to hear speech clearly and may still struggle in noisy environments.

Severe hearing loss

The quietest sounds people with a severe hearing loss can hear are 70-94 decibels. If you have a severe hearing loss you will need hearing aids to access speech and you may also rely on lipreading.

Profound hearing loss

The quietest sound people with a profound hearing loss can hear are 95 decibels or more. If you have a profound hearing loss BSL is likely to be your first or preferred language. Some profoundly deaf people may opt for a cochlear implant which allows for access to speech.

Worried that your child may have a hearing loss?

Here is some useful advice if you suspect your child may be having difficulty hearing.

Why do you suspect your child may have a hearing loss?

  • They don’t respond when there is background noise?
  • They are turning up the television to be able to hear it?
  • Not responding if you call them from some distance away, e.g. calling them when they are upstairs and you are downstairs?
  • They are mishearing things you say and becoming muddled or confused?
  • Their speech appears affected, such as, missing initial sounds.
  • They failed the school hearing test.

First steps

  • Make an appointment with the GP
  • Speak to their class teacher to establish if there are any problems at school with listening.

What happens next?

  • The GP will make a referral to the Hearing Assessment Clinic (HAC)
  • HAC will test your child’s hearing in a specially designed audiology room.
  • HAC will provide detailed information about your child’s hearing.

How and when would a SENDsuccess Teacher of the Deaf become involved?

  • A teacher of the Deaf would become involved after a formal diagnosis of a hearing loss has been given.
  • Our involvement would depend on the type and degree of hearing loss.
  • On receiving a referral from the HAC, we would make contact with school and/or families.

If a diagnosis has been given where can schools and families find further information/support?

Promoting Positive Behaviour in Pupils with Down’s Syndrome

Down’s Syndrome is a genetic condition where a child is born with 47 chromosomes in each cell instead of 46 due to a full or partial extra copy of chromosome 21 (Down’s Syndrome is also known as Trisomy 21). This additional material alters the course of a child’s development  and results in the characteristics of Down’s Syndrome. Each person with Down’s Syndrome is a unique individual who share all their parents genetic material; they will possess the features of Down’s Syndrome to varying degrees.

There are some strengths and weaknesses that can characterise the syndrome and influence behaviour:

Strengths Areas of need
  • Social Skills
  • Social Understanding
  • Visual Imitation
  • Visual Processing
  • Decreased Task Persistence
  • Early Expressive skills
  • Escape Motivated (Avoid difficult tasks)
  • Some areas of Motor Development
  • Some areas of Cognitive Ability
  • Hearing and Visual Impairment

This relative social strength, in conjunction with a propensity to avoid difficult tasks can become a barrier to learning, negatively impact on the acquisition of critical skills and influence behaviour. A negative behaviour may develop into a ‘challenging behaviour’ if it is (unwittingly) reinforced. In order to prevent negative behaviours from escalating, it is important to remember that behaviours are often learned, influenced by context and outcome i.e. antecedents and consequences.

For example

When I bang my plate on the table, my Mum takes this as a signal that I would like some more food so I am rewarded with more food, therefore I will bang my plate again when I want more food on my plate in the future.

  • Context : I am still hungry
  • Behaviour : Banging plate
  • Outcome : I get more food.

To prevent minor behaviour issues escalating therefore, it is vital to reduce inappropriate behaviour by teaching skills to get needs met through employing more appropriate behaviour.

For example

if I am taught how to sign ‘more’ I can signal to my Mum what I want more appropriately.

  • Context : I am still hungry
  • Behaviour: Signing ‘more please’.
  • Outcome : I get more food.

To promote positive behaviour:

  • Identify how the behaviour is learnt.
  • Look at ways to change the environment to reduce behaviours that challenge.
  • Provide opportunities to reinforce desired behaviour.
  • Teach new skills.


Strategies for Supporting Positive Behaviour

Strategies to promote positive behaviour can be categorised as :

  • Preventative
  • Proactive
  • Reactive 

Preventative Strategies

Preventative strategies are implemented to prevent inappropriate behaviours from developing.

To provide positive attention (to reduce attention seeking behaviours) :

  • Ensure time for individual teacher attention is allocated.
  • Reinforce the desired behaviour immediately with a tangible reward. Please note that cumulative rewards may have little meaning to a pupil with short-term memory problems.

  • Ignore attention seeking behaviour as much as it is realistically possible and reasonable to do so and re-direct
  • Praise for success.
  • Build on the pupil’s strengths.
  • Ensure the pupil with DS can work with peers who act as good role

Remember: Where attention goes, behaviour grows!

To reduce avoidance behaviours:

  • Develop a range of strategies to distract and re-direct attention. Distract rather than confront.
  • Match the child’s ability to concentrate with the length of the task.
  • Opportunities to make their own choices will help to reduce behaviours that challenge. Check out our article on Choosing Boards for some ideas.
  • Identify a ‘calm’ area where the pupil can go when they are upset.
  • Teach skills to address weak areas.

To develop comprehension skills:

Pupils with DS tend to have a very good visual memory and as such are good visual learners so the use of visual resources is very important.

  • Clear rules and expectations – symbols, pictures, keywords – an example is illustrated below using Widgit software.
  • Good behaviour prompt photos (photos of the pupil sitting on the carpet, lining up, putting hands up… ).
  • Short clear verbal instructions.
  • Consistent approach employed across all staff


Other strategies to support understanding

  • Communication books.

This is an example of pages in a communication book produced by the ACE centre whereby the pupil can use the symbols on the right to explain why they are feeling upset.

Photographs can also be used in the book.

