embedded strategies for CVI

Take a Seat!

Watch your children with CVI move to get into a chair. So often I see this done tactilely. They turn and backup slowly until they feel the chair seat against the back of their legs. I believe this is due to the difficulties judging distance, the visual complexity of this task and visual motor difficulties.

I have had great luck working with the PT and OT to help children understand where the chair is in space and how to move their body into the seated position.

Here is one example. Just by placing red tape on one arm of the modified toilet we could teach the child to find the highlighted armrest of the chair, cross midline, hold the red highlighted area to stabilize their body and to turn to sit. As they improved their skills, we were able to reduce the size of the color highlighting and finally remove it. This provided safe and more independent toileting.

 

 

Reading for a Child with CVI

Please watch these important webinars about teaching reading to children with CVI. Pay especially close attention to the fact that the methods are not uniform. They are in consideration of the visual behaviors of CVI of individual children. No reading approach is for every child. That “visual brain” and that “reading brain” are different in every single child.

The first webinar is by a parent of a child with hemianopsia, Monika Jones of the Brain Recovery Project. Although the webinar is not about reading specifically, there are some important considerations for reading presented. Those reading considerations match the visual abilities of the children with CVI impacted by this brain based visual impairment.

https://www.perkinselearning.org/earn-credits/self-paced/vision-after-occipital-lobectomy-and-related-surgeries

The next two webinars are by Judy Endicott. Judy is the grandmother of a child with CVI. Using her expertise in reading and her building understanding of CVI, Judy embarked on a journey to teach her grandson to read. What I love is that Judy was wonderfully diagnostic of her grandson’s abilities and needs.  Her approach to teaching reading followed her grandson’s lead.  She developed each step in the reading journey based on his successes and difficulties. If something didn’t work, she moved on to try something else in partnership with her grandson. Like any great teacher, she has understanding of the different developmental levels of learning, how the child with a neuro-typical brain learns, and that all learners have individual abilities that require instruction matched to those abilities and needs.

Part 1:

https://www.perkinselearning.org/videos/webinar/our-cvi-literacy-journey-phase-iii

Part 2:

https://www.perkinselearning.org/videos/webinar/our-cvi-literacy-journey-phase-iii-part-2

Troubling Misuse of Promising Practice

When a new approach to teaching learners with CVI is suggested, we need to ask ourselves:

  • Does this match our understanding of the unique learner’s visual behaviors?
  • Is there scientific research to support the use of this strategy?
  • If there is no scientific research, is it a “promising practice” that we can carefully try and carefully apply to each unique student’s situation?
  • How do we decide to use this “promising practice”?
  • How do we use it as it was meant to be used?
  • How do we evaluate its effectiveness since not all inventions will be useful for all learners? (I hope the words collect data popped into your mind here!)

Recently I visited a school to consult for a student who was barely using any central vision to access literacy. The TVI had learned about word bubbling in a conference. Word bubbling is a promising practice suggested by Christine Roman in her book Cortical Visual Impairment: Advanced Principles.

This TVI took the app for word bubbling and suggested that all the child’s literacy materials were bubbled.

  • This does not match the student’s visual skills. Central vision use would be essential for this intervention.
  • This is not the suggested practice from the text: Cortical Visual Impairment: Advanced Principles.
  • This was randomly applied with no diagnostic evaluation of the tool as applied to the student.
  • The TVI never partnered with the reading specialist who would be the expert about the teaching of reading. That collaboration would be essential.
  • There was no data on the effectiveness of this strategy for this unique learner.

Here is just one example of a sentence this poor student is now struggling visually recognize:

 

Please:

  • Understand your student’s visual behaviors.
  • Try promising practices with careful consideration of those visual behaviors.
  • Use the strategy as it was meant to be used.
  • Collect data on the effectiveness of your trial. (Baseline data then progress data)
  • Random application of any strategy is as inaccessible as doing nothing..

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!

