Building Visual Recognition

Over the years, I have begun to think about learners with CVI in terms of visual accessibility with two distinctly different sets of visual skills: Visual Attention and Visual Recognition. When we understand the child’s abilities in these two areas, we can understand how accessible their visual world is and how reliance on compensatory skills is so essential for educational programming.

Visual attention is the precursor to any visual recognition. It must be understood that a child simply can’t have visual recognition (understanding what they see) without visual attention (actually looking, shifting to visual elements and seeing details).  Both visually attending and sustaining that attention are essential first steps before any visual recognition can develop. Check out Jeremy Wolfe’s work on visual attention in his Visual Attention Harvard lab. https://eye.hms.harvard.edu/jeremywolfe

When thinking about visual attention in assessment, I am looking at overall visual attention.

  • How often does the child look?
  • What kinds of things do children look at?
  • What is the length of time that children can hold that attention on the object?
  • It that length of time enough for children to see the details and feature of that item beyond just attending to movement, light or color properties?
  • When they look, do their eyes shift to the elements of objects or pictures?
  • What is the child’s visual curiosity for the world around them?

When thinking about visual recognition in assessment, that understanding of the visual attention skills is vital. Visual recognition requires:

  • Frequent and repeated looking
  • Sustained looking
  • Looking with the ability to shift central gaze to all parts of the items
  • Recognition of objects outside context. (Is the spoon recognized as a spoon without the child being told it is time for lunch, without being in the feeding area, without food smells, the bib cueing). 

When children are extremely impacted by CVI, there is simply no recognition because the ability to attend is so very fragile. There is no real visual recognition but isolated attention to certain types of color, motion and light. They may look as if they have “favorites” but really any object of that color, with motion and with light gets the same response. There is no recognition of the object itself.

If you don’t look at items, or when you so look, you don’t look long enough to understand, you don’t shift to the visual elements, the chance of building that visual library is at great risk. It is this visual attention that becomes our focus for creating accessibility.

“Wagon Wheel” Search

I just love this strategy proposed on CVI Scotland!. We know many children with cortical/cerebral visual impairment (CVI) have visual field differences that we must consider in educational programming. Teaching this methodical search strategy will help create greater access to the whole visual scene whether the child has upper, lower, left or right visual field differences. I have used it with great success!

https://cviscotland.org/news/wagon-wheel-approach-11-06-2020

The Importance of Predictability: Seeing What You Expect to See

With no well established visual attention, there will be limited visual recognition if any. The “visual library” is sparse due to the inability to look and shift attention to the parts of the item for the details of that item. For children with CVI who have limited visual attention, there may be visual attention to color, light or motion, but we can not assume this is visual recognition.

To assess visual recognition for these children who briefly attend to “favorite toys” that are bright colors, lighted or moving, we must be very clearly diagnostic about what we are observing. Is it only visual attention to color, light or motion or some level of recognition?

Example:

If you think the child attend to and recognizes the red stuffed dog, present that and record the reaction. Do they smile or reach excited towards it? Now present another red toy of a similar size. If the reaction is the same, it is likely that child is heavily coding his or her world by using color not recognizing that item by shape or detail. The object itself has no meaning. It is a just a red “thing”.

Our goal for students with such limited visual attention is to create environments that support visual attention by controlling distracting light, noise, clutter and motion. We foster that visual attention and strive to create object meaning, object recognition.

To create meaning and to foster visual recognition, we want to create a predictable world where the same objects are used in a meaningful routine. In this meaningful routine, the repetitive use of the same objects in combination with the smells, tastes, tactile input and sounds clue the child’s understanding and therefore provide access to the visual information connected to meaning. It is this predictability in meaningful contexts that allow our children with CVI to begin the visual recognition journey and to begin to build that visual library.

