FVA for Students with Multiple Disabilities, Part 1_0_0

As our housekeeping. We do appreciate your feedback and your topic suggestions.

Let me introduce today's speakers, whose time I am taking away. Rajiv K. Panikker, is a CLVT with the Arizona State Schools for the Deaf and Blind. Having begun his career on our campus as a teacher aide and houseparent, he is also a member of the Perkins family. Rajiv has had numerous experiences in residential schools, public schools and at the University of Colorado as an assistive technology specialist. He's our fields version of a triple threat, being credentialed CLVT, COMS and TVI.

Presenting as well today is Joanne Szabo, full-time physical therapist at the Arizona State School for the Deaf and Blind. Joanne brings more than 25 years of pediatric experience, having worked in the NICU, acute care, early intervention, and school-based services. Joanne received board certification as a pediatric clinical specialist in 2013. She's had her work published in teaching exceptional children and pediatric physical therapy and presents and educates on topics related to serving children who are deaf, blind, or visually impaired with multiple disabilities or deaf blindness.

Welcome both of you, my friends. The floor is yours.

All right, thank you. How's everybody else doing? Well, I hope and enjoying the day. We're gonna go ahead and get started. As Robin said, I've Rajiv and the topic today is-- the overview, what we're gonna do, is we're going to be talking about challenges in assessing students with multiple disabilities and the role of the evaluator and the team. And I'm just gonna forward the slides as we go along.

So some of the things that we wanted to discuss today is building an FVA for a student with multiple disabilities, apply collaborative strategies, and review case studies.

So here's where we have some audience participation. So give us your input. What are some of the challenges that all of you are facing associated with working with a student with multiple disabilities?

So thanks. Valerie is gonna put the chat box up in the center of the page and make it a little larger. So just share your challenges with us. I will read out some of them. We probably won't get to all of them but just to help those of you who might have difficulty seeing the screen. So we're hearing similar symptoms, students who are nonverbal, CVI-- we hear that a lot-- autism, positioning, people who can't move well, students who are unable to speak or respond meaningfully, a deaf child possibly with vision issues. So we're hearing a lot of communication or giving a response. Gagging reactions, that's an interesting one. Alert statuses. Having a space or room that's less than ideal, you know, we'll talk about that. Immobile as well as nonverbal. Maybe the student doesn't like the toys or the items that are presented. They're just not interested in. Helping teams make sense of eye reports, certainly heard that before. Students using a communication system and different levels of expertise and approaches by different team members. So maybe some different methodologies in place.

I see a few people are typing. We'll take just a couple more. One doctor not agreeing with another doctor's diagnosis, dual sensory loss, inconsistent communication modes. And not being familiar with the child-- being asked to assess a child maybe you've not met before. Aggressive students or other kinds of behavioral issues, which someone had mentioned earlier in the roll.

These are all great.

Interference by a nurse, hm. Medically fragile. Seeing CVI repeated a lot. I'm not speaking out ones that we're seeing repeated over and over but I know that both are Rajiv and Joanne can see them. Non-English speakers-- you guys probably have more experience with that than we might, here on the east coast. Overly medicated. [LAUGHS]

You guys let me know when you want to move on because I'm sure we could--

I think we have this. So let's go on. It's a really great start for us, gives us a feel for how we want to move forward. So we will try and address as many of these as possible. And I'm just gonna forward the slide right now to you.

OK.

Thank you.

So hi. This is Joanne. I think the list that I just saw covers so much of what we're gonna talk about. I want to say, first off, that this is part one of two presentations and this-- our case study and what we're talking about are kids that have ocular impairments. And in the part two, which will be in September, we're gonna address specifically CVI. And we did that specifically because when we presented this presentation initially at the International AER Conference in Florida, we had a lot of people wanting information on both sides. So we have expanded this and then we are going to give the one on CVI in September because CVI is handled in such a different way as far as the team approach and ongoing assessments and things like that. So we're gonna focus today on the team approach for kids with ocular, just specifically ocular, not CVI impairment.

And so some of the challenges that we saw listed up here, the kids that I see specifically every single day, are the kids that have the multiple severe impairments and the ones that have the gross motor or the fine motor delays, the speech and communication delays, the cognitive delays, and the social interaction delays. And those are all the things that you guys listed-- kids that aren't sitting up well. They don't have a good source of communication or they're using a communication device. They really aren't even able to cognitively understand what we're telling them, and then the social interaction, that's huge for those kids that have autism and things like that. So we kind of are all on the same page with the challenges that we know we face with these kids.

And then again, the severe sensory impairments, I saw some of that come up, and those are typically with the kids often that have the diagnosis of autism, and those are the tactual sensitivity. So some of the kids may be hypersensitive, meaning they don't want to be touched. And some may be hyposensitive, meaning they need a lot of touch to actually alert themselves to respond. And again, we know the visual impairment, the auditory, that was listed as well. A lot of kids that need sign, obviously, here at the School for the Deaf and the Blind, we deal with that a lot And then vestibular impairments, meaning either they could potentially have really poor balance or it could be vestibular in the sense that they don't like movement, movement sets them off, or they need movement. So kids are on all ends of the spectrum. But definitely those are a lot of the big challenges that I work with, that we see and that we have to deal with when we're trying to do a collaborative FVA for these students.

In addition to those issues, the biological influences-- these kids tend to be very sensitive, more so than just regular kids to things like if they're hungry, if they're tired. Especially, as you all know, kids who have visual impairment or blindness have really wacky sleeping schedules, often don't sleep at night very well. And then on top of that, you have the additional disabilities. Someone mentioned medication. That's a huge issue. Often, just after they're medicated, you're not going to get a lot of information because they're gonna be really drowsy, and sometimes in our classes, the kids even fall asleep. So that has to be a huge consideration as well. Just their health-- are they not feeling well that day? And comfort, are they in pain? Is something bothering them? I mean, that's going to set off all their behaviors.

