A Speech Language Pathologists (SLP) guide to children with Cortical Visual Impairment (CVI) with Jenna Friedman

Transcript: 

Hello and welcome to Perkins eLearning to Go. Each week, our hope is to provide you with an inside look at special education topics-- in particular, visual impairment. Through a series of interviews with leaders in the field and a fresh look at our webcast series, we know you will learn something new when you are on the go. Now it's time to sit back, relax, and let's hear what this week's podcast is all about.

Hello and welcome to Perkins eLearning to go, this is Valerie.  On today’s podcast we will be airing an audio version of one of our webinars.  This webinar featured Jenna Friedman, she is a speech pathologist.  She has done extensive research in regards to  Cortical Visual Impairment.  This is after many of her families reported they were not sure if their children could see.  During this webinar she will talk about her role as a Speech Language Pathologist and how they work with a child with Cortical Visual Impairment.  She will talk about strategies to address and utilize students’ unresolved characteristics of CVI to encourage more appropriate speech, language and feeding assessment and intervention. So without further delay, let’s hear what she has to say.

So CVI experience, throughout this presentation, I will be referencing children who have been evaluated by the CVI range. CVI range experts can include all different types of professionals, professionals with experience with the CVI range. This can include teachers of the visually impaired, PTs, OTS, ONM specialists, SLPs, teachers, et cetera.

I do believe very strongly that the CVI range should be administered for all children who have suspected CVI, and the Perkins Roman Endorsement ensures reliability of that professional. However, regardless of your level of familiarity with CVI, you most likely have multiple children on your case load with CVI as an SLP.

So a quick poll, I would love to know of all the people that are here right now, who is in SLP, and who has administered the CVI range.

Thanks, Jenna. So we're showing a few choices here, two choices, if you are in ALP, two if you are not. So you're an SLP who has administered the range is your first choice, an SLP, who has not administered the range. You're not an SLP, but you have administered the range, and you are not an SLP, and you have not administered the range.

And about 75% of you are reporting that you are SLPs. We knew there would be a high number of that discipline here today, who have administered the range. Next are people who are not in speech language pathology, but have administered the range. Great. Thank you.

Thank you all. Thank you. Thank you all for responding to that. It gives me good insight into who's here, and it certainly lets me know that, of course, there are a lot of speech pathologists here and knowing that you have not administered the range, I think that you'll get a lot of information in this presentation that will help you in just general accommodation and strategies in working with children with CVI.

So for those of you who might just beginning your CVI education journey, my best suggestion, and this is from my experience as well is to familiarize yourself with the three phases of CVI and the 10 characteristics of CVI. This webinar will cover general accommodations and adaptations that can be used in therapy sessions, classrooms, or home or natural environments, all based around the 10 characteristics of CVI.

It will include information for speech pathologists to consider integrating into your practice. And I'll show examples of how you can start to think about, how to think about setting up your speech, language, and feeding sessions, to ensure accessibility for children with CVI. And I will repeat as I spoke about before, the best practice is to have children you are working with assessed, using the CVI range, to make sure you know of the specific accommodations.

Just to quickly go over the three phases of CVI. Phase 1 is about building visual behaviors and getting the child to look. Phase 2 is about integrating vision with function. And phase 3 is about the resolution of CVI characteristics. As speech pathologists, we certainly will see and do see children in all phases of CVI.

So the role of a speech pathologist, the speech pathologist should always be involved with students who have CVI. As Dr. James E. Jan, who is a great researcher in the field of CVI said, "Due to improved medical care, children with severe brain insults have increasingly begun to survive over the last 30 years. The vast majority have tended to have severe multiple disabilities, including a variety of learning difficulties. A minority of them also have permanent visual loss, but normal or minimally abnormal eye examination. And it has become necessary to offer services for those whose visual loss is due to brain damage. And we are those professionals offering these services."

So a quick overview of just some of the medical conditions associated with CVI. You'll see this list here on this slide, and some of them are periventricular leukomalasia, asphyxia, or hypoxic ischemic encephalopathy, HIE, CVA, or stroke, intraventricular hemorrhage, infections, structural abnormalities, or trauma, such as a head injury.

