When we assess vision of a child who has communication problems, the exact nature of which is difficult to pinpoint, we have to allow time and use numerous play situations to reveal

• how much of the difficulties in seeing are related to perception of forms of objects and pictures,
• how much visual memory plays a role,
• how much is related to development of the concept of pictures representing objects
• how much may be related to dysphasia, hearing problems or difficulties in visual communication.

1. Draw around the puzzle pieces and other well-known objects with black and bright colour felt-tip pens when the child is watching and listening to the adult explaining, “we are drawing a picture”. Then the adult and the child admire the picture and compare it with the object. The child colours, or scribbles, the picture, after which the picture is studied again.
   
   
2. Another picture of the same object is drawn when the object is in different orientation. Again the child colours the picture and then the two pictures and the object are compared to help the child to understand that pictures of objects may look different and yet depict the same object.
   
   
3. The pictures are held in the child’s play area on the wall and visited often. If the child learns to remember that the object is related to the pictures and goes to look for the object when asked to do so or goes to the pictures when the object is shown, we can assume that the concept of pictures representing objects is emerging.
   
   When a picture like the previous pictures is later drawn without the object being present the child may not understand what (s)he should do when asked to bring the object. If this happens, then the picture of the object is related only to the earlier picture of the object. Another possibility is that the child does not see the pictures clearly enough to perceive the common features. Compare the new picture with the object and with the old pictures and test after a few days, how well the child understands that all three pictures represent the object.
   
   
4. Pictures of a few objects are drawn daily with some small variations. The child is then helped to find pictures of each object. Is one of the objects easier to recognize in the pictures? What is the role of different colours? Is the size difference a factor?
   
   
5. If a picture has been drawn without the child watching, does the child experience it representing anything? During drawing there is more information than when looking at a finished picture because of movement of the pen and the explanation that is given when drawing the picture. Some visually impaired children are more dependent on motion perception than normally sighted children and may therefore have great difficulties in perceiving images that stand still.
   
   
6. A further feature to be studied is the effect of contrast on the perception of pictures. If dark contour lines are changed to lower contrast grey lines, are the images more difficult to perceive?

What are we assessing in these play situations?

1. Is there difference in vision for black-and-white and colour information? If colours seem to give more information, should all pictures, later letters and numbers be taught in colour?
   
   
2. If the child can match pictures, what happens when pictures are drawn smaller and smaller? What is the role of visual acuity?
   
   
3. Does the child use objects adequately in communication? If not, then the use of pictures in communication may not yet be possible.
   
   
4. Does the child use gestures in communication, visual or tactile? When using visual signs, the signer needs to know whether the child perceives visual information in motion.
   
   
5. How does (s)he respond to a rolling ball when it does not cause any sound. Does (s)he follow the movements with the gaze. Does he copy simple signs. Movements of lips during speech are small and fast. Therefore observe the child’s eye movements when the child watches fast moving balls, bouncing balls or table tennis.
   
   Since these training sessions and observations take weeks or months, they are arranged to become a part of the child’s normal play situations. The interpretation of the child’s responses may be difficult. Therefore video recording the child’s behaviours is usually helpful because the responses can be evaluated as many times as felt necessary by the vision rehabilitation team together with the child's therapist and/or teacher.