Presenter:Gregory Santamoor, MS, TVI

ContentOverview of Session and Participant Learner Objectives

Introduction to Cortical Visual Impairments (CVI)

Interventions and Teaching O&MO&M Students with CVI in EVSApplying strategies based on student needs

O&M Instructional ApproachesIntegrating Learned Activities

Introduction to CVI →Your understandingDefinitionTerminology/DiagnosesNew DevelopmentsCausesIncidenceEducational ChallengesTeaching Approaches for children with CVI

Definition 1

“Cortical Visual Impairment is a temporary or

permanent visual impairment caused by the disturbance of the posterior visual pathways

and/or the occipital lobes of the brain.”

Ref: www.blindbabies.org

Definition 2

“Cortical Visual Impairment is a neurological disorder,

which results in unique visual responses to people,

educational materials, and to the environment.”

Ref: www.aph.org

Definition 3Cortical Visual Impairment refers “to a visual loss caused

by some disturbance to the ‘posterior visual pathway’ or

‘visual cortex’ which encompasses difficulty in processing and interpreting incoming visual information.”

Ref: Teaching Exceptional Children Plus article Volume 4, Issue 5, May 2008

CVI – AKA…What Is and Is Not CVIIs CVICortical Visual ImpairmentCerebral Visual ImpairmentNeurological Visual Impairment

Is Not CVIHemianopia –damage to optic nerve/tractAbsolute Scotoma –specific blind areaFunctional Blindness –possibly psychologicalVisual Agnosia –inability to recognize common object

Visual Neglect

Ref: www.aph.org

New DevelopmentsAmerican Printing House CVI Advisory Group in 2008 and ongoing efforts to recognize CVI as a separate visual impairment to receive Federal Quota Funds.

Creation of CVI website through APHInclusion of CVI through Familyconnect.org (NAPVI)

CVI included and recognized by NYS Department of Health as one of the most common visual impairments

According to Dr. Roman-Lantzy…

“Experts do not agree whether cortical visual impairment, neurological visual impairment, brain damage-related to visual impairment or some other term will ultimately be chosen.”

More from Dr. Roman-Lantzy…

“Cortical visual impairment is more commonly used in North America, while cerebral visual impairment is generally used in Europe.”

Causes 1

Hypoxia –lack of oxygen to the brainEncephalopathy –damage to the brainIntra-ventricular hemorrhagePeri-ventricular leukomalaciaCerebral vascular accidentCentral nervous system infectionStructural AbnormalitiesHead/brain trauma

Causes 2

Related Neurological problems

Cerebral PalsySeizure disordersCognitive impairmentHearing lossMemory dysfunction

Incidence

Cortical visual impairment is considered to be the PRIMARY cause of visual impairment in First World countries.

In the United States the top four (according to the NY State Department of Health Clinical Practice Guidelines in Visual Impairment):Cortical visual impairmentRetinopathy of PrematurityOptic Nerve HypoplasiaStructural Abnormalities

Incidence continued…

The most common cause of visual impairment in children WORLDWIDE is ________?__________.

And the answer is…

Ulceration (or scarring) of the cornea, secondary to Vitamin A Deficiency.

According to the American Foundation for the Blind, 30-40% of children with a visual impairment have CVI

Educational ChallengesSigns and SymptomsVariable visual responsesVisual Latency –delayed responsesUse of peripheral vision rather than central vision

Visual Novelty –prefer more familiar objects over novel objects

Visual field restrictionsPoor Depth PerceptionAbsence of visually guided reachBetter visualizing moving target than motionless

Educational ChallengesSigns and Symptoms continued…Figure-Ground PerceptionCompulsive Light Gazing/Photophobia Color preference (color may act as anchor)

Lack of sensory nystagmus vs. presence of motor nystagmus

Non-purposeful gazeDifficulty with Visual Complexity

Pattern on surface of an objectVisual array within surrounding environmentComplexity of sensory environment