And then speaking of behavioral, you know, the emotions, their interests, the environment. I think someone mentioned not liking to play with toys, and that's something we'll talk about a little bit later too, is some of these kids have to have pre-practice. Often, Rajiv, you know, he'll give me a LEA puzzle or something to go. Kids with autism, sometimes we have to work with him for weeks on just touching the pieces and getting familiar with them and wanting to even hold onto them because sometimes they just won't do it. But if we give them pre-practice and we let them, you know, kind of with some of these pieces of equipment, or toys, that let's say, Rajiv needs to do his FVA, we get a better response in the end.

And then lastly, we have to keep in mind on those really low level kids that some of them are just still learning how to respond to people and objects and that's why bringing in additional team members that know these kids, that can help you, sometimes can save the day for you. Because often it is so hard when you have a very low level kid, that's maybe still mouthing, you know, objects, putting them in their mouth or touching them with their face in different ways, and you're trying to get information out of them, and that's all they want to do. But typically, some kids, cognitively, are still at that level. So we have to actually work with them at that level. We have to let them, you know, put things in their mouth or not in their mouth but touch their tongue, let's just say, and explore it that way because cognitively that's where they're at and that is their learning style. And you may not know that if you don't know the child. I know some had mentioned not knowing the child can be a barrier. So working with the team can give you that information.

So some of the challenges that we've found for the evaluators are, you know, lack of familiarity with students, and several of you had listed that on your caption there. Then we also have lack of familiarity with multiple disabilities. The student may not receive O&M. Student is reliant upon equipment and staff support. And you know, that's a really important piece because if we don't collaborate well with other folks that we work with, we're not going to get a big picture about that student. Optimal learning conditions are unknown. Student may not be able to help or take part in the assessment process.

I did want to point out that, regardless all students should receive an FVA, LMA and O&M assessment, all of our students who are visually impaired or identify with a vision impairment. That's really important because if we don't have those pieces in place, we're not going to be able to share that information with the other team members on how our students are functioning.

So some of the solutions for team collaboration-- and you know, gather necessary information and understand this to complete the FVA and additional assessments. Get the job done in a functional and meaningful way. You're findings should relate to the concerns voiced by educational teams. So what we do here is sometimes it's as itinerants or site-based. It's really difficult to collaborate with every single team member. Sometimes it has benefited us to come up with a document that we send out, a team interview document that we send out, and sometimes we send that out electronically. And you all should have a copy of that. It'll be on a later slide that we'll go through, but I just wanted to touch base a little bit on that.

If I send this document out to Joanne and she's got a specific concern on a student, if I don't address that specific concern, when my report goes out, that report will have no meaning to her, in terms of how to address what she needs to do for that student. So I want you all to be aware whatever data you're collecting from other team members, that you address those specific concerns that each of those team members have expressed to you.

So collaboration, as you know, is important. Obtain information through informal and unstructured activities in the student's natural setting and during the student's everyday activities and the primary purpose of the FVA. Remember, you can't do this alone. That's why we have a team. We always have to work as a team, and that's really important. And I understand as itinerants and as site-based, it's really difficult to coordinate those type of activities with other team members but we have to make every effort to do that.

We've listed a resource here for Jan Erin and Irene Topor of 2010. If you don't have this book, you know, just flip through it. Get it from the library. It's got some valuable information in there.

So this is a flowchart that you should have, and I want to stress that this is not mine. I adapted this from the Colorado Department of Education. And I don't know if you can see the slide clearly, but it's-- what we've called it, here is the flowchart for literacy plans.

And the first box has functional vision assessment, which is completed by a teacher of the visually impaired. Then there's an arrow going down to the next box, which has learning media assessment, also completed by a teacher of the visually impaired.

Now, on the first box, there's an arrow going to the right, and we've listed a CLVE in there. This is a clinical low vision evaluation. Sometimes when you complete your FVA, that's when you can kind of tease out maybe this child or a student or client would benefit from getting a clinical low vision evaluation.

Now, the big box we have in there has-- within that big box we have educational, which is completed by the classroom teacher, and our TVI. Social/emotional by the counselor or case manager, motor OT, PT, O&M, certified O&M specialist, communication, speech language, cognitive, by the psychologist, transition. We've tried to list as many things as possible in there.

From all of those pieces, we get the decision made about the literacy plan by the team. Once that literacy plan is determined, that's the information that goes for the IEP.

Now, the last box on there is something that we put in there for our school is if all of these pieces are not completed, we will not be able to know how to select the reading medium for this child because it's all based on the functional vision and the learning media assessment.

OK, so this should look familiar to everybody. This is actually the expanded core and what we have done is kind of listed underneath the different areas of the expanded core curriculum some of the different providers that kind of work in those areas. And as a side note, I want to say before I finish talking about this, is that for individuals with vision impairment, it's really important for you guys out there who are the specialists in vision, like the TVIs and the O&M to help train all the other staff members on the expanded core.

Because I will tell you, as a physical therapist, we aren't trained on any of that. We don't even know what it is. We've never heard of it. Of course, because I work here, I do know what it is but most of my colleagues do not. And so if you're an itinerant in a public school and you're out there working, you really have to be the one to bring this idea to the table and say, hey, you know, we have the core curriculum but for our kids who are visually impaired and blind, this expanded core is just as important. And here's the areas and these are the kinds of things we need to look at to come up with our priorities for the year and then our discipline free IEP goals. And it's really important. I mean, that's something that a lot of districts are still struggling with, especially developing goals that are more inclusive.

But here, you know, as the person going in to do the FVA, you have to do a lot of training. First of all, you have to train the other staff on what the FVA is. I mean, again, most staff, they don't even know what an FVA is. And I know someone had put on their list about eye reports and you know, decoding them and talking about them, and all of that is really important to teach the other team members, you know, this is what the eye report says. This is what it means. This is the expanded core. And as you come in, you know, you can use these areas and teach them that this part of the curriculum is important, especially for PTs who may say, well, this isn't school related. You know, it's not educationally relevant. Well, for kids who are visually impaired and blind, there's a lot more educational relevance with other activities because of the expanded core.

So when you're doing this assessment, thinking about these other areas, you know, it may be the PE teacher if they need help down there, figuring out, you know, what this child-- how much they can participate and what they can see if they're visually impaired.