It is no surprise that when we provide the adaptations to the environment to foster visual attention, most children begin to recognize predictable items in the meaningful routines of mealtime. Mealtimes happen predictably three or more times per day. Parents report cups, bottles and spoons as the first kinds of recognized items. If you use the same mealtime objects with a child in a predictable and repeated routine such as mealtime, the child hears language about eating (auditory), smells the cooking or preparation of food in the context of the kitchen (context and smell), sits down in the highchair or dining chair (tactile and proprioception), and feels the bib being placed on (tactile). Those visual materials in context and with the other sensory information give visual meaning. It is no wonder these items are the starting points for visual recognition skills.

What Is It About Busy Places?

Many parents identify busy places as being difficult for their children. What is it about these environments that is so hard? This is where CVI careful assessment comes in so we can understand what exactly is problematic for that child’s visual brain.

Don’t be fooled that this difficulty is based on only one thing.

What are the some of the features of busy places?

  • There is increased noise
  • There is increased motion
  • There is increased unexpected visual input
  • There is an increase in the number of unrecognized items
  • There is an increases in the number of new faces

If these are some of the features of busy places, we need to understand each individual child’s reasons for having difficulty tolerating these environments.

How do we know which of these is problematic?

Here is some follow up parent questions I might ask to digging deeper for answers:

What happens at the family’s place of worship?

What might this tell me?

There is limited noise and controlled motion in places of worship. This environment might be familiar since the family might attend regularly. If the child tolerates this busy setting that is hushed, perhaps it is the issue of unexpected sounds that is more impactful to the child. Since the motion in places of worship is more linear and more controlled, perhaps it is the motion of other busy places that is impacting that child.

What happens in busy places with regular motion?

What might this tell me?

If the parents report that is more tolerance of places with more predictable motion (think roller skating rinks, hallways, airports walkways), perhaps the issue is that they tolerate places with predictable motion but not random motion.

What happens in new busy places?

What this might tell me?

If the parent reports that the child tolerates busy place that are familiar, perhaps the issue is the newness of the place rather than either motion or noise? In these new places, the child might also be fearful of unexpected changes in depth or disturbed by the unrecognized environmental aspects.

What happens if the busy place is full of familiar people or the identification of people is supported?

What this might tell me?

If the parent reports that their child can tolerate busy places with known people, the issue for the child could be more about lack of information access about the people around them. It might not be difficulties with motion and noise.

The identification of the child’s difficulty in busy places should not be assumed to be one thing. Careful parent interviewing can reveal the real reason for the child’s visual difficulties. It allow us to put the best supports in place for educational programming that directly addresses that child’s unique issues.

Yet another reason not to hand the parent an interview form to fill out. You would miss so much!

Beyond the CVI Meltdown

There is great attention to the topic of CVI Meltdowns first introduced on CVI Scotland. Check out this wonderful link on the topic https://cviscotland.org/documents.php?did=1&sid=55

The CVI Meltdown is the reaction that some children with CVI have to the overwhelming visual or auditory situation and/or to the unfamiliar.

The CVI Meltdown needs to be seen not as a behavior but as an effort to try to communicate their anguish to adults. The behavior communicates “This is too much”, “I can’t do this anymore” or “I have had enough”. They are communicating their fear of not understanding where they are, not understanding who is with them and not understanding what is expected of them. This complex visual/auditory world is just plain beyond their capabilities and they want us to know.

Some children have learned that meltdown behaviors are not tolerated or that adults don’t react well to them. These clever children use other ways to escape.

Here are some examples:

Avoiders:

  • Kevin and Henry close their eyes and appear to be sleeping. That solves the problem of visual complexity for them quite well. Adults think they are tired and let them rest.
  • Susan focuses on her drawing or on her iPad and needs reminders to “pay attention”. Focusing on the familiar object and activity in her hands is accessible since the classroom learning is not. Adults want her to “pay attention”.
  • Owen wants to go to the bathroom all the time. He is seeking that quieter, non-complex place to get away from overwhelming visual and auditory situations. He has learned that few adults will deny a child’s request for the bathroom. Adults take him to the doctor to see what is wrong with his urinary system. That checked, they see this as a behavior.
  • Bella asks for a snack often. Snack is a familiar activity with more recognized materials. She has learned that few adults will deny her snack. If she keeps asking, the verbal engagement often gives her descriptions of what is going on around her.
  • Jenny keeps her head down all the time. She has found this to be a way to avoid the complexity of the room. Adults are always telling her to “look up” but she always goes back to this head position in loud, busy and place with lots of movement.
  • Barry wants to stand near corners or in the back of the room when things get overwhelming. He finds that he can avoid peripheral movement in these places and it is often quieter there. Adults think he should “join the group” more.
  • Julie asks to go to the nurse multiple times a day. The nurse’s office is so quiet and calm. Adults first take her to the doctor and then see this as a behavior.

