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.

 

Valuable CVI Awareness of “Mistakes”

Awareness of the unique visual behaviors of CVI can provide teachers, parents and other service providers with context and understanding when learners with CVI make “mistakes”. I put “mistakes” in quotes because the “mistakes” that learners make will always allow us to understand their visual perception of their world if we consider them in the context of CVI. Matt Tietjen’s What’s the Complexity Perkins Elearning online class helped me to think more deeply about these visual “mistakes”.

Images in literacy materials in the community and at school are supposed to add information that supports the text or the situation.

This map symbol confused rather than supported my student’s understanding.

Seeing this icon on a subway wall, my student asked why there was a picture of a purse on the wall. This allowed me to understand the inaccessibility of this highly symbolic image of this map icon. It helped me understand how the student completely missed details in this image. It helped me understand how my student only really understood the shape of this square image and because he visually understands that purses are square shapes, he mistook this for a purse. “Why was a purse on this wall?”  “Am I missing something?” he wondered aloud.

Seeing this icon in a library book, another student identified it as a “flower”

Once again, the highly symbolic image was not understood. The student only perceived the shape not the meaning that the icon was supposed to provide. The “mistake” was made due to the impact of CVI on the student’s functional vision. The “mistake” helped remind me of the inaccessibility of highly symbolic images and helped me to remind me to always ask Matt’s question “What do you see?”

These two students can verbally communicate through their “mistakes” to help me understand how they see the world.

For our students with non-traditional language, we need to also diagnostically consider their “mistakes”.

In an assessment, it was clear that another student who is using a communication device understood the green “yes” symbol and the red “no” symbol when answering questions regardless of where the symbols appeared on the device page of 6 symbols.

I swapped out the red and green symbols for completely different symbols that were also colored green and red. The student continued to answer questions “yes” and “no” by hitting the “wrong” symbols based on color seemly with no awareness of the icon’s details and icon’s shape information.

 

  

 

 

 

 

It was so important for me and for her speech therapist to understand the reliance on color when using the device so color is considered when adding any newer icons.

“Mistakes” are a window into how student understand their world and how they function in their world. Without understanding CVI, these mistakes could be thought of as cognitive lack of understanding rather than the reality of visual inaccessibility.

Are You Making Your Assessment and Service to Learners with CVI Fun?

First and foremost, our children with CVI are children. Children love predictable games, funny noises, and social interactions. Children like to play the same games over and over again. We can get our goals and objectives accomplished with learners if we understand what makes learners happy and what it is that they deeply enjoy. The parent is the most essential reporter of their child’s preferences. We need to move away from what we think children will like to what the parent knows the child will like. That is the basis for faster, fuller and longer lasting learning.

Some ideas, based on assessment of the child’s visual skills:

Instead of holding materials to gain a child’s visual attention and once they look you move on to another object, create a game that sparks a social, auditory and tactile sequence.

• “Find the pom pom. It is silver with many shiny streamers”. Once the child looks, wiggle and tickle their arm while making a funny noise.
• The parent reports that the child likes his/her feet tickled. Present an object that can represent that tickling game. “Here is the symbol for tickling. It is yellow and round like a ball”. Once the child looks, tickle their toes using a funny voice!
• For literacy, pick a predictable book with a distinctive colored cover. Make sure is enjoyed by the child. Once the child looks, “That is the Farm Animal book with funny sounds. The book is square with a green cover”.

Why? All kids are kids no matter their abilities.

• Creating fun, predictable interactions with children is the basis of a strong trusting relationship which allows the child to show you optimal skills in all areas. (Another plug for direct service to students with CVI)
• When interactions and learning are based on what the child likes, the memory of that interaction is solidly stored in the brain.
• Fun interactions guarantee that the child will be motivated to communicate at the highest possible level. (Expanded Core Curriculum area)
• Creating visual recognition using these “symbols” for games allows you to build a repertoire of symbols that will be the basis for choice making based on building visual recognition.
• When you see the way children communicate (large body movements, smiling, raising their arms or vocalizing), you can acknowledge that communication and help the child understand your needs for understanding their communication. “I see a big smile (touch the side of their mouth in an upward motion). When I see that smile I know you want more”. “I see a large body movement. That tells me you like this game”.
• You can build literacy choices and experiences supported by storyboxes, yet another set of visual opportunities. http://www.pathstoliteracy.org/storybox-ideas-norma-drissel
• You will have fun too!