You know, a part here, where I put orientation and mobility, it says O&M or PT. It says that, not because the PT is the O&M but it's because a lot of our kids coming into this school, believe it or not, don't have O&M on their IEP. Often, it's a PT. And so, like Rajiv may have to come to me to say you know how is this child doing? Or if they're walking, you know, how far are they walking or what device are they using? Because O&M isn't yet in the picture. We haven't yet gotten them on board. Or it may be a child in a wheelchair and we have to go through a process of getting an O&M evaluation, but we don't want to hold up the rest of the process waiting for that to happen. So, you know, it may be that the PT is the one you have to go to and talk to them.

You know, again, for independent living skills, it could be the OT. Maybe they're doing a tooth brushing routine in the morning in the classroom and you know, the FVA, they can talk about what's going on in those activities. If they're having trouble, they may need help figuring out, you know, how can we make accommodations for this student during these different types of activities?

So just keeping in mind to use your entire team, but you are the experts and you're gonna have to teach, do a lot of teaching, because a lot of these professionals out there just don't have this information and you do have that information. So that's important to keep in mind. But again, looking at all these different areas, you have a lot of different resources of people that can help you set up the environment, work with the student, and help you get better information because we all know the kids. We know how they work in our environments. It may not be perfect, but at least you'll know maybe some of the limitations and problems that we're having with the student in those environments.

So moving right along, well, you know, preparation as a TVI, what type of information do we need? So we've got, you know, you collect-- for me, one of the starting points is reports from the eye care specialist. Oftentimes, with our students, they're not current. So sometimes that's half the battle is trying to get a current picture and stressing the importance of, you know, getting a current eye exam, especially for our students that have a progressive eye condition, for example. If we don't get current information, then we're not providing the team with information that could be usable for them.

Oftentimes, the eye report does not give a complete picture of vision use for our students. You know, there may be areas of uncertainty that I documented that we don't know about. I also like to review clinical or vision evaluations if this student has had one. Also, the information is not obtained by observation. The evaluator may not know the child well.

When we have our clinical low vision evaluations here on campus, I attend every one of them. I do have a good feel for the students and the staff. I try to see if the teachers or the O&M specialist or any other staff member would like to attend just because with our low vision docs, it's a lot easier if there is somebody there who knows the child. I don't work with a lot of the students directly. I do work with some of them, but I rely on the other team members for that information and you know, we share that with our clinical low vision doctor.

The family in the view is also a really critical piece, and I know a lot of you-- there are several forms out there. Most of you who are seasoned TVIs or O&M specialists, PTs, OTs, every discipline has an interview form of sorts. Now, we've thrown one in here that you should have as part of your handout. If you choose to use something similar, that's fine. If you have your own, that's fine, too. These are just thoughts that have helped us over the years.

And when I first started here in my position as a low vision specialist, there were so many forms. And I've been a TVI for, I'm going onto my 26th year now. And there's so many forums out there. When you get out of school, you're given one for protocols, and so it's kind of difficult to see what's going to work, what's not going to work. And that comes from just working with your families and your teams to determine what's going to work for you in that situation.

So we've come up with a form that we think has worked well for us and one of the main things about the form is that it brings the team concerns into focus, and that's really important. Because we can go in there as TVIs and do our assessment, do our thing that we are all really good at and then write a report, which we're all good at but sometimes, those reports don't make sense to the people that they go out to, and we want to make sure that we address that piece.

So we've come up with a form that's the multidisciplinary team interview form. It develops a picture of the whole child-- current participation at school, physical abilities, communication mode, how provider see student's vision use, what modifications are being used, issues that affect testing, helps meet the team member needs, area of concerns are documented, questions about vision use, you know, and goals are identified.

And this is where we get information about behaviors and you know, things that we can discuss with our team members, in terms of what we need to be looking for or how we need to work with this the student. Now, the next few slides is going to be the team interview for the FVA. The forum is, I think, it was distributed electronically. I'm not sure. But for us, we are a fairly spread out campus. So sometimes we run into each other pretty often, sometimes not, which may be a good thing or a bad thing in the case. But we try to get this out electronically to the families, to the team members so that each person that works with that student, we try to get them to complete the form. So if the student lives in the residence hall, we get the residence hall to complete this, too. So we have the parent, teacher, the student, if possible, TVI, O&M, PT, OT, communications, we try and get all of those interview forms done.

So and this is just-- for the next few slides, as I said, is just a brief description of what's on the form. So we have the description of the student's use of vision, including working distances, changes in vision, conditions that might affect student's vision, physical limitations, cognitive differences, medications, et cetera, student's independent reading level. And that helps me with the independent reading level to determine what I need to be using, in terms of my protocols. Visual difficulties with school-related tasks, hobbies, visual difficulties with these hobbies.

And I wanted to add something on this, too. So this is something that, as Rajiv said, every individual discipline fills out. So like, I'm gonna list on here for Rajiv, specifically how I think the student is using their vision with me. So I may be talking about, you know, if I'm walking the student, if I see them identifying landmarks, if I see them missing landmarks, you know, whatever I"m seeing. And then again, conditions that might affect the student's vision, I will list in there. You know, maybe they have a hard time holding up their head. They need to be in a stander. I'll list all those things for Rajiv, and then again, visual difficulties with school-related tasks, it would just be specifically with what I'm doing with that student.

So like, you know, OT may have things that they're having difficulty with, I may have things that I'm having difficulty with, the teacher may have things. So each form is gonna give Rajiv a different picture of the student in different environments throughout their school day.

Yeah, perfect.

So then we go on to adaptations, accommodations, low vision devices currently used, and that's good information for me. Best lighting for the student, you know, and sometimes some of our students work with a teacher for the visually impaired, and I'm the one that kind of coordinates the functional vision assessments. So I can gauge that, in terms of what's the best lighting for them. Joanne tells me, OK, you know, when they come into the room, they're shading their eyes or something like that. So that gives me that type of information.

