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.

 

Child with Visual Recognition Difficulties

My friend is a parent of a child with CVI with visual recognition problems. 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?

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.

Morning Meeting Ideas for Children with Limited Visual Attention

The first place to start in developing a morning meeting routine, of course, is to assess each child to determine their visual needs. Understanding the child’s functional visual skills allows you to create goals and objectives and to provide across-the-day accommodations and methodologies to meet those needs.

• Materials in morning meeting must have considerations for color. Best colors are often bright and saturated. Single colored items are most accessible. Your presentations must consider that the child is only seeing color, not shape to discriminate one thing for another. If you have all red things, they can’t do this discrimination. Because this child is very visually impaired, compensatory skills should also be considered.
• Items presented must be 3D, real, familiar and functional objects NOT PICTURES! 3D objects will provide visual access, tactile input, olfactory input and auditory input and can be seen in all perspectives.
• Pictures are completely inaccessible for this child who is not using central vision effectively. (Central vision is essential for children to understand any 2D materials).
• Materials in morning meeting must meet any assessed need for motion. Shiny items are considered can seem to move due to reflected light. Movement should be gentle and slow not fast and frantic. Frantic motion can overwhelm the child.
• To foster looking at the presented morning meeting materials, light must be controlled, limiting the child’s lightgazing.
• Because light is important to encourage looking, light the materials that are presented or use materials that light up.
• Because fixation is brief, the material must be presented for longer so the child has another opportunity to visually locate.
• Because peripheral fields are stronger than central visual fields, the materials must be presented off center in the best assessed lateral visual field.
• The lower visual fields are often not functional well so eye level is recommended. Upper fields can also be inaccessible.
• Make sure the “action” of morning meeting is within their best assessed visual field.
• The child can only look at items in near space. The exact assessed distance needs to be respected and materials presented within this distance. This is typically within 18”-24” of the child’s eyes.
• Give the child a copy of the material being used with other child in turn. This provides visual access for the child even when materials are being presented to other children at greater distances.
• Faces are very complex. This child will have difficulty looking at faces. Be mindful that the child may be attending but not able to make eye contact or even look towards your face if you are talking. Greet them with your name and tell them what you will be doing with them. Call their name before delivering a message or asking a question. Research shows that adults often do not talk as much or as long to children without eye contact. Adults should be aware of this and monitor their behavior with children.
• Provide quieter environments. This can be difficult in a larger group of people. Consider having smaller morning meetings with a smaller number of children. Teaching assistants can be used when designing these multiple morning meeting sessions.
• Create morning meetings of less children so the movement, visual complexity and auditory complexity is more controllable. There is no rule that morning meeting needs to be all the children in one morning meeting. Have several smaller meetings.
• Provide non-complex backgrounds for all learning materials.
• Where non-complex shirts. You are the the visual background!
• Seat yourself in the same position as the child to see what the child sees. You will be surprised how much visual complexity you will notice and need to control.
• Position this child solidly for best visual skill use.
• Use familiar materials and familiar routines. Use consistent materials to build visual familiarity. Predictable routines in morning meeting will support visual recognition of materials and help children predict the sequences.
• The child will have increased processing time for looking for understanding what is seen. Using the assessment and taking data will help identify how long the child requires for visual attention, which visual field is faster and which visual field has the most sustained visual attention abilities. The material needs to be where the learning is accessible and for as long as the child requires.

 

Building Literacy Around What Children Care About

We all pick up books based on our preferences for topics.  Why should our children with CVI be any different? Parents have a wealth of information about what their children’s passions. These are the favorite and visually familiar things we should build our literacy materials around for our children.

My student is fascinated by cell phones. I grabbed a Google image of a cell phone (actual size) and chose a fairly complex book. I applied Velcro to the back of the cell phone image and to multiple places on each page.

   

The book became The Ten Ladybugs and the Cell Phone.

Because my student really likes this item and had a firm visual memory for this item, his success was almost immediate. Once he could locate the cell phone picture, he could hand it to me and play with a cell phone for a minute.

With this success, I can go several places with this skill.  I can increase the complexity of the background and/or decrease the size so the cell phone becomes more symbolic (not the exact real cell phone size).

This makes learning interesting for my student and I can work toward my goals. We are both engaged and happy to work together! We move to increase and expand my student’s literacy interests based on their preferences not mine!

Literacy: Searching for a Visual Attribute

My 3 year old student who is non-verbal had no interest in any literacy materials when she arrived in preschool due to ocular and cortical/cerebral visual impairments.  Her preschool provided rich experience based literacy using adapted books matched to her ocular visual needs and matched to her CVI assessment. Each book had an accompanying storybox with 3D materials to support each non-complex picture.

I wanted to check visual recognition of one 2D image.  I choose the book Zoom! Zoom! Zoom! I’m Off to the Moon by Dan Yaccarino. It had a series of images of round pictures.  As a consistent visual feature, I used a shiny, gold, round sticker. I presented this sticker on a white non-complex background. I knew my student loves the Itsy, Bitsy song. With hand under hand support, each time the sticker was presented we would touch the sticker together and I sang part of her favorite song.

With her success with pointing to this one sticker, I applied the sticker in different places on each page of the Zoom! book.

 

 

After a week, she was looking at the pages and finding the shiny sticker each time. She would lean closer to reduce the complexity, isolate her index finger, point and look at me and smile. True recognition! With the increasing interest, she really studies all the classroom adapted books and even chooses books during her free time on the mat.

“She Sees When She Wants To”

I wish I had a nickel for all the times I’ve heard this comment about children with CVI: “She sees when she wants to.” I would be a rich woman!

Looking is not a choice.  Shown any item, we with typical vision, need to look at things in our world to decide whether we want to interact with it or not. We can decide to grab it, eat it, throw it or ignore it but we must look to determine what it is first!

So why do our children with CVI seem to see some things and not others? Why do they have this inconsistent visual regard to materials in their environment?

I find my students look and look and reach most consistently with those materials that are familiar. These are the materials that my students have formed a strong visual memory of. Its firmly in their visual library. Looking at it and recognizing it are solid skills.

My student, Judy, lacks visual attention for most materials in her environment. She requires the strictest environmental controls for visual location and for sustaining her vision to most materials. Judy does love Goldfish crackers and water bottles. She can find a goldfish cracker on her tray immediately, reach to it and gobble it up. She can spy a water bottle 6 feet away, smile in recognition and cross the room to grab it. She shows no other visual recognition to any item at this 6 feet distance except light.

People who do not understand CVI or understand how important familiar materials are to children with CVI, misinterpret this as a “behavior”. They blame the child for lack of interest. Seeing this ability in the context of the CVI, is the only way to interpret this ability and to expand a student’s access to the world with lateral learning.