The What’s the Complexity Framework: Designing a Visually Accessible School Day for the Child with CVI

This is an online CVI related class through Perkins elearning conducted by Matt Tietjen.

October 23^rd to December 10^th, 2017

It provides educators with 35 ACVREPs, 35 PDPs, 35 CEs, or 3 Graduate Credits

Matt is a passionate and gifted practitioner serving students with CVI in all Phases (Roman-Lantzy). He recently developed this framework to help teachers, TVIs, therapists and parents assess the complexity of visual presentations, learning activities and learning environments for students with CVI. I signed up to learn more about this important new tool for my work with students.

Here it the description:

“We will study the characteristic “Difficulty with Visual Complexity” in-depth, explore its central relationship to the other characteristics, and examine the ways in which it can impact behavior and access to education for a child with CVI. Our study of visual complexity will integrate the literature on cortical and cerebral visual impairment.

Participants will learn how to use The What’s the Complexity Framework in order to evaluate the complexity of school environments, tasks and materials and to guide educational teams in creating more visually accessible, appropriate learning activities for children with CVI.

In addition to learning how to rate the complexity level of a particular environment or education task, we will also emphasize the importance of balancing the complexity of the environment and task in each activity, managing cumulative complexity and visual fatigue throughout the school day, assessing interpretation of two-dimensional images, and providing direct instruction in salient features.”

http://www.perkinselearning.org/earn-credits/online-class/cvi-complexity

Two Interconnected Expanded Core Curriculum Areas for Children with CVI

As a Teacher of Student with Visual Impairments, I am certainly focused on the improvement of visual skills for my students with CVI. I am also interested in how my students understand everything that is easily understood by their sighted peers due to their incidental learning. These intertwined Expanded Core Curriculum (ECC) areas must be considered for that equal access.

These two important areas of the Expanded Core Curriculum must be considered separately and together. These are:

1. Sensory efficiency skills
2. Compensatory Skills, Functional Academic Skills (Including Communication Modes)

Sensory Efficiency Skills: This area is especially important for the child with CVI but in a totally different way than that considered for a child with ocular impairments. We are expecting improvement for student with CVI. Functional visual assessment provides the baseline for functional visual skills and sets the stage for this improvement using strategies and objectives matched to the assessed needs.

Compensatory Skills, Functional Academic Skills: This area must be considered to support the building functional vision of the student with CVI. Vision is the distance sense that supports what is heard, smelled, felt and tasted.

Think about a classroom where someone drops something. The child with typical visual abilities can turn, look and determine what made the sound and determine that the sound is not a threat. The student with CVI hears the item drop and due to lack of visual location abilities or lack of distance abilities, does not turn, does not understand what made the sound and might remain in a state of stress wondering if this sound is a threat or not. We need to build this understanding of environmental sounds by labeling the sound, bringing the child closer to the sound, bringing the sound to them and allowing them to make the sound themselves for complete understanding. If someone drops a tray in the classroom, I make sure to bring a tray to the child and allow them to see it, feel it and push it off the tray to create the sound. Once understood, the sound will not create stress and allow the child to return to the learning. This approach provides the student with the same access to the visual, auditory, tactile, cognitive/language information enjoyed by their sighted peers.

For functional academics, focus needs to consistently be on ways to create and foster the highest level of independence possible to live and work in the future. These are skills that should be worked on from birth! Think of the value of organizational skills for a child with limited visual abilities. Getting objects from a storage place and returning the item to that store place when completed builds independence and understanding of the student’s environment.

For communication the CVI assessment can help us determine whether we provide tactile sign language to the student with deafblindness or just visually presented sign. If the child is only using peripheral vision, they could never see and understand the small, distinct visual-only sign that requires central vision use. If a communication device is used, the CVI assessment provides information about the accessibility of pictures, the ability to recognize pictures, the number of items that can be seen and recognized at one time (complexity of array), and what size is needed (due to complexity not acuity!). For literacy and communication, the CVI assessment provides information about the unique need for color highlighting, spacing and print size (due to complexity not acuity!)

All students with visual impairments need the ECC considered and provided in their educational programming. Students with CVI have the same educational needs but with consideration that CVI is completely different from ocular impairments.

What Do iPads Do to Support Students

As discussed many, many times, the strategies for CVI must match the assessment results. We never can just randomly apply a strategy because it will not fit the functional visual needs of the child. If it does not fit the functional visual needs, it will not provide visual access and will not foster improvement of cognitive and visual skills.

