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?

Supporting Language for Visual Attribute Understanding

In the CVI world there is great emphasis on understanding visual attributes to support for children with CVI. This is the consistent visual description language based on experience with objects with those attributes 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 visual attribute 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 visual attribute 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 visual attribute 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 visual attribute 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, visual attribute 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.

Visual attribute 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

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 visual attributes

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 “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  visual attribute 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.

Using Color Highlighting Effectively for Students with CVI

Color is such an important tool to use for students with CVI in all Phases (Roman-Lantzy).

In Phase I, color can support initial visual location using the student’s preferred color. Identifying that preferred color in assessment can be the key to building more functional vision

In Phase II and III, carefully use of color highlighting can facilitate vision for function. Color highlighting in these Phases will help support understanding of where materials are in space, where to place materials and where to reach to grab effectively. It can be used to draw visual attention and to support discrimination using highlighting of salient features in communications systems and literacy. For Orientation and Mobility, color can support distance attention and understanding. Color highlighting must be well understood and well applied for the optimal benefit when building student visual learning.

Check out this Perkins E-Learning Teachable Moment I recently did to learn more!

http://www.perkinselearning.org/videos/teachable-moment/color-highlighting-children-cvi

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

Specific Ipad Apps for Phase III: Matt Tietjen

Much thanks to guest blogger, Matt Tietjen, for these specific ideas to use an iPad to support students. Invaluable!

Goodnotes: You can take pictures of educational materials, zoom in on important details, isolate one problem or diagram at once and also write on it.  You can use the writing feature to highlight salient features, or the student can use the writing feature to complete the assignment. For example, I have a student who does best with one math problem per page rather than several.  Each morning of the week, her class gets a “morning math” worksheet with several problems on it.  The paraprofessional would use Goodnotes to take a picture of each problem on the worksheet and quickly create a digital notebook for that worksheet, with one problem per page. The student could then flip through the notebook and write on the iPad to solve one problem at a time.  Her final product could be saved in a folder on the iPad and also turned in by emailing it to the teacher or uploading it to apps like Google Drive or Dropbox.

Snaptype: Very useful for minimizing complexity in worksheets by taking a picture of a worksheet, zooming in on one problem at a time, and allow the student to type an answer for each problem using the onscreen keyboard or an adapted Bluetooth keyboard. Great for math worksheets!

Photo Album/ Camera: Yup! Just the regular old photo album and camera on the iPad. Can be used to reduce complexity and capture distance information in so many ways. Here are some ways I am using it:

• For all those circle times/morning meetings when the teacher may only decide a few minutes ahead of time what book she is going to read, the para can get the student’s iPad and snap a picture of each page (only takes a few minutes to do an entire book). The student now has a personal copy of the book on her iPad that she (or staff) can flip through to follow along with the teacher and zoom in on any important details, masking out irrelevant surrounding information on each page.
• Create an “album” for wall materials. Take pictures of each poster, word wall, map, etc. on the classroom wall and save them to an album on the student’s iPad. That way, when the teacher is referring to that map, word wall, etc., the student can follow along and zoom in on the pictures at her desk.

Bitsboard: Awesome for making custom flashcard activities for touching a named picture, reading bubble outlines without words in them, touching a picture from an array when its salient features are named, etc.  You can use this app to create custom picture touch games using anything you want – photographs of the child’s favorite objects, 2D image assessments, letters, numbers, words, etc. Many of my students like it a lot.

Counting Bear: Great for math. It visually marks each item as you count it. Students still have to practice systematically searching the array of items in order to count but with the support of visual markers to help them keep track of what has already been counted and what items still need to be counted.

Pictello: Fantastic for making custom made stories – either modifications of actual children’s books, experience stories or stories that the student helps write. You can include pictures, photographs, videos, etc. as part of the story and it reads the story aloud to the student. Can be great for creating school-to-home daily or weekly communication logs where the student helps take pictures of items throughout her day and then uses the app at home to communicate about her day to her family. She could also use the app with her family to create experience stories about vacations and special events to share with friends and teachers at school. For example, a student could take pictures of her weekend activities and create a story called “my weekend” that she shares with her class during morning meeting.

Voicedream app: You can use this app to read (or listen to) any pdf or word document as well as anything from Bookshare. It has a more natural reading voice than some of the other text to voice apps (in my opinion). You can adjust font style and size, and you can set the app to mask some of the text so that it only shows one line at a time, 3 lines, or 5.  It also has a yellow highlight that moves from word to word as the automated voice reads.

