CVI

cortical visual impairment
cerebral visual impairment

University of Massachusetts Online CVI Class: Starts September 12th

VISN 648: Cortical/Cerebral Visual Impairment

Class #: 14819
Locaton: Online
Instructor: Ellen Mazel
Credits: 3

Course Description: This course provides an in-depth study of CVI and resources available for assessment and instructional strategies. Participants will further examine and explore the unique educational needs of children with CVI and the skills related to teaching these children in a full array of educational settings; Pre-K through grade 12. Topics include teaching strategies in the core and expanded core curriculums, such as: literacy, career-vocational skills, visual efficiency and compensatory auditory strategies. Instruction will also address material modifications and accommodations.

Required Text:

  1. Cortical Vision Impairment: An Approach to Assessment and Intervention
    • Author: Christine Roman-Lantzy
    • Copyright: 2007
    • Available from: www.afb.org

The Brain: David Eagleman

We should increase out understanding of the brain as we think about children with CVI. The more we know, the more critically we can evaluate theories and interventions. We can understand the medical information we receive in reports. We can begin to understand the latest brain research and it is sure changing quickly!  Even texts and articles about the brain from 5 years ago may contain disproved information.

David Eagleman explores the brain in this new series “The Brain”. This looks like a wonderful series from PBS (Public Broadcasting Station).

http://video.pbs.org/program/brain-david-eagleman/

Here is his website: http://www.pbs.org/the-brain-with-david-eagleman/home/

I just ordered his new book The Brain. I’ll let you know what I find out about the visual system!

Vision Impacts All Development for Kids with CVI and Other Visual Issues

Cognition

Understanding of Objects/Relationships between objects: child with visual impairments, including CVI, are aware of fewer possible objects in the environment with which to interact. Those that are touched and experienced are often misunderstood with fragmented and limited conceptual understanding. Interactions between objects and events are inaccessible without tactile and auditory support.

Object Permanence: Objects must be tactilely explored to even know of their existence. Object permanence develops later for children with visual impairments including CVI. Without vision, there are just fewer opportunities to build learn this concept.

Cause and Effect: Objects must be touched to create a reaction and the reaction must be tactile or auditory.

Spatial relations: Visual relationships between items are limited. Comparisons of attributes (size, shape, color, relative size etc.) are limited. Positions between and among objects must be explored tactilely and through auditory channels.

Concept development: The child must directly explore real items in the real situations in the real world to gain more complete understanding. Incidental learning is missed and concepts reinforced more often.

Communication: Children lack complete access to the facial expressions, body language, gestures, and referenced pointing, all of which build language concepts. They might have limited or no eye contact to promote social interactions. Children with limited eye contacted are addressed and communicated with less often and for shorter period of time. Because they are listening, they are often described as “good babies”. Because they are quiet, people leave them alone more often. They might have reduced language tied to concepts due to limited object and interaction experience. (dogs, puppies, Collies, Golden Retrievers are all dogs). Pronouns are confused due to lack of a visual reference. Play is often are self focused play (tactile, movement or auditory play) rather than outwardly focused on materials in the world. Children often imitate parts of language heard echoing language.

Gross Motor Development

Children with visual impairments may seem passive and need intervention to purposefully explore and know what there is to explore. The developmental milestones occur with some fragmented sequences (limited lifting head while on the stomach, delayed sitting, standing, and walking). These all benefit from compensatory skills use to build motor skills. (let children crawl to sounds rather than handing toys to them all the time, placing sound making toys up on surfaces to encourage pulling to stand and cruising). With less movement there is often low muscle tone in the truck and arms.  With less experience and without vision there is delayed or poor protective and balancing skills.

Fine Motor Development

Mouthing remains a primary tactile sensory organ for a longer period of time. This is seen as rolling items on the lips and tongue rather than biting items.

With poor experiences using the arms and hands, there is overall weakness. This impacts Braille learning. Tactile defensiveness may develop as people grab their hands to exploration items. The child had no idea what their hands with encounter and they begin to resist this interaction. This lessens reaching to explore. Parents and teachers should use hand under hand exploration to allow children the option of disengaging. Without direct teaching there are delays in activities of daily living such as hair brushing, tooth care etc.

