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.

 

Staying at Home: Cook with Your Child

As we think about engaging and learning while at home, cooking provides a multitude of multisensory learning opportunities. Pick one food that your child loves and create an opportunity to cook that food repeatedly throughout the week. Pick a quieter time and quieter place for this activity for optimal visual abilities. Create a non-complex surface with increased spacing of materials. Block distracting light and movement around the activity. This can be a long or very short activity.

Some simple favorites:

• Koolaid
• Eggs
• Smoothies
• Nachos
• Peanut butter and banana sandwiches
• Chex mix
• Ice cream sundaes
• Yogurt parfaits
• Pre-packaged Mac and Cheese
• Chicken Nuggets
• Pizza

Let’s think about what this one activity provides our students with CVI:

Visual Benefits: Remember to engage visual skills at all times. Tell your child what they will see. Show the item to the child without talking. Describe the visual features of the item. Show again without talking. Allow tactile exploration.

• That repeated visual opportunity will provide visual prediction that your child needs to develop visual recognition of the foods, the packaging, the utensils and the storage containers that are regularly and consistently seen.
• Thinking about the support of color, picking packages, utensils and containers of very different colors will help the child discriminate and recognize each based on color.
• That will allow you to describe the visual features: what the food, packaging, utensils and the containers look like.
• Repetition provides opportunities to develop visual memories.
• The movement of the cooking sequence draws and helps maintain visual attention.
• Using these real materials will allow exploration of the different visual perspectives of the visual materials.

Compensatory Skills Benefits:

• Activities engage visual, auditory, olfactory, taste and tactile senses; all of which support visual recognition skills.

Language Benefits:

• Creating foods provides opportunities to develop sequencing and following directions.
• Provides opportunities to use position words: “on top of”, “add to”, “in/out”.
• Provides opportunities to use attribute words for the visual aspects and tactile aspects of the foods.
• Provides opportunities to use cooking vocabulary: “mix”, “fold”, “stir”, “beat”, “add”.

Cognitive Benefits

• Provides opportunities to use concepts: hot/cold
• Provides opportunities to use concepts: more/less
• Provides opportunities to use concepts of attributes: big/little, long/short, curved/straight
• Provides opportunities to use concepts of the appropriate storage of foods (those stored in the cabinets, refrigerator, freezer).
• Provides opportunities to understand the properties of liquids and solids
• Provides opportunities to use for grouping and categorizing
• Provides opportunities to understand parts to whole: sliced banana vs. the whole banana.
• Provides opportunities to for food handling: peeling, cracking

Reading Benefits Reading in print, Braille, symbols, pictures

• Provides opportunities to for reading in print, Braille, symbols, pictures
• Provides opportunities to create lists of things to buy to get ingredients
• Provides opportunities for reading and following directions of the recipes

Mathematics Benefits:

• Provides opportunities to for measuring and weighing
• Provides opportunities to understand one to one correspondence
• Provides opportunities to understand time concepts
• Provides opportunities to understand temperatures
• Provides opportunities to understand size concepts
• Provides opportunities to count
• Provides opportunities to cut into foods into factions
• Provides opportunities to fill and dump
• Provides opportunities to understand portions

Science Benefits

• Provides opportunities to experience cause and effect
• Provides opportunities to use chemistry
• Provides opportunities to understand how foods are different in form: milks require pouring while mayonnaise requires scooping
• Provides opportunities to understand how heating and freezing impacts foods
• Provides opportunities to use force for cutting, separating

Social Benefit

• Provides opportunities for sharing
• Provides opportunities for cooperating

Motor Benefits

• Provides opportunities for opening and closing containers
• Provides opportunities for holding heavy and light materials
• Provides opportunities to use two hands together
• Provides opportunities for stirring different textures with different tools
• Provides opportunities to use pouring, scooping, kneading

Advocacy Benefits

• Provides opportunities to plan
• Provides opportunities to make choices.

Career Benefits

• Provides opportunities to sort needed ingredients and tools
• Provides opportunities for cleaning needed tools
• Provides opportunities to set up for completing a task

Technology Benefits

• Provides opportunities to use recipes on iPads
• Provides opportunities to use blenders, mixers and other kitchen equipment
• Provides opportunities to use the oven, the microwave and to use stovetops

Even if your child is not eating foods, participating in tube formula feeding is also an opportunity for many of these same learning experiences.

Each activity can be easily adapted for the various functioning abilities for each child. Some will be independent with supervision and some might require hand under hand support for participation. Touching, looking at, pushing something into a container is all participation. All levels of abilities can be engaged and learning fruitful for all!

Want more? You can use these to follow up after your cooking. Use again and again!

• Take pictures and make a Powerpoint book of the ingredients or process
• Find a Youtube of a character making the same food. Follow up your activity with this literacy material: Here is one about making pizza https://www.youtube.com/watch?v=gX2vQNNC80c
• Make a recipe book
• Make a symbols book for the utensils

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.

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.

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.

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.