With that reminder, I was asked about ideas for iPad apps for children who struggle with visual recognition. Just providing a student with an iPad does not guarantee access. We need to assess the child, think about their visual needs and carefully use the iPad as a tool to provide that access.

What can be some general needs for students who struggle with visual recognition?

Impact of Color: The student might benefit from color highlighting to draw visual attention to specific areas on 3D and 2D materials. That color supports visual attention to the specific place.

Light: Backlighting can helps foster access to materials especially in 2D (pictures and text). Some children do not benefit from backlighting and this should be part of the assessment.

Visual Processing Time: There is still a need for increased time for full visual exploration and full visual understanding.

Visual Field: Lower visual fields might be affected in some children. Other children struggle with visual attention in all fields or “hyper attention” if the scene is too complex. (attends to just one part not taking in the whole scene).

Visual Recognition: Presenting new materials in new kinds of presentations might require the verbal narration of visual attributes.

Clutter: Clutter can affects visual understanding of objects, increased display clutter, of faces, and of the sensory environment.

Distance: Near information is more accessible. Distance curiosity is not typical so distance information is missed.

How do we want the iPad to support the student? 

Impact of Color:

• Tools for color highlighting help support salient feature discussion in pictures and text.

Light:

• Backlighting helps with understanding and easy of access to prevent fatigue.
• Moving to 2D: taking pictures of their items in the environment and then providing the 2D on the backlighted iPad.

Visual Processing Time:

• Provides ability to capture images and videos for longer visual access time.
• Capturing images can be reviewed as long as needed.

Visual Field:

• iPad placement is flexible matched to child’s best visual field.

Visual Recognition:

• Expanded understanding: Example: Here is one kind of mouse in the book but these are all the other kinds of mice.

Visual Clutter and Access:

• Enlargement: for things at distance, for small items in complexity and for literacy
• Overall ability to use settings and apps to reduce complexity of images.
• Studying facial expression in photographs and videos: salient language of faces matched to voice (auditory). There can be instruction about facial expressions that match the auditory information.
• Visual attributes of items in photographs and as part of texts.
• Increasing spacing of words and sentences to reduce clutter.
• Masking: clutter reduction with tools in Photos.

Distance:

• Videos on the iPad: to bring information about events and concepts that occur at distance: Example: We are reading about giraffes. I think about providing a child with access to where that animal might live and how they move.
• Access to distance classroom events: Examples: learning song hand movements for circle time.
• Community access: taking photographs of signs and environmental materials that can be explored on the backlighted, near placed iPad.

What’s the Complexity? Workshop

This month I attended a full day workshop titled: “What’s the Complexity?” with creator, Matt Tietjen, M.Ed. CTVI. This assessment tool was developed to look at the visual behavior of complexity as it is intertwined with other visual behaviors of CVI.

The “What’s the Complexity?” framework takes a close look at the visual behavior of Complexity,  that is most difficult to control and the visual behavior that seems to effect children’s visual functioning to the greatest degree. It provides a way for parents and educational teams to assess complexity in all forms. It helps parents and teams choose appropriate materials, design appropriate environments matched to appropriate tasks and then to plan across the complete learning day for the student with CVI.

The “What’s the Complexity?” framework also provides us with a well thought out system to assess the student’s interpretation of images. We evaluate the child’s understanding of photographs of their real items (my spoon), colored photographs of other classes of items (the class of spoons), understanding of realistic or abstract cartoon icons of items (spoons in cartoon form), colored icons (Mayer Johnson spoon) and black and white line drawings (black and white drawing of a spoon).

This is an important new tool for us as we serve our children with CVI. It will help support our recommendations for children’s accessible media. Fantastic!

I understand that a graduate class will be offered regularly at Perkins elearning to deepen the understanding for using the “What’s the Complexity?” framework. I will certainly be signing up for this!

 

Non-Complex Concept/Choice Board

To reduce complexity on a concept/choice board, I used corrugated black plastic to create the board.  I used black Velcro so the Velcro would not become another item in the array. (It disappears against the black plastic).

I wanted to be able to notice any visual behaviors so created a window. I was concerned that my eyes and face would become another item in the array. Using black screen like the kind used in window screens, I covered the peek hole. Now this board can be held up at the child’s best distance and at her eye level. I can watch exactly where she is looking and at what she is looking no matter how quickly she looks. I can reach around the board and create movement to draw her visual attention to the described item.