So as you can see from this list, there is a huge overlap of children who need speech therapy and children with CVI. My point in showing you this is to show that these children of CVI are already on your caseload.

So the role of a speech pathologist. As you all know, we have many roles, but typically for most of the children we work with, our main role is communication. A quote that I have always, always thought about and think is so important by Pat Mirenda, who is an expert in AAC. She says that, "Breathing is the only prerequisite that is relevant to communication. Breathing equals life, and life equals communication. It is that simple."

So whether the children on your caseload are working on oral speech, signs and gestures, AAC and that includes no tech, low tech, or high tech or a combination, considerations must be made for the impact CVI has on their learning and engagement.

Let's get started. The next part of my presentation is going over CVI characteristics and the interaction with speech, language, and feeding. The strategies that I'll go over are broad, and since we do so much as SLPs, and you'll see that I organize them as general commendations to think about based on the 10 characteristics of CVI.

Number one, light gazing and non-purposeful gaze. So for all children that we work with, we always have to think about positioning, where they're sitting, standing, working during our sessions. For children with CVI, they're often found to stare at lights or have difficulty redirecting their attention.

So I always want you to think about when you're working with these children with CVI, you could work on positioning lights behind the child or even using lamps instead of overhead lighting. The way that you set up your session, even something as simple as changing the overhead lights to a lamp could make a really big difference for a child.

Another thing to think about for this characteristic is using lighted objects in your therapy. You'll see on this slide on the left hand side a boy using the light aide during speech therapy. In the middle, you see a girl using a lighted stick as part of her therapy, and on the right hand side, you'll see in one of the rooms at the center that I work at, we put up Christmas lights to bring some attention to certain parts of the room.

So on the left hand side of the slide is actually a room that I work in in the center that I'm at, and I circled some of the places where I'm sure this looks very similar to many of your speech environments. You see lots of puzzles, lots of toys, lots of objects. You see a circle over that overhead lighting and a circle outlining all of that light streaming in from outside.

On the right hand side, you can see that I used a big black cover to cover up some of the clutter to help bring attention to what I'm working on. I've dimmed the overhead lights and put up some lamps. And the only thing that would make this better would be if I could get some darker curtains to make that room really accessible,

iPads. I'm sure as SLPs you all use iPads throughout the sessions, whether it's for motivation or part of your part of the work that you're doing. So I put up here some really great apps for kids with CVI. Some of these I use all the time. Tap-N-See Now, EDA play, Infant Zoo, Big Bang Pictures. Light is really, really helpful. So using these backlit devices can make a big difference in your therapy.

We need to help children engage with their environment to encourage engagement with others. As a speech pathologist, we would never do a speech session without toys. You would never bring a child into your room and sit him down and say OK, we're going to start chatting, we're going to do some work, and have nothing fun around you.

So with children with CVI, if we're doing a speech session with inaccessible items due to functional vision, it's really no different. So moving on to color preference. What colors alert the child to look? That's something really important think about for all the kids you're working with CVI or suspected CVI. Dr. Roman says that individuals with CVI often have a strong attraction to visual targets of a particular color. So using preferred colors throughout your therapy to attract the child's attention toward specific objects or symbols can be very helpful. And if you're not sure what colors they can see best, use red and yellow.

So you'll see this picture here of a really sweet boy looking at a red pompom during his therapy. So he is a child who alerts very well to the color red. So going off that example, if you see a child who attends very well to the color red for any type of therapy you're doing within our realm, you can use that color. So for example, for feeding therapy, if you were doing feeding therapy with a child, who attends very well to the color red, you could use a red spoon, a red bowel, use red Mylar tape around a cup to help them attend.

At school, you could use red tape to highlight a child's cubby space. If a child is working on reading, you can use red to highlight the salient difference between two similar letters like B and D. And if you're doing speech therapy, you can use red objects to attract attention.