Also sun protection is really important for all of our kids, mobility concerns, both from the mobility instructor, PT, OT. Student's schedule-- I like to get this. A lot of the folks that we send this out say, well, I don't know what the student's schedule is. But as Joanne said, it's specific to each of these individuals that completes the form. So that way, I know when I start my observations, I can go on these days at this time and see them in different environments, and that's mainly for me.

The last point we want to bring attention to is the main goals and objectives for functional vision assessment. Each one of these from each of these individuals is extremely important for me. So if Joanne has a specific goal for why she would like information-- what information she would like from this functional vision assessment, it's my job to make sure that I address that specific goal. So once each of these individuals from different disciplines completes this part of the form out, then I know it's my job to make sure that I address it so that they have usable information.

So what will you gather from this form that we've come up? For me, it'll give me the information of what I would need for tools for the FVA. It will give me information on what environments I will need to be in to conduct this FVA. What the possible obstacles or behaviors, who or what can help minimize them, motivators, and if, as Joanne alluded to earlier, pre-practice is necessary. You know, we try and get our students, our staff, the materials they need to practice. We'll go through what they need to do and sometimes it takes a week. Sometimes it takes longer. And then I'll come back and you know, we'll work together on doing what we need to do to get the information we need.

And also you know, it depends on staff-wise who we'll need. If it's I need Joanne or a teacher aide with me because the students most likely are not familiar with me, so I like to get to know them a little bit. So I like to make sure that those pieces are taken care of.

And that also brings a plan for the aggressive students because we all have those students. But you know, there's always that one person that can work really well with that student or knows their behaviors and knows how to get them to work for a certain period of time and it's critical that that person is identified and that person is at the FVA.

Now, we had a lot of questions about CVI, so we threw this slide in there anticipating that would come up. So we just wanted to remind everyone that we will address the CVI piece but not right now.

September.

In September. I guess we have a tentative date, but we'll need to do some talking about that between Robin, Joanne and myself.

So what's next? Where do we go from here?

So if you have the form and you had everyone complete the form that you work with, or at least a few critical team players, once you have all your forms, what would be your next step? Does anybody want to venture out?

Once again, we've got the chat box open, and you can put in your answers there. I also wanted to note that Valerie has added a couple of the forms that you've been talking about. It's in a pod called Files Two. It's right there on your screen. These will also be available on site with the presentation and the recording. But if you want to download that now, in order to take a look at it, or if you're attending as a group, you can select the title and a download file button will appear.

So coming right into the chat right now, Stephanie says, observe the child during various routines where the team has indicated concerns. So you use the tooth brushing example from earlier, certainly observations in multiple settings.

Very good.

This may take a little longer to type up but please do. Go ahead, I'm sorry.

I was gonna say initially the two brave ones, that exactly right.

So interviews to better understand the responses and receive clarification. A cumulative folder review, that's an interesting point. Once you have all the information, begin to see the child on different times and dates.

And the cumulative folder review you may have already done prior to.

Someone had mentioned in the initial chat about the eye doctor's reports and how you tease the information out, and that's a really important piece for students with multiple disabilities. Some of the doctors are really good with working with students with multiple possibilities and then we have some that are not as good with working with students with additional disabilities. And I think if you build those relationships with your doctors, you get a better understanding of the collaboration. We have found that while working with our doctors, we are able to get information or share information with them that's pertinent, and they can give us information.

And the one thing that really irks me as a TVI is seeing something on a report that says CSM or F and F, and to me, when I see some of those, I'm not here to offend anybody but when I see CSM or F and F that means LD to me, lazy doctor. Because I think that we can get better than CSM and F and F for a lot of our kids, and sometimes when you get a report with those acronyms, it makes our job more difficult because we're not really sure where to go. But sometimes our reports will give our staff more information than the doctor's report would.

So Rajiv, for those of us who aren't visual specialists, what is--

Thank you, I was just going to ask.

Yeah, this is the where I have to go, like--

OK, F and F is fix and follow, CSM is central, steady, and maintained, and we get that a lot from a lot of our doctors but mostly with the doctors who are not familiar with working with students with multiple disabilities.

And I think someone brought up that point of doctors that don't agree. We see that a lot with CVI kids, too. We have kids that we don't, and sometimes you have to do your best to work through it or refer them-- or not refer them but suggest that additional--

Yeah, you know, I mean, I think there are going to be situations where doctors don't agree with each other's findings. And also, you know, you want to be really careful with CVI in particular. Like I said, we're saving that for another discussion but since the topic is up, is that oftentimes, we have students that present as if they're CVI, and then all the staff goes, oh, this kid is CVI, but we don't have a doctor's diagnosis of CVI. So it makes it difficult for us to determine because once you start programming for a student with CVI and the student is not a CVI student or there's no diagnosis, that puts us in a very precarious position. But we'll get to that at the next presentation.

All good thoughts.

Everyone was right, observations, observations, observations, that's the key. I work with a lot of graduate students from the University of Arizona, and they're placed here for a low vision internship, and I tell all of them that almost 85% to 90% of your FVA comprises of your interviews and your observations. The remaining 10% to 15% is your assessment piece itself. And I just want to hammer that in because I think that is really important. If we don't find the time to conduct the interviews and to observe, we are not going to get a good picture of how this child is functioning.

So general questions-- for me, when I'm gathering information is what size symbol can the student identify? How much contrast is needed to see the symbol? Are there limitations in color discrimination? Where should materials be placed in the student's visual field? Does lighting need to be modified? And I gather this information from the form that we get.

OK, and then as we-- as Rajiv, I would say, is conducting his observations, you know, he continually, like he said, accesses different members of the team. And I think-- and some of this has already been discussed-- but just to really point out that trying to figure out what is the best time of day to see these kids, especially your really low level kids. Sometimes it's, like, first thing in the morning or first thing in the morning could be really bad. Maybe it's, you know, right before lunch, they're a little more awake. The medications are less effective at that point. Maybe Mom and Dad had medicated them in the morning before school. Especially seizure medications often tend to cause kids to be very drowsy. And then, you know, days of the week.