Phase III: Child with Visual Recognition Difficulties

My friend is a parent of a child with CVI with visual recognition problems. On the CVI Range, he scores in Phase III (Roman-Lantzy). She constantly describes the impact of CVI on her son that she witnesses every single day. These children with visual recognition problems due to CVI have really, really good central vision use that is consistently used. Because they are looking, people think they have visual access just like we do.

This is her story about a family trip to Montreal. Of course, Omer really doesn’t care for these adventures into noisy, busy and new environments where objects and people are not known and therefore not understood. CVI is an issue of visual recognition after all. He wants to stay in the hotel room that is quiet with few people moving around. He understands and can visually predict the bed, bureau, TV and chairs. He knows the people in the room are his family so that reduces the stress. Because the family understands this difficulty, they picked a quiet restaurant for lunch.

On the table at the quiet restaurant, Omer he saw a glass of room temperature water with bubbles.

 

Omer never saw the bubbles in a glass of water before. A few weeks prior, he had seen and experimented with putting salt into water and drawing on that experience, thought the bubbles were salt. Pretty smart but wrong…

For kids with CVI and visual recognition problems, it takes so long for them to visually process newly seen events and materials. Omer was working so hard to close the gap of information that he missing. He is desperately trying to link previous information to this novel visual target.

Omer never saw the bubbles in a glass of water before. It was his first time seeing it and he was fascinated! He asked his mother to take a picture of it so he could zoom in for a good look and verbal explanation.

I am so proud of Omer’s advocacy! What I do worry about is what is number of times in his day that he encounters items, people and events he doesn’t understand and the we, with perfect vision, forget to make accessible?

The Neuroscience of Reading

As people suggest methods for our children with CVI to learn to read, I wondered what does the brain need to do in order to learn to read?  I found a local researcher, Maryanne Wolf of Tufts University who wrote extensively about the neuroscience of reading in her book Proust and the Squid.

As it turns out, the brain needs to do quite a lot. It certainly requires a high degree of sustained visual attention, which can be problematic for many of our children with CVI.

Reading requires the whole brain including the occipital lobes, parietal, frontal and temporal lobes. The brain needs activation in both hemispheres and needs the “language areas” of the brain to be engaged and active. There are steps to reading function from decoding to understanding what is read. This reading “thing” is quite complex which is no surprise given how complex the brain is!

When we apply reading methods for our students with CVI, we need to apply methods to the child not decide that all methods work for everyone. We need to be diagnostic. What is working? Why is it working and under what conditions? Is it working at all? What can we do to improve this complex process that includes learning to use vision and to build reading skills?

No one of us serving students with CVI can know everything. We can certainly educate ourselves but will not be experts in everything. We must seek out and collaborate effectively with experts. In this case of reading, we need to partner with reading specialists as we apply any techniques for learning to read.

One size will not fit all because every brain is different and learns differently.

 

 

Supporting Language for Salient Feature Understanding

In the CVI world there is great emphasis on salient feature support for children with CVI (Roman-Lantzy). This is the consistent visual description language that is used to help children with CVI understand what they see.

It is also important to remember that children with visual impairments often lack understanding of the basis of these language concepts.

They lack understanding of the meanings of position/directional words and any adjectives describing size, shape, number and sometimes colors.

Adjectives used in this salient feature language such as “long”, “tall”, “flat”, round”, “curvy”, “pointy”, “floppy”, “wagging”, or “skinny” may be meaningless without direct teaching of these concepts.

Position words: used in this salient feature language such as “middle”, “over”, “under”, “top”, “bottom”, or “upside down” are irrelevant without the context for position in space that is taught and directly experienced.

Shapes: used in this salient feature language such as “rectangle”, square”, “circle”, “triangle”, or “center” lack meaning without tactile and visual exploration directly with real items of those shapes.