What is it like for a child with CVI?Akin to looking through Swiss cheeseImagine trying to find one person in a football stadium while standing on the 50 yard line

Like looking at modern artSimilar to looking at an unfinished jigsaw puzzle

Continuously playing “find the hidden object”

Visual Pathways Cross Section

Damage to Optic Nerve and tract

General Teaching Considerations

Allow for intermittent breaksChild should be positioned comfortablyAvoid challenging a child with CVI with a visual task and other fine or gross motor task

Work in a simple uncluttered visual environment

Use familiar objectsRepetition is importantUse vibrant colors such as red, yellow and orange

Teaching Considerations cont…

Use toys and materials which are motivating to child

Pair visual tasks with other sensory systems such as audio or tactile (to support visual task)

Use verbal descriptions of materialsArrange optimal lighting – preferably from behind child

Move the target you want him/her to seeUtilize different visual fields for optimal responses

Allow for additional time

Ref: www.blindbabies.org

Additional Suggestions from Teaching Exceptional Children Plus

Use boundaries or borders around target when possible

Use technology (changing settings on PC/laptop)

Recognize that behaviors (i.e. maladaptive) may be a way child is communicating

Start sessions at levels child can achieveConsider less inclusion – What is the best LRE for the child?

Keep team members informed

Role and Approach of O&M Instructor

Connect and consult with TVIConnect and consult with rest of team –including family!!

If possible, take part in Functional Vision Assessment and Learning Media Assessment

Review Functional Vision Assessment, if you do not participate in the process

Get updated eye reportAgree upon approach and strategy with team members that is consistent and that meets student’s needs

Be flexible as your approach may need to be changed to better suit the student

Characteristics of Cortical Visual Impairment Checklist

Children with other types of visual impairments may exhibit some of these characteristics.

CHILD’S NAME_____________________________ AGE________ DATE______

RESPONDENT’S NAME & RELATION TO CHILD________________________________

A child may be suspected of having a cortical visual loss when the extent of visual loss is unexplained by ocular abnormalities. Etiologies may include cerebral palsy, asphyxia, intracerebral hemorrhage, and meningitis.

Please check any areas below that pertain to the child.APPEARANCE___Does not look blind___Blank facial expression___Lack of visual communication skills___Eye movements smooth, but aimless___Nystagmus (rapid eye movement) rarely seen

VISION FUNCTION___Visual function varies from day to day or hour to hour

___Limited visual attention and lacks visual curiosity___Aware of distant objects, but not able to identify___Spontaneous visual activity has short duration___Visual learning tiring___Closes eyes while listening___Balance improved with eyes closed___Look away from people and objects___Consistently look to either side when visual looking

___When visually reaching looks with a slight downward gaze

___Turns head to side when reaching, as if using peripheral fields

___Uses touch to identify objects

MOBILITY SKILLS___Occasionally "sees" better traveling in a car

___Difficulties with depth perception, inaccurate reach

___Unable to estimate distances___Difficulties with spatial interpretation

___Avoids obstacles, but unable to use vision for close work

IMPROVED VISUAL PERFORMANCE___When in familiar environments and when using familiar objects

___When told "what" to look for and "where" to look

___When objects are held close to eyes when viewing

___When objects are widely spaced___When looking at one object verses a group of objects

___When color is used to assist in identification of objects or shapes

___When objects are against a plain background and paired with movement and sound

K. Appleby’s compiling information from article by: Jan, J.E., Groenveld, A., Sykanda, A.M., Hoyt, C.S. (1987) "Behavioral Characteristics of Children with Permanent Cortical Visual Impairment." Developmental Medicine & Child Neurology, 25,755-762.