Social-Emotional Development

Bonding is often impacted due to lack of eye contact. Parents and teachers need to look for non-visual cues to a babies needs and interactions. Children are dependent upon parents and teachers to introduce and provide explorations of the environment. Children often have the “good fairy” syndrome.  Things appear and disappear in their world. Overall independent must be supported.

 

Story About Regaining Sight

I think you might find this article very interesting:

http://www.cbsnews.com/news/43-years-blind-man-regains-sight/

This man was visually impaired for 43 years.  He has a typical brain but his brain was denied visual input for many years.  Look at the visual issues he still struggles with after his sight is restored.

  • trouble recognizing things
  • trouble recognizing faces
  • problems with depth and he needs to still use a cane to travel safely
  • visual overload
  • finds color the easiest to visually process

He is displaying many of the characteristics of children with Cortical Visual Impairment in Phase III.  It is important to remember that this man had the benefit of typical vision before the chemical accident that blinded him. Even with the benefit of visual memories (that most children with CVI never have), he remains visually impaired.  His eyes are now fine, but his brain is struggling to understand the visual world.   I would love to hear a followup story and find out what skills have resolved.

Phase III: So often undiagnosed and misunderstood!

Phase III can be so difficult to understand, assess, and to explain to others. People must understand how important strategies are to kid’s full access to visual learning.  The CVI Range helps take an objective look at visual skills to build appropriate strategies.  As a teacher, I am constantly explaining that “looking” is not always “understanding”. In Phase III, there are still several characteristics that impact learning:

  • Distance: kids still tend to be “close lookers” and spend most time visually exploring only the near world.
  • Facial recognition and facial expression understanding: Faces are the most complex visual targets and well into Phase III, some kids still struggle with this important social skill area.
  • Visual complexity: busy places, busy backgrounds and busy literacy materials are still difficult.
  • Auditory complexity: noisy places reduce visual abilities.
  • In places with high sensory demands or with challenging positioning, kids return to easier behaviors such as light-gazing.
  • Movement of others in the environment can still distract central vision use.
  • Extra time to visually examine is still needed.
  • Being tired or ill affects visual skills.
  • Kids still struggle to imitate a visual action.
  • Kids still struggle to understand the visual implications of what is seen.

Guiding Principles

I just love Dr. Roman-Lantzy’s Guiding Principles for working with children with CVI!  They highlight professional practice, the need for assessment, the need to have the highest expectation for improvement, the need for precise planning and the ultimate respect for children!

Precision:

  • You must use the CVI assessment to accurately  provide the environmental and learning supports to build visual skills.

Intentionality

  • With assessment you must understand where the student is functioning and where you expect them to function next.  Dr. Roman says not understanding where you are going with your instruction is like a couple of people lost while driving: “Yes, we are lost but we’re making good time”.

Reciprocity

  • Observation is of the ultimate importance. You must respond to the child’s cues.  Put yourself in the child’s shoes and always consider the environment.  When a child is unable to use their vision ask: How is the environment effecting this child’s visual functioning.

Expectation of Change

  • CVI skills improve.  This is a central concept to your teaching.  Assessment must be accurate, interventions must match to the CVI assessment and the environment must support vision use.  As you reassess, make changes to encourage further building of vision skills.

Attention to the Total Environment

  • Complexity of the environment is the major reason that visual skills are poor.  Provide the needed support so the child has access to the instruction at all times.

 

Another Solution for Accurate Visual Motor

When children move into Phase II and III of CVI as measured on the Christine Roman CVI Range, using vision for function is the primary focus for learning.

IMG_0831

This picture shows a solution for a student who was struggling to place objects by shape into a container for recycling.  Just adding red color highlighting to the edges of openings allows the child to more accurately visually locate the hole and accurately sort each recycled object.

What is important to remember is that this is the needed support until the child has success.  Once the child is completing the task, we want to remove the supports gradually by cutting back the red tape to a thinner and thinner border with each increasing success.

Put supports in place after assessment and remove them carefully as you measure achievement.

Children Creating Their Own Movement Strategy

Seeing better with movement is a characteristic for children with CVI.

Children with CVI will do interesting things to stimulate their brains and to discover the strategies they can use to see better. Head movement or full body movements are often two types of strategies that children come up with on their own.

The puzzle for us is to figure out when they create movement.  If we determine when, we can adapt the environment for better visual regard.