But the main thing is positioning for some of these kids, too. You know, there's certain kids that we know when they're in a standard, for example, and they're really secured, the only thing they have to do is sort of hold their head up, they can often use their vision really well. So sometimes, you know, that may be one of the only positions you can work in. Or you know, if they have a wheelchair or a classroom chair that's pretty supportive may be a good position. But finding that information out is probably going to be one of the best things you can do, because if you have very limited time with the student, you want to optimize that time.

Especially if you're an itinerant and you're coming in and out and you don't have all day to be, you know, trying to get information on this child, it would be coming in and getting the best position for that child in the classroom or it could be in the therapy room. It doesn't necessarily have to be in the classroom, especially for these kids who have multiple, multiple impairments. Sometimes the classroom isn't the best place, unfortunately. Maybe it's too loud. There's too many kids in there. Especially kids who are on the spectrum, a lot of those kids need to be taken into a quieter environment and the OT or the PT who works with them often knows their sensory needs and can get them ready for testing. I think that's an important piece. So you need to really utilize your team members and talk to your team members about how to get this done.

And again, like I said, you know, before coming here and working with Rajiv, I never had anyone approach me, you know, like itinerants saying, hey, we need to do this FVA. I didn't even know what an FVA was, actually, till I started here because no one had ever even told me. I hate to admit that but that's the truth. Because it's not something that's often discussed with other team members.

So just keeping in mind-- you can switch to the next slide-- that you want to, you know, use your team to set up the right positioning for these kids. The optimal learning environment is obviously where you want to start, or at least, for sure, test them in that environment. And then, at that point, like Rajiv said, if you're trying to answer questions that team members have, you may have to go into non-optimal environments to try to figure out how to make that environment more optimal for those providers if that's something that they need help with.

Just to piggyback on what Joanne had said earlier, the time of day for the observations and the environment is really critical, and we really understand the constraints that you would have as an itinerant, but I think that utilizing the other team members to gather that information would be really helpful and would be something that may eliminate some of the stress that you would have from trying to gather this information all by yourself because you shouldn't have to gather this information by yourself. I think that all of our disciplines has a lot to offer for our field, especially when it's coming to working with our students and we need to utilize that as much as possible.

Right.

Lost my mouse there for a minute.

So here's some of what, I think, are basic components of what a report should include, and all of you have information on this. I'm going to go through this very quickly. You may use some of it. You may disagree with some of it, but this is what we have for our standard report template, that, you know, we'll be happy to share with you if you want. Maybe after the presentation, you know, we could-- I think our emails are on the end of the presentation. So if you want to shoot me a quick email, I can get information to you.

So basically, we have history, assessment tools used. And in history, we put ocular history, medical history, and all of these other pieces in there. We have the assessment tools used, like I said, acuities, visual fields, contrast sensitivity, color vision, lighting, visual behaviors, depth perception, working distances, distance near, suggestions to improve visual efficiency.

Now, I want to bring up a point about depth perception. I don't use a formal test for depth perception. I don't use the Stereo Fly. I used to use it when I got out of graduate school, and I haven't used it in years because I think that is something that a doctor should be using, and it's not my role as a TVI.

I use more functional type things from observations, and you know, if a student is underreaching, overreaching, tripping, has a significant acuity loss in one eye compared to the other, I'm almost guaranteed that there's gonna be a depth perception issue, but I don't use any of the other formal testing modes that some of us we're trained to use. So I've changed my way of thinking a little bit, but I find that that has been useful to gather that information.

Once again, I want to make sure that, you know, hit the point across that almost 85% to 90% of your FVA is gonna be observations and interviews and the rest of it is the assessment piece itself.

OK, so here at the end, we're gonna go over a case study of one of our students. And just to give you a quick history on this student-- he's a 12-year-old boy. He had a profound hearing loss. He had posterior brain abnormalities that weren't diagnosed. They just knew there was something not right, but they didn't have a specific diagnosis for him.

So he wasn't able to close his eyes and because of that, he had some bilateral corneal scarring. He had conjunctival drying, and then what they did was they sutured the sides of his eyes closed to help with that. You can pronounce that word, Rajiv.

Tarsorrhaphy.

Yeah.

And he also had exposure keratitis, meaning he had corneal drying or inflammation from incomplete closure, as Joanne had indicated earlier. So he had a lot of these issues. Now, I'm gonna say that I had a connection with this student because I have corneal issues myself and I have keratoconus and have had two corneal transplants. But this kiddo was a great kiddo to work with, and if we hadn't collaborated with teaming, we wouldn't have got very far with this kiddo.

So the information from his clinical low vision evaluation-- his distance acuity was 10/60 in his right eye, 10/60 in his left eye. His near acuity was 0.8M at six inches, which is typically newspaper-sized print, 1.0M at six inches for continuous text, which is magazine, approximately. His fields were 20 degrees centrally, right eye, 45 degrees, left eye. The recommendations from the CLVE were no low vision devices but sun lens evaluation for glare control.

OK, let's skip this because we have time constraint. We're gonna skip this part of it-- I mean, your input, if that's OK, Rajiv? And we'll just go on and hopefully, we'll have time for questions at the end. OK.

OK, so what we do here is we do a static visual field. Static visual field is a measure of the outermost boundaries, left, right, top, and bottom of the visual field. And this is performed in everyday environments with the person in a static position keeping head and eyes still. So we have a hallway in one of our buildings here that we set up, and we have the student standing at one end of the hallway looking down towards the plant at the other end of the hallway. And we've got pieces of colored paper on the floor, on the bottom, top, left, and right.

So as the student is looking down the hallway, we ask them what's the closest paper they see on the top, bottom, left, and right, and then we mark that. So the area within the circle that's drawn is where this child's visual field is. And we've done this with most of our students that we're able to do this with. If we can't use this specific task, then we accommodate and do something else.

Now, this gives us information and also we did something called early morning field and some of you are familiar with this. We have the luxury of a mat that has the degrees listed on it, and we have the student on one hand and another individual at the other, and someone else is walking beside the student, and we can judge where that student's visual field early warning, when he first detects someone.

Now, this is a preferred field test that we use, and this is a measure of a person's regular pattern of viewing in everyday environments with no limitations on head and eye movements with the emphasis on where visual information is most often obtained.