O&M suggestions for children with CVI

The follow suggestions are based on the Texas School for the Blind presentation on March 31, 2012 by Lisa Colaci, COMS and Ruth Ann March, COMS

Color Preference

Wear student’s favorite color Mark key locations with the student’s favorite color

Consider using AmbuTech red and orange ball and roller tips

Use tape in a student’s favorite color to mark the placement of hands (or the lower bar) on a pre-cane device

Point out red lines on sides of aisles (grocery store)

Direct focus to overhead department store signs also often in red

Incorporate preferred color in maps for student’s use

Attraction to movement

Mark key points on route - helium balloons (favorite color) tied to weight

Use Mylar pompoms to mark key destinations

Use hand motions to direct attention or provide directional cue

Visual ComplexityAvoid wearing overly busy clothesExpect the student to have difficulty recognizing faces; provide verbal prompts in social settings

Provide opportunities to practice recognizing faces by using photos of key people seen regularly

Spend ample time familiarizing to new classroom/school prior to beginning of year before teachers begin decorating

Schedule at least one lesson after teachers have returned

Provide ample practice the first few days of the school year after students return

Visual Complexity cont…Try to limit visual complexity when choosing training sites, especially when teaching a new skill

Use of telescope, binoculars, digital camera or cell phone may help control for visual clutter (as well as be a motivator)

Cane or pre-cane device may help student focus on what is ahead

Looking at the cane as it moves may help cut down on visual clutter by decreasing array

Cane movement may attract student, promote use of vision, but distract from awareness of other key visual information

Visual and Environmental Complexity

Because of difficulty attending to more than one source of sensory input at a time, try to limit auditory prompts as they tend to interfere with vision

Use physical prompts, especially those that involve movement

Visual NoveltyVery connected to visual clutterUse sequence of photos with increasing complexity to introduce/familiarize to new landmarks

Preview planned destinations with your student

Give student pictures of desired items when teaching shopping or how to find a landmark on a new route

When introducing a new route, make picture book with the student present in pictures, of key points on the route

Use preferred color for background

Visual Novelty cont…Keep it visually simple; put only one picture to a double page

Use the picture book to review route before practicing again

On any new route, allow time for exploration, perhaps initially with a guide, so the student can become familiar with new surroundings and you can point out key areas

Expect cane skills to temporarily decline when working in new area until the environment becomes more familiar

Visual Novelty cont…Introduce new cane skills in familiar environment to help avoid visual distractions

Watch for evidence of visual and/or physical fatigue

As vision resolves, tactile and visual exploration will occur more simultaneously, but only when child is ready

Allow for delay between first seeing and then acting upon a visual target

Know visual field preferences

Lighting considerationsNot the classic photophobiaThe presence of shadows creates complexity. Teach student how to recognize shadows and what causes shadows to change

Or avoid times of day when shadows are present

Reflections from windows, standing water or shiny surfaces may distract and cause changes in performance

Attraction to reflective surfaces can be utilized to mark landmark or promote visual field expansion

Good NewsIncreased support and understanding of CVI including State and Federal changes

Children with CVI can improve their skills and use of vision with the right approach(es)

The brain has plasticity and for children with CVI, this could mean additional improvements

Recognition that LRE for children with CVI does not necessarily mean inclusion

Team approach works wondersPresence of CVI does not always mean cognitive impairment

Your lessons can be simplified for children with CVI

Resources www.aph.org/cvi www.afb.org www.tsbvi.edu → http://www.tsbvi.edu/component/content/article/124-general/112-characteristics-of-cortical-visual-impairment-checklist

→ http://www.tsbvi.edu/program-and-administrative-resources/3276-cortical-visual-impairment-an-overview-of-current-knowledge

http://drleahyvarinen.com/ → http://www.lea-test.fi/en/assessme/sfracvilect/cviorg.html www.aerbvi.org www.familyconnect.org www.hadley.edu → http://www.hadley.edu/Resources_list/Cortical-Visual-Impairment.pdf

www.lilliespad.com http://www.dblink.org/lib/topics/cvi-bib.htm www.adaptivedesign.org

This presentation is dedicated to the memory of

Dr. Harvey H. Mar, Developmental Psychologist (1951-2012)