Latency. Latency is the lag time before a child responds to visual object. Communication partners need to wait quietly and patiently while their child is slowly processing the incoming visual information. I always say this to speech language pathologists, because we like to talk. Wait longer than you might expect. How often do we set up opportunities for a child to communicate? How many of you have open bubbles, blue bubbles, closed them, and waited for a child to communicate? Oftentimes for children with CVI, you need to wait longer than you might expect.

I suggest getting to know each child's individual wait time and respecting it as you do your work with them. As speech pathologists, latency is so key, especially when you're working on joint attention or turn taking.

Visual novelty. Children with CVI prefer familiar objects over novel objects. This was mind blowing for me as a speech pathologist when I learned this, because I am always looking for the new exciting toys to pull out and really get the kids I work with excited. But for kids with CVI, they often much better attend to objects that are familiar to them that they've seen before or similar to objects that they have seen before.

So I always suggest asking parents during your evaluation specifically which toys their child likes, rather than categories of toys like cars and trucks. You can even tell them just bring those objects when you're doing work with them.

It's important to understand how to select new objects to work on based on the critical elements of a child's preferred objects. So you'll see on the slide a child named Juliet, whose picture is in the middle of the screen, she loved Elmo, loved this big red Elmo doll. So when I was looking for a new toy to use with her during her sessions, we pulled out this red toy that you see here, that lights up. It's red. It's yellow. It has Elmo in center. And then when I wanted to bring a book to use with her, you could see on the right hand side of side, I pulled in this Elmo book with the same two colors that she's been looking at the previous preferred toys.

Visual reflexes. We do not work on this characteristic, so I'll skip over it and move to the next.

Need for movement. This is so important. As a speech pathologist, we are typically basing our session at a table or on the floor, sitting in one spot. Speech pathologists are typically the therapists who get the offices, rather than being out on the gym floor with the OTs and the PTs. For kids with CVI, movement is often needed to initiate and or sustain visual attention, and we know that movement alerts the brain. So even if this is not something you can sustain for an entire session, movement activities are really great warm up and a great way to jump start the visual system.

Shiny objects are interpreted as movement due to the light's reflection. So in your therapy sessions, you can use objects with properties of movement, objects that shiny reflective surfaces, such as Mylar, pompoms, balloons, or paper. And you can use Mylar tape to create borders around work spaces and bring attention to important items.

You can see in this picture on the right a student of mine sitting at a chair, an activity chair in her home, actually, with her brother next to her. And her mother has outlined this tray in red Mylar tape to help bring her attention to the tray, and she uses this trade for play, for activities, and also feedings. So it's been very helpful overall.

Dr. Roman says that, "Some students with CVI will increase their ability to function visually by using movement, so actually moving their own head or body in order to provide themselves with visual stimulation." I put this up here because they think as speech pathologists, it's really important for us to know this. I know that before I knew all of this about cortical vision impairment, something often many of us would say to our kids is OK, you need to sit still, we're paying attention, let's look over here. So it's really important to know this about kids with CVI and really think about it and interpret their behaviors correctly. Are they moving because they're really trying to get a better look at something? And if they are, what can you do to help them?

Visual field preferences. Visual field preferences are present in almost all students who have CVI. As speech pathologists, I know we are often centering target objects, toys, or devices. So when you're working with kids with CVI, first of all, always great to sit on the child's preferred side, and rather than putting objects right in the middle, I always suggest following their gaze and placing target objects in the areas they're looking, even if this seems that you're picking up these target objects or toys and kind of moving them around throughout your session. I think it's so much better to move your toys, your tools, rather than continuously repositioning the child that you're working with.

I pulled this picture from a guidebook for an EyeGaze device that I use in my therapy with some of the kids that I work with. And this picture up on the slide shows how to calibrate this EyeGaze device. And you'll see, this picture looks great. The girl is sitting beautifully on the chair at a 90 degree angle, looking perfectly at the computer. I found that this very rarely happens with the kids I work with, certainly even more difficult with kids with CVI.

So this is just an example, if you are to work with EyeGaze or really any type of device or system or just a tool in general. The directions might say center everything, but now you know better, and you know that they can work on an angle. Get creative with your positioning and really think about what's best for the kid that you're working with.