Now, we walk with our student and tell him to pick out everything they see visually. It doesn't matter what it is, whether it's gravel, grass, a fire hydrant. For each area that the student picks something out, we put an X on there. If you notice that his lower field, there appears to be limited X's on there, and I'm gonna tell you that we feel that the reason that he's got that limited field in that lower area is not because he wasn't looking down because when we did this assessment, he was in his wheelchair. So he missed that total area that was covered by his wheelchair.

OK, so Rajiv, this student-- you know, Rajiv had got to know this student. I worked with this student, did these tests specifically that he's talking about. But then on the form, you know, if that functional vision assessment would come to me with all of those X's and O's, which is great information, but I'm still going, OK, how does that translate into what I'm doing? Other than, when he's in his wheelchair, I know that he's not seeing, you know, things right in front of him, down at the bottom. But how does that help me do what I need to do? So on the form-- that's the next slide-- it'll say right here, it says that-- this is what I wrote to Rajiv exactly-- so that the student walks with a posterior walker. He occasionally needs reminders to look down and to the side if he hooks his walker like on a, like, the side of the door or a chair or something like that. He doesn't always initiate freeing his walker. So I wasn't sure if he could see whether or not it was being hooked on something. I wasn't really sure if he could see when he looked down because his eyes were sutured. I noted that looking up he was having trouble seeing things. He also had balance problems because the posterior part of his brain was malformed, but I also didn't know if, you know, he was having trouble seeing up. He needed cues to tilt his head back, so I wasn't really sure if he was aware that he was missing some of this information.

But part of the problem was I was working with his class in the library. And so like here, on my form for Rajiv, I said, well, what's the best placement of objects for optimal viewing? And what kind of modifications does he need to improve his vision use like when he is walking with his walker? I didn't know if there was something I could do to help him, you know, better, like, not hook his walker on things, and that's more of a safety awareness thing.

And so Rajiv actually came with me to the library to figure out, OK, because part of it was he was missing a bunch of books on the shelves. And he was supposed to be able to go to the library and walk with his walker and pick out books with his class. And so that's what we were working on.

And so we went to the library and we set up--

Do you want the next slide?

Yeah, well, you can talk about this, Rajiv, if you want.

So what he was typically doing, we set up an environment where what he needed to do on a regular day with his classroom, we did that together as a team, collaborating. So it enabled us to test his fields, determine that he was able to see small items in all of his lower fields when walking and then he was missing items in his upper, left field when he was walking, using his walker.

And the way we did that, I don't know if you can see in the picture, there's a lot of little colored objects on the ground. And so he had a walk down the rows of the library because it's a very cluttered environment and first, just to see if he could see those things and he could, actually. So he just needed some reminders to look down, but he was able to see, which it was good information for me. So I could sort of demand that he be more accountable to using his vision and looking down.

And then, you can't see it here, but we had colored blocks and things that were put in between some of the books in the bookshelves at different heights, to ask him like to look for the red blocks, and they were fairly large. And consistently, he was missing the blocks that were up on the left side of, like, the library. So we knew, like, that was not a good area for him, as far as, you know, expecting him to look to see books. And so that was information I could use to help him finish the functional activity in the library with the class, and it was information I wouldn't have been able to get just from reading a traditional FVA report.

And also, one of the other pieces that was really important for us to share with the team, is that with the scarring of his cornea, he was very, very sensitive to direct sunlight, but he never wore a hat or sunglasses. So that was the other piece that we had to throw in there because when he came into any indoor environment from outdoors, the feedback that we got was he just takes a long time to do anything. You know, why is that? And so once we got a glare control assessment done, he was more efficient. He was able to adapt to those changes in lighting.

Transition.

Transitioning from classroom to classroom.

I think we ran out of time.

I think we ran out of time, but here are some of our references that we've listed on the handout.

Our contacts.

And good luck collaboratively meeting the challenges of your students with multiple disabilities. And here's our contact information.

Do we want to take questions that we can answer?

I would like to. You have a bunch of them, actually. So if you guys can stick around for a couple more minutes-- we understand that some of you might need to drop off. We're gonna keep recording so that this conversation will be also recorded. But you did have a number of questions and some of them are really drilling down into some of the items that you mentioned. So I'm gonna try to take these in a certain kind of order.

Do you have any comments on the order of when some of these-- I'm gonna go back to the individual's questions-- when some of these tests should be done? So for example, should the student see the ophthalmologist first or the developmental behaviorialist? Or do you have any opinions about whether that sequence of assessments makes a difference?

I'm gonna start and then Joanne's gonna jump in, OK? For me, as a TVI conducting the FVA, I always like to have a copy of a current eye doctor's report just because if I don't know what the diagnosis is, then I can't make recommendations. Irregardless of what the doctor may list as an acuity or if they've addressed field losses or whatever, if I don't have a diagnosis, I can't come up with any or even share information on that particular diagnosis with the team because they may not know what some of the implications are for that student, for that diagnosis.

Now, someone had mentioned the cumulative folder-- it's a really good point. Is that once I review the eye doctor's report, I've reviewed information from the team members, that's where I gather all of that information. So I really don't have a particular order on how we do things. And you know, I don't know how it is. I haven't been an itinerant in a long time but I just remember my days as an itinerant and my days here, sometimes getting that information is the bigger issue than anything else.

So if I don't have that doctor's report and the chances are I'm not gonna get it, I'm gonna get started. But I'd like to have something now. If we have a kiddo who's been here and hasn't had an eye exam, you know, annually, I'd say best practice is they need one every year for all of our kids who are visually impaired. Sometimes that doesn't happen. We try to stick with the best practice policy of every year they need to have an eye exam, and it takes a village. It takes all of us to make that happen. So you know, and I think anytime you can encourage, you know, ocular health for all of our students, I think that's a big piece.