Please see the communication hierarchy document for further information on the progression from photographs to symbols.

  • Social story/Visual Guide

Social Stories were developed by Carol Gray, for pupils with Autistic Spectrum Disorders however they can be used with a wide range of individuals with learning difficulties.

A Social Story provides accurate social information in a reassuring way, which can be easily understood by the person it is written for. The aim is to improve their understanding of an event or expectation, therefore leading to a more effective response to it.

Social Stories can reduce anxiety because they provide information about what might happen or provide guidelines on how to behave.

  • Communication Passport

A sample of a communications passport

A sample of a communications passport (see

A communication passport provides information on how that young person communicates and other personal details that are important for staff to know to support expressive and receptive understanding.

An index page that could be found in a communications passport

  • Feelings cards

Cards which show a range of expressions are useful to support a young person’s ability to label an emotion. This may help to support the student to identify how they are feeling to prevent an escalation of behaviour.

A feeling card produced using Widgit Software

A feeling card produced using Widgit Software




Functional Behavioural Assessment

If a pupil is still displaying behaviour that continues to be challenging despite implementing proactive measures, it is really important to understand why a pupil may be behaving in this way and what the function of the behaviour is.

To be able to analyse this behaviour and to build a better understanding of why the behaviour may be occurring, there are a variety of tools that help:

Frequency Charts

When a behaviour occurs frequently it may be helpful to record incidents using a frequency chart. This will enable you to identify patterns e.g. time of day, subject area, seating plan.

ABC charts

Choose one behaviour to monitor.

Collect data in the following way for 2-4 weeks.

  • Setting’ – factors that may increase the likelihood of the behaviour occurring such as: sleep, hunger, illness, allergies, bowel discomfort etc.
  • Record what happened immediately before the incident in the ‘Antecedent’ column – do not make the mistake of trying to establish what the ‘trigger’ might be; if there is a trigger, this should become apparent in time.
  • Record the exact behaviour in the ‘Behaviour’ column. It is important that only the person/ people immediately observing the behavioural incident should complete the record.
  • Record what happened following the behaviour in the ‘Consequence’ column – what you did and what the student did.

When you have collected data meet with staff involved to analyse the ABC charts.

See the pupil’s behaviour as communication – what are they trying to tell you? – a pattern may emerge in either the ‘antecedent’ column (something causing the behaviour) or the ‘consequences’ column (pupil getting something as a result of the behaviour).

Once it has been established why a pupil may be behaving in this way, it is important to teach alternative behaviours to meet the same need appropriately.

The functions of behaviours can be summarised as falling into one or more of the following categories :

  • Sensory Stimulation
  • Attention or Interaction
  • Escape from Demands
  • Social
  • Reduce experiences of pain or relief from ‘internal’ discomfort.
  • Tangible reasons.


If after completing a number of ABC charts over a period of time, the function of the behaviour is still not evident, completing a Functional Behavioural Assessment (FBA) will help to gain further insight and inform an evidence based behavioural intervention.

An example of a FBA : La Vigna & Willis “Aide to Functional Analysis”.

Behaviour Support Plan

If a pupil needs additional support to manage their behaviour, a Behaviour Support Plan is written; the SENDsuccess teachers can support you with developing this if required. Please see the following proforma.


In Summary

Many of the behaviours that are encountered with pupils with DS are not unique to Down’s Syndrome and will mostly arise out of frustration due to a limited ability to communicate their needs and feelings clearly and wanting to exert some control over their lives.

Due to additional difficulties with short-term memory problems,  shorter concentration span, motor co-ordination and learning difficulties,  it can be much harder to accomplish what a student with Down’s Syndrome is expected to do and hence more vulnerable to developing behaviours that may be inappropriate.

Challenging behaviours are less likely to emerge if the pupil with Down’s Syndrome :

  • Feels secure in knowing that s/he can do what is being asked
  • Follows a differentiated curriculum which is well matched to their needs : the task is not too easy or too hard;
  • Knows that there is a reward for completing the task and it is clear what the reward is.
  • Their preferences, wants and needs are respected.

Toilet Training

We’re often asked when toilet training  should begin and how to go about it. As always, it’s going to depend on the individual child, but these are some indications that a child might be ready:

  • They draw an adults attention to the wet/soiled nappy.
  • They tug at their wet/soiled nappy in order to remove it.
  • They are remaining dry for a couple of hours or more.

When you feel the child is ready it is usefully to start with recording the child’s toileting patterns on a chart.

You should start introducing the toilet at nappy changing times; this will allow the child to become familiar with sitting on the toilet and the area.

You should have a clear routine, take the child to the toilet every half an hour giving praise for doing so even if they don’t “perform”.

When the child uses the toilet (even without them realising it) there needs to be an appropriate reward that is personal to each child.

From this it is hoped that the child makes the connection between using the toilet and being rewarded for it.

When the child is using the toilet more frequently, the toileting intervals can increase to hourly and more.

Be prepared to remove the nappy and have lots of spare clothes. The nappies sometimes don’t allow the child to feel when they are wet or prolong the process.

Helpful strategies

  • As a teacher or member of classroom staff,  don’t worry if the parents aren’t yet toilet-training  at home — if the child can master it at school it will become easier for the parents. ( The child may need to have a nappy to go home in for a while)
  • Use photos/symbols to act as a visual cue.
  • Have toilet symbol accessible for the child to use (on toilet door or on a key ring that the child has)
  • Set a timer or alarm to remind staff and children of the routine.

Be prepared for accidents and if things don’t work out have a break and try again at a later date.


Toileting chart – Word document


© Whitefield Academy Trust.