Decreased visual complexity. Complexity is so huge and such a big characteristic. So I've attempted to break it down just a bit. There's auditory complexity, which means the complexity of the sensory environment. Speech pathologists talk. We all like to, and I know we're all constantly talking throughout our sessions. But for kids with CVI, auditory background distractions draw children's attention away from seeing. And they often have difficulty fixating in a noisy environment.

Complexity of pattern. Many children with CVI do much better with simple patterns versus more colors on their surfaces. And the complexity of a visual array, objects placed on visually complex backgrounds and objects placed too close together can be very difficult to see. So what can we do about this during our session?

For auditory or sensory complexity, the best suggestion I can give is limit noise or talking when looking for a response. As speech pathologists I know this might seem weird, because we're the ones always cheering kids on, what do you think, what's next, what's your answer, but really just remaining quiet, giving kids time to respond is so so key and so important. And also limit touching. Limit hand over hand queuing. That's very important for kids with CVI as well.

For patterns, wherever you're sitting with a child, whether it's at a tray, at a table, on the floor, on a carpet, look at the environment, look at the carpet. Are there a lot of colors? Are there a lot of patterns? I always prefer to work on a plain black surface wherever I am working with a child.

For visual array, this covers so many things as well for speech pathologists. For kids who are working on AAC, this could mean how many symbols on a page, how many objects on a table, and even how many words in a sentence and working on literacy.

The absence of a visually guided reach. Children with CVI often look, look away, and then reach. They often will locate or fixate on a target, turn away, and then reach in the direction of the target. And you will find that looking and reaching can occur as two separate, rather than simultaneous events. I put this picture up here, because it's just a wonderful example of looking and then looking away and reaching.

So what this means for SLPS, this is so important for us to think about when you are requesting a child makes a choice and how many times do we do that, ask a child to make a choice. So whether they're looking, reaching, or looking and reaching, think about what they're doing. Make sure you're honoring the child's look or reach as accurate, and get to know each child that you're working with. Get to know their own look and reach pattern. As speech pathologists, we often require eye contact with us, with target objects, but for kids with CVI, eye that's often not possible at the same time that they are reaching for an object.

Distance. This is the characteristic that I would say a speech pathologists, we are often set up well for this characteristic, as we typically work very close to the children, we are working with, whether we're sitting on the floor or sitting at a table. But think beyond what you're doing with them on a one to one session, and think about language acquisition and incidental learning. Make sure that you're bringing items within a child's functional visual range to show them what you're talking about. Your speech sessions maybe set up very well, however, think about functional situation and the child's life.

So in a classroom, this could mean where's the child sitting, and what can they see? What needs to be brought closer to them? At home, for early intervention, or home based care, is the family communicating with the child within their visual range of functional vision? And the community, what is happening in the community and what can you bring closer? A nice example of this could be having 3D animals with the child while they're at the zoo, if they can't get close enough to the animals.

There is so much variability in speech and language, especially when children are developing skills. We all know that some days with kids, we might hear great sounds, great words, great sentences at one time of day, and more struggle at a different time of day. We do know that children with CVI's vision does not fluctuate. It is the environment that fluctuates. So when you're working with kids with CVI, think about how you can alter the environment, whether it's positioning, objects, distant, lighting, et cetera, so that the child can interact with more ease. And I guarantee that this will lead to increased communication.

So I want to take the next part of this presentation to go over some specific rules for speech pathologists. There are so many. We work in so many different environments and settings in different ages and diagnoses in all different types of children. But I want to touch on three certain areas, three big areas that we work in, and point to some resources if this covers much of your caseload.

The three areas that I'll go over are AAC, feeding, and literacy. Before I do that, I would love to know what setting do you all work in?

OK, the poll's coming up on the screen now. And choose the one that, it's a single select, so the one that's your primary or the majority of your time, early intervention, school based, hospital based, so that might be a practice that you have as a clinician or long term care. Do you have a private practice, or some other? It's helpful for us to know what your therapeutic environment is.