This is really helping the team understand whether this child understands the visual information, the concept being discussed and or the choices being made. I can present 1, 2, 3 or 4 icons on this board depending on the child’s assessed presentation needs.

Lack of Visual Access Masks Language/Cognitive Abilities

Young Jack, who has CVI, is in school where the team was using pictures in his communication system. Jack seemed to show no understanding that the picture of the “spoon” represented “snack”. When he wants snack he whines or cries until someone familiar with his limited communication gets him a snack.  It is so hard for Jack to show adults what he knows or understands. His abilities to communicate using symbolic representations seems severely limited.

The new TVI assessed Jack around the well known visual behaviors of CVI.  She determined that 2D pictures were visually inaccessible for this child. She advocated for the change from 2D photographs to 3D symbols for his communication.

With this new 3D symbol system, “snack” is represented as a spoon mounted on a black 5’X7” card.

  

Jack began to show adults that he indeed understood the new 3D symbol system.

• Jack smiles when seeing the 3D symbol for “snack”.
• Jack consistently chooses the “snack” symbol when given a choice of “snack” or a foil. (A foil is a meaningless object or a non-preferred object)

For more about “foils” see    http://www.swaaac.com/files/assessandimp/aacbasicsandimplementationbook.pdf under “Implementation” section.

• Jack pulls people towards the snack table when presented with the 3D “snack” symbol.

Jack also began showing similar understanding of other 3D symbols in his new communication system.

When using photographs, Jack’s abilities to communicate using 2D symbolic representations seemed severely limited until the assessment determined that these 2D photographs were beyond his visual abilities. Creating symbols in 3D that are accessible allows Jack to truly communicate his wants and needs. This ability shows the team what Jack is capable of.

The collaboration between a TVI who understands CVI and the team puts Jack on the road to building communication. Jack looks more capable as he is now able to show what he understands. The team has higher expectations for his learning. The building successes using the 3D symbol system can later be thoughtfully transitioned to photographic symbols in planned way based on his visual understanding.

 

 

Fall CVI School Checklist

Fall is here and schools are opening their doors to students.  The fall is an exciting, fresh beginning that I look forward to each year! It is an especially busy for TVIs as we assess children, educate staff, adapt materials and environments and support parents, students and teams.

Here is a fall checklist for CVI for Teachers of Students with Visual Impairments:

1. Complete CVI Assessment

All TVIs should become competent in the assessment of all the visual behaviors of CVI. There are just too many people not using brain based criteria for their assessment of children with CVI. If the brain based areas are not assessed correctly, the results will not provide the child with the correct goals and objectives or the correct adaptations, accommodations and methodologies needed for their optimal visual functioning. This misalignment will limit the child’s visual improvements.

2. Share CVI assessment results with parents. Parents will benefit from a discussion about the overall concepts of CVI so they fully understand their child’s visual skills and needs after the assessment. With this fuller understanding about CVI, they can more effectively understand their child’s visual skills. With this background knowledge, the accommodations, modifications and environmental supports make sense. Parents need this background information to advocate for their child across a lifetime, every year as staff and schools change.
3. Conduct and inservice to the educational team about the overall topic of CVI. With a firm understanding of the CVI concepts, teams can better understand their students visual functioning and their unique educational needs. The accommodations, modifications and environmental supports have more context and will be more consistently used if fully understood.
4. Conduct a second inservice to the team about how CVI effects each individual student. Each child with CVI will have unique educational needs based on their own individual assessment results.
5. When classroom schedules are completed, look across the learning day to ensure the CVI adaptations are in place at all times.

(Example: In morning meeting the child is at the correct distance from the learning materials , has visual access to the better visual field, has an identified “wait time” for visually processing, has materials in the most accessible bright color and that color is considered to be a way the child discriminated and recognizes, has the light controlled and used optimally, has the motion distractions removed or movement used to draw visual attention, and has the complexity of the environment matched to the assessed needs.

6. Create a “cheat sheet” to hang in learning areas so staff can quickly refer to the recommendations for best visual field, best distance, best best color, and other CVI recommendations around assessed needs.
7. Check that the classroom has areas for learning that are adapted to assessed CVI needs. If the child requires a non-complex, quiet separate learning area to preview materials or to learn skills this needs to be an identified and provided area for learning.