Some questions:

  • Are they moving their heads when looking at things at near? Near items can be viewed against plainer backgrounds: floor or presentation board, and we see the movement stop or lessen. (Complexity and Distance characteristic)
  • Is there movement when trying to see familiar objects? (Novelty characteristic).
  • Is there more movement when looking at unfamiliar things? (Novelty characteristic).
  • Is there more movement when trying to discriminate pictures or 2D symbols? (Complexity characteristic)
  • Is there more movement against more complex backgrounds. (Complexity characteristic) In my CVI assessment using the Christine Roman CVI Range, I present materials against more and more complex background to evaluate visual skills. I often see head movements as the background complexity increases.
  • Is there more movement while walking through the environment? (Remember the distant environment is very complex.) I have one child that moves 4-6 feet forward and turns around to the right. I believe she is creating movement to understand the environment. With the help of the movement she created, she can feel safer moving forward further.
  • Is there less movement with the benefit of a backlighted surface (iPad, computer or TV). (Lightgazing characteristic)
  • Does the child “grow out of” the need for movement? I have many babies with CVI that stop self-created movement when their vision improves. (CVI improves as the child begins to understand their visual world!)
  • Do they make things move to see them better? I have several children that bang the table, make the items “jump” then reach to get them. So smart!

We need to see this movement as a strategy and don’t try and stop it.

  • I evaluated a child that stood up quickly all through mealtime. He stood quickly while looking at his plate then sat and reached accurately for the food. When the staff tried to stop this “behavior”, he could only find his food tactilely and ate like a blind child using only his sense of touch.

 

 

Blog Response: Littleroom

 

I really appreciate the questions. Your questions bring up great ideas and topics for blogs!

I received this blog question regarding the Littleroom:

Our colleague wrote: “I would also love your thoughts on the objects placed in the Little Room. How often would you change the objects? Would you move the same objects to different areas of the Littleroom? And do you have a good way to document how a child interacts with the toys, which toys are more often explored, etc?”

My response:

When thinking about providing the child with CVI with a littleroom playspace, I think about my goals. If my goal is listening, touch and activation using compensatory skills, I use a regular littleroom with many objects hung close to the child for accidental activation. As the child begins to know where things are, I raise the objects just a bit at a time to encourage reaching and more distant exploration.

If my goal is looking, I think about the visual environment and use the CVI Range assessment to make the design:

  • Color: use the favorite single colors.
  • Movement: hanging things in the littleroom on elastic already move the perfect amount.
  • Latency: the littleroom allows things to hang in the child’s visual space as long as the child requires.
  • Visual Fields: I hang materials in the best visual field.
  • Visual Novelty: once the child is looking in their best field to an object, I move it to the weaker visual field. Use the favorite toys first.
  • Complexity: Visual complexity: cover the top of the littleroom with a white gaze or felt (see picture below) so the child has a great plain background not a complex ceiling with tiles and lights. Auditory complexity: The toys can make noise in the littleroom and although the child might stop looking, its just fun. There is time to look again.
  • Distance: all the materials in a littleroom hang at near!
  • Visual Guided Reach: with accommodations for latency, field, color, movement and complexity, the child has the best chance of reaching.
  • covered little room005

 

I keep things the same in the littleroom for as long as a child needs. I think we think kids are bored but children like sameness. (I think of how many times I read the same book to my daughter!)

I will response to the last part of the question tomorrow.

 

 

 

Understanding Faces and Facial Expressions

all the same

Faces are very hard to discriminate!  Look at these faces above.  Are any of the photos the same person???

Changes in hair color, haircut, glasses and even facial expressions completely change the face.

Children with CVI struggle to discriminate faces and facial expressions even well into Phase III.  I will often ask parents to come in to the classroom for a surprise visit.  I ask that they enter quietly.  The child might look and it is clear there is no recognition of this very familiar face.  I ask parents to remain quiet and to move to 12 feet, then 6 feet then 3 feet.  This helps me assess the child’s facial recognition.  When the parent then greets the child verbally, the child lights up to voice and turns to find their much loved parent.

The child might have an easier time discriminating faces at home since there are fewer possibilities (Mom is the only woman who is 5’6″ tall with brown hair.  Dad is the only tall man with a beard).

This is important information to know so we can support children.  One simple strategy is to just introduce yourself.  Children with CVI often find it easy to code by color.  Greetings like “Hi Sue, its Ellen.  I have a green shirt on today” help the child with facial recognition problems find you in the room just by searching first for green.