So we've got a lot who are school based, about 60%, about 22, almost 23% in early intervention, also, again, not surprising. Some private practice, and a few of you are in other. Thanks.

Thank you. So AAC, augmentative and alternative communication. The best suggestion I can give upfront is to think differently than your typical progression of AAC. When you're working with kids with CVI, you might be doing things differently than you are with other children. For example, picture exchange communications system, otherwise known as PECS, that could be super frustrating with children with CVI. Symbol based communication often uses cards, and on those cards are often many different colors, fonts, or items on one page. So if you are using a system like that, it's really important to think about what are you showing this child and are they able to really see it.

When feature matching for an AAC device, always think about the 10 characteristics and how they affect what the child can access. So for example, for a child that you know attends very well to light, light increases attention, you might think to use a backlit device, like an iPad or another type of tablet. A good example of this is that using yes/no cards is very different than doing yes/no iPad when you have that backlit device.

For AAC, I always stress, it's so important to get the child you're working with to buy into it and to understand the value of AAC. Do not lose hope when children are not showing interest in low tech or no tech AAC. I suggest sometimes trying iPad based communication apps or even EyeGaze. You can always introduce no tech or low tech later on. Novelty is tough for kids with CVI, as we went over before, but by then, the system will already be familiar. And then they will have both types of devices.

I really do believe that EyeGaze is an amazing tool for assessing where kids are looking on a screen. You can always start with screen engagement, just see where are they looking, what are they engaging with. Do not rule out EyeGaze just because a child has visual difficulties. I've seen so many children with CVI have great success with EyeGaze.

If you work with a lot of children with AAC and have your children with CVI in your case load, which I'm sure that you do, there are so many resources out there. I would suggest starting with Doctor Roman's webinar, Cortical Vision Impairment: Everyday Impact on People Who Use AAC. And I put the link on the slide here. It's an excellent resource and just a great place to start if this is a big bulk of your caseload.

Feeding. On a personal note, feeding is actually my specialty. The practice that I work at is a feeding and speech practice, and as Robin had mentioned before in my introduction, I actually got into working with children with cortical vision impairment, because so many children on my feeding caseload had CVI, and I heard parents tell me all the time that we need help with feeding, and by the way, we're really not sure what our child can see.

And I felt, how will I get these children to eat or speak, or whatever we were working on, if I don't know what they're interacting with in their environment? So that was kind of my starting point for CVI. So with feeding, I suggest knowing what colors are seen best by this child that you're working with, so you can use that with your feeding materials. It really helps to set up a feeding environment to screen for complexity. This can include the tray that the child is eating off of or the table, the area surrounding them, even down to the shirt that you're wearing.

If you notice a child's visual attention is wavering during your feeding sessions, check out the environment and the tools that you're using. And I bring up sensory aversions, because feeding aversions are so common for many different reasons in children with feeding difficulties. Vision is part of sensory. I'll talk about an example nice and quickly about a child that is at the center that I work at.

Another therapist called me in because she said the specific child was not eating very well in a highchair. He would sit up in a high chair and was just really struggling. But he ate so well reclined on his mother's lap. So we realized is that when he was sitting up in a high chair, the environment was just too complex for him. But when he was reclined, he was staring up at the ceiling, which was a plain background, and he did fantastic.

So knowing this, we were able to change the environment, and he was then able to sit in his high chair and eat, which was a much better position for feeding. He was able to see what was coming to his face.

I'll move on to literacy. Literacy is so important for speech pathologists, since reading and writing often fall under our scope, especially in schools. We are the specialists in phonological awareness and phonological processing. And it's so important to remember that children in phase three of CVI continue to need accommodations and often these accommodations are with literacy, reading and writing.

So two big things to go over, print motivation and print awareness. Print motivation is one of the most important pre-reading skills. You want to make sure that the books you're working with the children with CVI can actually be seen by them. You want to make books predictable, such as Brown Bear Brown Bear, a great example of a book that I'm sure we all love and use. Pay attention to color and complexity.