OK and as far as seeing a behaviorialist, I think, like, what Rajiv said, with so many of our kids, they don't ever get to see probably all the specialists we want them to see, unfortunately. And it could be insurance reasons. It could be lots of reasons that are out of our control. And so many times we have kids that come in to the school that, let's say, we know that they're probably on the spectrum or autistic and sometimes, especially the young kids, they're not diagnosed. And you know, we make recommendations for them to possibly see a behavioral specialist or a neurologist and sometimes, you know, the family is on it and they make the appointment. And here in Tucson, to see a behavioral specialist, it can take half a year, if not longer. We have basically one.

And so the order, I think, in the perfect world, you know, they would come in with a diagnosis from a neurologist or behavioral specialist. They would have their eye reports, and we'd all be able to read the reports and be happy. But I think in the real world you just kind of operate from, like Rajiv said, the standpoint of you make recommendations and if you don't get the information you need, you still have to move forward. I mean, sometimes with kids like that we know potentially are autistic, we just treat them as such, but we can't label them as such.

So you know, we set up the environment. And that's the same with kids with CVI. We get a lot of kids that we think may have CVI that aren't diagnosed yet. And we set up the environment as such. We document that they're showing certain tendencies. We work with them the best we can to our professional knowledge, which might be a child that, you know, has autism or has CVI and we don't always have that diagnosis right away. We work as a team, you know, to continually talk about it and hopefully, we get it. But you know, there's like this student we showed you the case study on. You know, we knew there were some posterior malformations of the brain but to this day, we don't have a diagnosis as to what it is, what's going on with that particular situation. But we can't force the family to, you know, take the child to the doctor.

Obviously, with eye reports and stuff, there are certain requirements for the MET and things like that but I mean, we just work with the information that we have the best we can. So it doesn't totally answer the question, but I mean, I think what we're saying is, you know, there's not a set order. It makes our life easier to have it done, you know? And I don't even think an eye report over a behavioral specialist's report, they're both important. So it's not like one is more important than the other. It's just that we don't always get that.

Just be aware that, you know-- just throwing something out there-- oftentimes, we have kids who are supposed to wear prescription glasses and then when it comes time for our functional vision, they're not. You want to make sure that's documented because that's going to skew your report and your findings totally. So we try to make sure that if they're there without their glasses, that we get an opportunity to get them back in with their glasses so we have both results.

That's correct, or the other thing may be the glasses just may not be working for that student, and they haven't been back to see the doctor. Because I know kids with special needs or multiple disabilities, they can't communicate that they don't like those glasses, but I'll tell you, I have numerous times kids will somehow get those glasses off and break them or whatever they'll do to them because I think they're not working for them, but nobody knows that it's probably making their vision worse. It's hard to know. But that happens a lot as well.

And that's the critical piece of getting, you know, an eye exam with an eye doctor on a regular basis for ocular health to see what's working, what's not. You know, sometimes some of my kiddos have very mild prescriptions. They may or may not be beneficial to them but you know, as long as the doctor's recommended the glasses, we'd like to make sure that we have our students evaluated with the glasses, with the prescription glasses.

OK, I know we're running a little bit over time. There were just a couple of other questions that I thought were particularly interesting, given the presentation that you had made. We didn't get to talk specifically about nonverbal kids, and I wonder if, briefly, you have some suggestions of tests or methods that have worked for FVA with kids who, let's just specifically say nonverbal, that answer may be different if you're using a communication system, but let's assume that the child is a very, very early communicator.

OK, well, I would say the kids that are-- you're saying kids that are young, as far as early communicator?

The person who asked the question wasn't specific, but I was just trying to, in the interest of time, maybe we talk about just a child who does not have language, whatever that means for you. You know, maybe they're they're an infant or they don't have a communication system that they can use.

For very young students, infants, et cetera, we typically don't see those because they go through our early childhood program. And so we collaborate-- if we are asked, we collaborate with our early childhood program to determine those needs. Now the functional vision assessment piece itself, I mean, there are obviously going to be pieces you can use and pieces you can't use. So what you do from a functional standpoint is going to be dependent, again, on your observations and your interviews to see what's gonna work and what's not gonna work. Because if you go in with a whole box of stuff and you go through a protocol and you start it, most likely you're setting yourself up for not getting a good functional vision assessment.

Yeah, I would say those are the kids that often, like, Rajiv will come into a session like OT or PT. If we're working with kids, a lot of times it's preferred toys. It's looking at what kinds of things are they drawn to? What kind of things are they playing with? And that gives a lot of information about, you know, their vision-- or not playing with or not accessing. But like, those kids that, let's say are nonverbal, often, you know, they may not be communicating. It depends on if they're nonverbal and following directions or nonverbal and not following directions. I mean, that's a big difference right there.

Yeah, that's an important distinction. Thank you. Thank you.

Yeah, because if they're nonverbal and following directions to some degree, then typically a lot of those kids work really well on structured routines. They have structured routines, and staying in that routine is often your best bet, instead of pull them out of the routine, especially if they don't have a lot of language it's hard.

So you know, if you go into the classroom and you can see, you know, in the morning, they have check in and they get their picture and they're able to place it. You know, maybe their using a visual board that's black and they're placing it in the white, in this case, or they're matching, a lot of times with those kids, it's routine and they learn. Even though they're nonverbal, they learn what they need to do. And you can watch them in those environments and see, you know, how they're using their vision, how close they're sitting, how far, the colors, the toys.

Like I said, a lot of times, you know, Rajiv will come over and talk to me and I'll say, well, I can tell you for sure. It's like these are the balls they like to play with. He doesn't like this, and it may be again, often a CVI kid, who, because they have the neurological involvement, and often some of those kids don't have language but it could be that, you know, every time they come in, he'll go to the red ball or the yellow ball. Or I can play with this size ball. They're interested in this kind of activity. And for those kids, a lot of times, it's really just observations and talking to the people that know those kids and trying to get your information from those routines that the child already knows.

Because you can't take a child that doesn't have a lot of language into a novel environment and really expect them to maybe understand what you want them to do, especially if they're not following directions real consistently or if they're fairly young. Using the stuff that's in their routine, or again, you know, pre-practice with them. You know, some of those kids, if you give the stuff to the teacher, you know, whatever it is you want them to look at-- like I said, we use the LEA puzzle here a lot. They can practice with those things before you get in there with them.