YouDoodle: can use it to import pictures and highlight salient features (as Christine Roman-Lantzy has taught us). I also have a student who likes using it himself to highlight salient features on photographs he has taken.

Google Images and Youtube: I use Youtube and Google images quite a bit.  If I wanted to bring distance info. (like giraffes) to a student who was about to visit the zoo, I might show him a few videos on the Youtube app about giraffes and where they live.  When there is an abstract picture in a children’s book (which is almost always) I often open up Google Images and find a real photograph version of the same thing and compare the salient features between the real photograph and the more abstract illustration in the book.

Calculators: for students high on The Range and in the upper grades, using scientific and graphing calculators can be a real challenge due to complexity of array.  It seems that calculators that incorporate color coding to reduce complexity of array may be a better choice for many kids with CVI. Here are a few promising ones:

• Kalkulilo Scientific Calculator: uses color coding to help reduce the visual complexity of the keyboard and group keys by function.
• Scientific Graphing Calculator (William Jockusch): Each graph on a coordinate plane is a different color and is color-coded to match the equation that goes with it. This type of color coding really helped my high school student in algebra II this year.  She had a physical TI-84 Plus calculator, not this app, but it was color coded similarly.
• Calculator (Infinity Symbol) incpt.Mobis:  This calculator uses color to differentiate symbols from numbers and other parts of the equation. Can help reduce complexity of array.

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.

“Duckness: How Do We Know?

Look at this series of pictures. (From American Printing House for the Blind website)

How can very young children with intact visual skills understand that these are all ducks?

They understand “Duckness”.

They have a keen understanding of the visual attributes that make up this “Duckness” because of shared visual experiences with others and with access to pictures, TV and movies that feature ducks. This develops effortlessly for children with intact visual skills.  Without direct instruction, they understand that real ducks are different sizes, colors, and ages. They understand that ducks can be seen in different perspectives depending on where and how they are standing. They understand that ducks can be flat in pictures. They understand that ducks can be symbolic in toys, signs, pictures, colored cartoons and in black and white drawings.

Our children with CVI lack this visual access to “duckness”. They lack the expanded and repeated knowledge about ducks. If they have seen a duck, their idea of “duckness” is limited to that one duck. Due to reduced eye contact with people and with reduced eye to object abilities, adults do not explain the shared salient features that all ducks share.

As adults serving children with CVI, we should be aware of this limited access and limited understanding that can occur in 3D and 2D. We must create opportunities to expand children’s access matched to their assessed functional visual skills. We must evaluate all our materials with this visual access limitation considered. We must adjust our own interactions and instructions to include visual attribute language of the same and different visual feature of items.

Visual Experience, Joint Attention and Visual Features

Here are some questions to consider:

• What is the visual inaccessibility at distance for this child?
• How solidly is vision, cognition and language are linked for items in the child’s world?
• How is the child’s joint attention? (in typically developing, sighted children helps build these visual, cognitive and language skills through joint attention with an adult and these  are based on the child/adult experience.

It got me thinking about my own daughter’s visual, cognitive and language development. She was a typical developing toddler with full visual access.

We lived on our sailboat in Boston Harbor. We were surrounded by ducks daily. My daughter would see these ducks everywhere, everyday. (visual experience)

When she looked at or pointed to the ducks, we shared gaze to the ducks and I would label this animal: “Duck” (shared gaze, language)

As she language skills grew, she would begin to point and label them as “Duck” as well (building language and shared gaze).

When we traveled on land, she began to label other animals as ducks. She understood that dogs, cats and other birds we saw were not human but animals (cognitive). She over- generalized that any animal that was not human was a “duck”.

Sharing her gaze and sharing her experience, I pointed out the visual features that made these other animals different and labeled them as different. “No. That is a dog, he has 4 legs and is furry”. (cognitive, shared gaze and visual attribute features).

Very soon, my daughter was able to use her cognitive comparison skills to label each animal she saw with the correct name based on the visual salient features: shape, number of legs, how then moved, where they lived, how they sounded.

Supporting children’s visual, cognitive and language skills must be carefully planned, based on experience and presented at near by providing supports around visual attribute language. They must be presented in planned, accessible ways due to the inaccessibility of distance events and materials.  This link must be facilitated to build visual, cognitive and language skills by comparing and contrasting visual attributes that are experienced, highlighted and shared.