With print motivation, you're teaching directionality, that you're reading from left to right, and children need certain motor skills for reading and using books. To get children interested with page turning, I often suggest using a drop of glue from a hot glue gun or plastic bumpers to help with turning the pages.

Print awareness talks about how print on a page represents words that are spoken, so one word per page and discussing salient features of letters and the shape of words, when you're working on reading with children with CVI. Another good example of an accommodation for literacy is using blocking materials, to block out excess detail on a page, and for letters and words, using sharpies and pens and markers to draw visual attention to key features and salient features of letters. Using large print, and we go back to backlit technology is often very helpful for children with CVI.

My goal in this presentation, especially in speaking about literacy is to bring awareness that there are so many strategies we can employ as SLPs to help children with CVI learn how to read and write. There are so many wonderful specific resources out there. So if this is something that you do with the kids you work with, I encourage you to keep learning and keep researching.

A great place to start is with Diane Sheline's resources. She's done a lot of work with children with literacy and has great resources that have taught me so much, specifically literacy for children with CVI an overview and implications for different phases. And I've included a link on this slide.

So where to start. This is truly-- We're getting towards the end of the presentation, and this is my favorite part, because whenever I go to presentations or continuing education, I always want to think, how can I use this information as soon as possible? So I want you to be able to teach to make intimation that you've learned today and get started as early as tomorrow. I know that we all have so many children with CVI on our caseload.

I encourage you to keep going back to the 10 characteristics and think about how you can employ what you know about the characteristics, the goals you have for the children that work with. So I give you the four box advice. I learned this from Dr. Roman when I was going through my CVI endorsement process. She spoke about how when working with parents with children with CVI, she would suggest breaking their day into four boxes, so meaning, using the first box as morning, then early afternoon, late afternoon, evening, something like that, and thinking about two strategies or accommodations you could do for each area of the day, leading to eight overall.

So I'm going to take that advice and kind of transform it into how you all and how we all can use all of these different strategies with the kids that we work with.

So I would encourage you for all the children on your caseload who have CVI or suspected CVI, draw these four boxes, and think about two things for each box, environment, objects, queuing and variation in behavior during session. So for the first box, for the environment, I encourage you to think about the complexity of the environment, the distance, where the child is sitting, where they're being taught, and even lighting. And think about two accommodations or things that you can change that can create a big difference for these kids.

For objects, think about the objects that you're using in therapy. Can you start using something that's more novel, or that's more familiar to them? I'm sorry, not novel, that's more familiar to them. Or even if you start using objects that are their favorite colors. For the third box, I heard you think about queuing. What are the queues that you're giving the children that you're working with during their session? Whether it's hand over hand or verbal models or even wait time. What are two things that you can change that can help these children keep moving forward?

And the fourth box, I encourage you to think about variation in a child's behavior during their session. Keep track of when behavior varies, and really use that to think about what is happening during this time, and what can you do to change that?

So I want to thank you all so much for being part of this presentation and listening to all that I had to say. I have put my email on the slides, so if you have any questions or want to go over anything that I spoke about or clarifications or really anything, feel free to reach out and email me. And it was such a pleasure being able to present on a topic that is so important to me.

Great. Thank you, Jenna. Thank you so much. This is where the magic happens, because we do have time for questions. And I thank those of you who have sent some ahead of time. I'm going to get to those in a minute. Please use the Q&A box to enter questions. Understand that I may bundle some together if they're similar in order to help get to as many as we can.

Let me also remind you Jenna is not in a position to diagnose kids that you work with or give specific feedback on kids that you work with, kids that she has not seen. But certainly if you can form your question in a theoretical way or in a what's your best advice way, we can get to that.

So Jenna, let me ask you just broadly to talk about your kids who do have auditory impairments as well as CVI, because certainly, you have a lot of them. You've talked a lot about the communication part and the feeding part. Can you talk some about auditory impairments specifically?