But the best advice I have for someone who's nonverbal is just to make sure that you're working with someone that knows the child really well. Because you can't go in there on day one and try to figure out how to communicate with the child. You need to access the people that already know how to make that communication happen with the child. Because there is a way to communicate with that child, it's just that it's not gonna be your traditional, you know, question and answer like you would give to a child.

Yeah, so you have to find the person that knows how to communicate, whether it's a picture or symbols, it's whole objects. I mean, there's some kids where you may come in with a 2-D representation of something, and they would say this child is not understanding anything on paper. It's all whole objects. So everything has to be done with whole objects, you know, that they're familiar with. And these are the five objects they're familiar with. Here you go. You know, figure out your test around these five objects.

I mean, that's the reality sometimes with these kids, but that's where you need to work. You have to work at their level. And you may not be able to do all the tests you want, but at least you'll get some information.

Yeah, exactly. And especially, you know, someone-- the question revolved around early childhood, infants, and I think once again, you've got to go back to the observations and interviews, the parents, you know? And especially if it's an infant, sometimes the parents may not be ready to participate, and we need to be respectful of that. So the other team members that are working with that child and the family, you can gather a lot of information from them, at least precursor type information.

I'm glad you brought that up because we had a question from a parent, and I'll make this the last question, if we can do this. We've got a number of questions we didn't get to. If we could maybe communicate between the group of us by email and maybe make an FAQ handout or something for the presentation.

But you mentioned the parents, and again, an essential part of a collaborative team. And one of the parents noted, you know, she came to the meeting and there were a lot of these questions that she felt like, you know, caught off guard, wasn't giving the most reflective or thorough answer that she could have, and is wondering is it ever common practice in an FVA situation for the parents or the family to have those kinds of questions ahead of time so that they can be prepared for that conversation?

Well, the form that we send out for our FVA-- I'm gonna address that piece first-- we send that out to the parents as well. So whether they complete that as hard copy and send it back to me or electronically, it really doesn't matter, as long as I get a copy of it. And we've been fairly successful with that. Because I want to make sure that from a TVI standpoint, that I'm addressing the parents needs as well, the parents questions as well, because that makes no sense for me to disregard that. The families are the biggest part of-- we just went off. Sorry about that. My screen went to sleep.

No, no, no, we've got you. We've got you.

So the families are really important and they're an important part of the team, and they continue to be an important part of the team. And we like to get them as involved as possible. Now with the meeting itself, I don't know what the specifics are, in terms of what specific questions they were looking to get prior, but if you're looking at, you know, a copy of the report, the functional vision report ahead of time so they can review it, I don't see any problem with that, personally. I mean, we've had situations where a draft copy was sent out. I'm gonna be really frank and say that, when I write a report, that's from my professional bias. So I'm not gonna change the report because somebody doesn't like it. That's not my role. My role is to do what's in the best interest of each and every one of our students. So you know, having said that, I take every piece of information that I gather from every team member, including the parents, very seriously.

Right, and I wanted to add to the parent-- and I'm glad to see that there are parents actually on this webinar-- is that, you know, you have the right to say, I'm just not prepared to answer these. Can you give me the paper and let me fill it out and get it back to you? Because I could imagine as a parent, if what I'm assuming you're saying is, the TVI arrived or the O&M or whoever was doing the assessment, and then you had a bunch of questions for you and you weren't ready to answer those right on the spot.

And so, you know, it's OK to say, you know, could I write down the questions and then call you back or could I think about this for a little bit? Because I could see how, you know, you might miss something or that could be frustrating for you if you're, you know, kind of overwhelmed at the moment with all kinds of questions. So don't be afraid to say, you know, I want to answer these, but I want to do a good job at answering these questions, so you know, please can you just give me a copy, let me write it down, and get it back to you? You can try to answer, you know, on the spot what you can, but it's OK to ask to have, you know, something to give them after the fact.

I think that sometimes as providers, you know, we're busy and we're rushing around and we don't always think ahead to maybe give the family or the parents something, you know, ahead of time. And so it's a good sort of point to bring up, you know, that all of us, as providers, have to try to think ahead. And that's why here, you know, we do that. I know, Rajiv, if he sent me something and said, I need this, like, in an hour, and I'd probably be like, whoa. You know, I can't do it. I need time. I have to sit down and think about, you know, what I see from this child and what I want to write and make sure that it's, you know, thorough. So as a parent, you also have that right to say, hey, I need a little bit of time. Don't be afraid to say that and ask for, you know, time to answer questions if you need it. It's OK because I think the provider would rather have, you know, all the information than just a quick answer if you're not sure or you need more time.

And I think that's really helpful because it's difficult sometimes for us to remember that for the parent, this is the first time they're doing this, usually, right? And so someone in your situation, who's doing it all the time, and they can look to you to set the tone of what's OK or what's expected here, and I think it's important to hear that from you.

And I also want to add that when we send out the form to families and parents and caretakers, I actually make the initial call to them because they don't know me. I'm just the guy doing the functional vision assessment, which they have no idea what it is, oftentimes. So it's my responsibility to call each and every one of them and say, your child has been referred for me to do this assessment, and I explain what the functional vision assessment is and then I talk about the form. And I give them the choice of either completing it over the phone with me, electronically, or via hard copy.

OK, great. Well, we're gonna have to leave it here. I appreciate the extra time and for all of you who were able to stay. We're gonna address the questions that were asked in the Q&A box, probably in a form that we attach to the webinar page. You'll get information tomorrow about the recording, the presentation here, the different forms that were referred to, and you'll be able to download all of that. If you are interested in earning credits for having participated in the webinar, we have a tutorial format, where you just complete an assessment assessment based on this material and you can earn continuing education credits, and all of that information will be in our thank you email tomorrow.

So let me thank our colleagues, Rajiv and Joanne, on behalf of the Perkins e-learning team. I want to thank Valerie today for running the console and as always, we look forward to seeing you guys next month. Thanks so much. Bye.

Thank you.

Thank you.

Bye.