Distractors:

  • Billy becomes the class clown. When someone enters the room, he can’t recognize their face. He greets new arrivals with “Here comes trouble” at which point, the person speaks to tell him to stop with the silly comments. Billy can’t stop because this is the only strategy that works for his lack of facial recognition. Adults see this as a behavior.
  • Chad is a charmer. He wants to sing you a song or tell you a joke. He changes the interaction to an auditory event when the visual is too much or he is fatigued. Adults love a good joke and a good song.
  • Perry talks too much. He asks lots of questions and is engaging adults in verbal interactions. He developed this nice strategy to get auditory information that he can’t get visually. Adults see this as a behavior.
  • Gary’s mom describes him as “dramatic” in new situations. That drama is verbal and by engaging verbally, he can figure out what is going on. Adults deal with the drama that they see as a behavior.

What if people understood CVI? I believe if teams understood CVI, they would understand these behaviors as communication. They would know why these children were distracting and avoiding. I would love for staff and parents to listen with “CVI ears” to what their child is so clearly communicating.

 

Perkins Launches CVI NOW!

In November 2018 and July 2019, Perkins School for the Blind convened a Cortical/Cerebral (CVI) COLAB and CVI Symposium, to tackle the “wicked” problem of CVI. A COLAB as defined as “a gathering of stakeholders who together share, learn, and create a deep understanding of a complex problem” (Demosophia LLC). International and national stakeholders included parents, vision professionals, vision researchers, ophthalmologists, neuro-ophthalmologist, optometrists, university personnel, agency personnel and CVI advocates came together to discuss the triggering question. “What do you believe are the challenges that impede progress regarding CVI?”.

From these CVI meetings, Perkins developed a more expanded and more inclusive understanding of CVI and became committed to sharing that knowledge with the wider community. Perkins is committed to sharing what we know today and to keep an eye on the latest research and promising practices for serving learners and families impacted by CVI.

In that effort, Perkins today launched the CVI NOW website and, for parents, the CVI Now Facebook page. Check it out and if you are a parent, join the Facebook page that’s just for families.

Go visit www.perkins.org/cvi-now and take a look!

Dr. Lotfi Merabet: Conversations about CVI with Dr. John Ravenscroft

Check out this conversation between Dr. Lotfi Merabet and Dr. John Ravenscroft, two leaders in the field of CVI. The CVI field needs research now more than ever as the educational programming and assessment claims continue to rise with limited understanding of how the brain even works.

There is not one size fits all for our students for assessment protocols, environmental needs or learning access needs because each child’s brain is different, each brain injury is different, each brain has different experiences and each brain rewires uniquely. CVI is as complex as the brain and to simplify CVI means children are left out, not fully assessed and not fully served.

Check out Dr. Ravenscroft’s other conversations with other theorists and practitioners. There is a wealth of knowledge!

National Institutes of Health: CVI

This just published by the National Institutes of Health. There is growing awareness about CVI in the medical community and in organizations that provide funding sources. This appears on their website.

Great things happening for the kids I love! 

https://www.nei.nih.gov/about/news-and-events/news/vision-loss-children-whose-eyesight-may-be-2020-requires-new-diagnostic-and-teaching-strategies

Learning From Home

Listen to the American Council for the Blind’s Podcast: Learning From Home. This addresses the essential partnerships that school based team members must have with home based team members in the education of children with CVI during this pandemic. It stresses the importance of natural routines, consistency, collaboration and extended learning with direct teaching and supplemental activities.