Number and Size: used in this salient feature language such as “two”, “one of each”, “single”, “short”, “large” are not well understood without direct and repeated teaching of number and size that children with typical visual skills understand through everyday incidental visual experiences. Think about this example of everyday incidental interactions that teach number, quantity and size:

Mom has 3 cookies: 2 small and 1 larger one. She gives 1 small cookie to Billy. Billy sees that mom now has 2 cookies: 1 small and 1 larger. Billy, of course, notices that mom still has “more”: the larger one and a small one while he has the other small cookie.

Children must have multiple understanding of words. If the concept is long, the child must learn that there are multiple kinds of long, that is not a narrow meaning.

“Long” can mean:

  • A distance
  • A length of time
  • Many (as in “a long list”)
  • Long sounds
  • Long hair
  • Long item (as in “long ruler”)

Without directly teaching these concepts for essential language and cognitive understanding, salient feature language is empty language with minimal meaning behind the words.

We must build concepts with direct teaching with hands-on experience with real materials in 3D. Providing learning materials in 2D without this direct teaching will not provide these concepts.

Salient feature language can not be the support we want for building children’s visual understanding without doing this background work to solidify the understanding of the words and the concepts.

https://www.tsbvi.edu/curriculum-a-publications/3/1069-preschool-children-with-visual-impairments-by-virginia-bishop

Central Focus for CVI: “How Does This Benefit Kids and Families?”

I have the pleasure of working at Perkins School for the Blind as the CVI Program Manager. My supervisor, Ed Bosso, has one central question for me every time we meet:

“How does this benefit kids and families?”

I try to take that question into consideration for everything I do.

  • How does this statement benefit kids and families?
  • How does this interaction benefit kids and families?
  • How does this idea benefit kids and families?
  • How does this CVI training benefit kids and families?
  • How does this assessment benefit kids and families?
  • How does this collaboration benefit kids and families?

There is certainly increasing understanding of CVI since I first learned about it in 2002. Now our task is to stay focused and to use that building energy and building understanding creatively, scientifically and collaboratively to move this field forward in all ways.

To support the medical field, the educational field and research field in understanding CVI, that central question, “How does this benefit kids and families?”, should be the first question we ask ourselves. Absolutely nothing else matters…

Accessible: Visual Recognition in Literacy

Many strategies for CVI that we see on the internet give us suggestions for visual access in literacy for students with CVI but they slip back into ocular suggestions: good contrast, larger size, reduced glare on the reflective page.

What is totally missed is the important concept that CVI is an issue of visual recognition. If the child has no firm idea of the item in real life, in real 3D form, we simply can’t then go to 2D pictures as a symbolic representation of that item.

Without visual recognition of things in the world, the flat, 2D images are merely squares of color and shape not a meaningful picture representation of anything recognizable.

Children may look at the images but the representation remains meaningless and inaccessible

Understanding What is Seen

For students with CVI, understanding what is seen is based on previous knowledge and the expanded understanding of salient visual features (Roman-Lantzy).

This wonderful example is from Judy Endicott who has a family member with CVI.

Judy shares this experience:

I asked Johnny (now 8), in grade 2 and 6.5 on The CVI Range, “What do you see?”

Note: (Johnny is not “into” football, and doesn’t recognize the Eagles logo, but Judy is always showing him different newspaper or magazine pictures to gain insight into his visual world, and help him use salient features to identify the image.)

Judy asks: “Johnny, what do you see?

Johnny replies: “A guy in jail.” (Johnny connects the helmet bars with the mistaken salient feature of “jail” that is known to him.)

Judy says: “Point to his head.”  (Johnny does this)

Judy asks “What’s on his head?”

Johnny says: “a helmet” (Johnny understands only part of the image).

 

Then Judy showed him the whole picture:

Judy discussed all the salient visual information more fully.

She talked about body parts, football, uniforms, etc.

Johnny could label all of the parts correctly when Judy pointed to them, but didn’t connect them initially to help him identify a football player wearing a helmet when Judy initially asked, “What do you see?”

The type of questioning that Judy used: “What do you see?”  insured that Johnny truly had access to the visual images and concepts. When it was clear that he truly didn’t have access, Judy knew this was the critical place for more instruction.