Sure, absolutely. So it's a broad question, but really the best way I can answer that really is to, you have to think about every child you work with individually, and figure out what's the best way to access them and teach them and get in there with them. So for children that I work with auditory impairments as well as visual impairments. I think that's when it's really important to have the CVI range completed for this child to know what they can best see, and use materials in your session to kind of give them everything that you can.

Have the most appropriate materials available for them, and really take time to see how they're reacting to what you're presenting and engaging with and kind of modifying appropriately.

Thanks. Do you have an opinion about the PODD system, the P-O-D-D system, either in general or specific to kids with CVI, versus say photographs or other kinds of--

Sure. Absolutely. I use PODD with a lot of the children I work with. I think it's a great system. It's difficult to give an overall general opinion, since as I said, every kid is so different. I use a lot of characteristics of PODD in programming devices that I work on, because I really think of pragmatically organized, and that's really what PODD is. It's a pragmatically organized device. That's a really great way to organize communication.

And in terms of children with CVI, I often find that PODD is sometimes too visually complex, and it needs to be modified. Every kid, of course, is very different, so I'll look to see whether it's pictures that they see best or words or what's already being provided in PODD.

Sometimes I have found that a lot of children, and this is kind of what I meant when I was talking about the typical progression of AAC, a lot of children will start with a PODD book, and then move to PODD on a device, so either on an iPad or an EyeGaze, however their best access method is. I have found that children with CVI, sometimes if I think that PODD is appropriate, I will skip the book version of PODD and just move to PODD on a device, because I think that backlit, the light really helps.

Thank you. Sorry. I was scrolling for some other questions. We learn a lot about the attractive properties of reflexive material, because of the way that it simulates movement. You talked a little bit about that. Have you tried that as things on slant boards, work trays? What's that done for you?

Yeah. Yes, all the time. I have Mylar tape with me everywhere I go. It's absolutely fabulous. It's definitely very helpful for establishing borders and kind of bringing attention to a workspace. I have also used it, actually as I'm talking about AAC, using it to kind of border an AAC device to bring attention up to that device.

Thank you. That was the follow up question about how to position it so it's drawing attention to the object you want them, or the work area, or the focal material, as opposed to the reflection itself, right? So you're suggesting maybe the border.

Yes. Yes, using it as a border. I've actually also, I always carried black, kind of black pieces of paper with me, with cut outs of squares. So if I'm working with a child on an AAC device, I can kind of use that to zero in on an object, and sometimes I will use the Mylar tape as a border as well, which is also very helpful.

I'm just skipping ahead a couple, because I'm trying to put these in order that, where one that leads to another. Because there's a question about the range that might take us down a deeper path, but you spoke, obviously, a great deal about the range. Can you pose, say one or two examples of things that you see on the range that may be common and information that it's providing for you? So you've broken down kind of the broad things, the movement, the novelty. At that real specific task level, is there an example that you could provide that shows how you went from I observed this, I responded to it, here's what I did for the student?

Sure. Let me think of a specific example. Well, a child that I worked with, I actually consulted in with a therapist that I work with who does feeding with a specific child. He was doing great. He was moving along. But I went in there and did the CVI range on the specific child to just kind of get some more information and see if I could give the therapist some specific suggestions of what she could do in therapy with the child.

And doing the range allowed us to figure out actually what colors this child was seeing. When I interviewed the mother, she really didn't know. She wasn't sure. She said, you know I'm really not sure what he was looking at. And we found that he was looking at yellow, and then he moved onto yellow and red, but we started with yellow, and kind of like the example I was talking about in the presentation, we use that to change over all of the materials this therapist was using in her therapy, and she saw a huge jump in his feeding abilities, because he was so much more aware of what was going on. So even just opening is mouth for a spoon.

I think before we made these changes he was relying on other senses and even just thinking about the spoon coming into his mouth, I don't believe he could see it until it was there. And now with changing it over using a yellow spoon, yellow Mylar tape, changing the background because complexity was an issue for him as well. That really made a very big difference for his feeding, just doing CVI range, and then also being able to give his parents specific recommendations and accommodations for what to do at home. So that made a very big difference in feeding.

Yeah, that's helpful, I think sort of showing that progression might be sparking ideas. Are there other kinds of feeding difficulties that you find are particularly common with the kids who have CVI?

Sure, so complexity is definitely a big one that comes up a lot. Feeding is such an invasive process, especially for children who have feeding aversions and lengthy medical histories of trauma or, you know, just overall difficulty with feeding. So I'm never scared to turn the lights off and put up lamps or Christmas lights or different colors, and just kind of take it down a notch. Definitely complexity, that's a big one.

I always look to see what parents are putting out on a tray for a child and what that tray looks like, and how you can kind of change that. Because I think with feeding, children often feel very out of control, and whatever control we can give them is so important and really makes a big difference. So certainly, letting them see what's going on and having an easier time with that makes a really big difference.

Thanks. I'd like to shift gears for a little bit to some social skills, social queues. So obviously your relationship in this kind of therapy and treatment with the child, there's a level of trust, there's a lot of give and take. It's all the basics of communication. What kind of strategies or successes have you found working with nonverbal queues or EyeGaze or teaching expression that might be helpful for our participants to know about?

Sure. So once I became educated in CVI, it really changed my perspective on eye gaze and eye contact, and things that I knew from more of a pragmatic standpoint as a speech pathologist, because for a lot of children with non-verbal communication or pragmatic difficulties, we're often working on eye gaze and making eye contact and all of those important social queues.

But knowing all that we now know about CVI, that's often very difficult for children with CVI. And I spoke a little bit about this in my presentation just in terms of expecting a response from a child. Before all of my knowledge about CVI, I would often say, look at me, look at the object. You're requesting a lot, and for children with CVI, this is often, it's just not possible, or not possible yet.

So that's something I really encourage all speech pathologists to have in mind for children on all parts of the range, because it's hard. Eye gaze, eye contact, we knew that that's hard. Faces are very complex. So what we might expect from a pragmatic standpoint is not always what we can expect for children with CVI, and there's ways we can kind of work them through it, or change what we expect, and change our frame of mind and our thinking to be just more accommodating, and in the long run that will probably help us reach our goals.

Thanks. Well said. I'm watching the time. We've got about 15 minutes left, and there's a bunch of different questions going back to AAC systems, some specific to PODD. I'm going to kind of bundle them together and see if we can break some of this down. So the question of, we hear this a lot about kids CVI, kind of transitioning from understanding a 2D image to understanding a 3D representation of that or the actual thing. And then there are some other questions here about sizes of pictures or representations. Are you finding more success using bigger pictures, or is it simply fewer pictures per page? Or do you find that can really vary between the child? If you just want to tackle those two.

Absolutely. So the first part of your question, talking about going from 2D to 3D representations, and all of that, that's a big thing in AAC. I see this a lot, because as speech pathologists, we pull out these devices, we pull out these pictures, and we're often expecting children to kind of understand what we understand, that this picture being this word means this thing in your life. And for all children, not just children with CVI, that's something that needs to be taught. And we can't really go in there expecting that all children we work with will just kind of have that knowledge to begin with.

But especially for children with CVI, we always are talking about salient features of objects, of items, and this is that time where this is so key and so important that if we are trying to move from one to the other, transitioning from 2D, 3D, you know, back and forth, real life pictures, that's something that I think really needs to be taught.

So you might have your activities for AAC, your typical activities, what you're used to doing with children. But I always encourage, kind of, maybe taking a step back, and thinking about the core words or the fringe words or whatever your target words are for the child in that moment, or in this period of time, and making those really teachable. So let's say you're working on them house items, or something having to do with the child's home, you might want to pull out a picture of a house and the child's house and really come up with--

And of course, for every child, it's so individualized, but really make sure that there's an understanding of what all these symbols and objects mean and we're expecting and hopeful that the child that we're working with is able to use these symbols. Symbol based communication to communicate with, it's so important to really hone in on what these symbols mean and then tie them to the child's world, that these words equal your world. And when you say these words, things will change. Things will happen. People will come to you. Objects will come. Things will stop. That's really the modeling that we really push for with AAC and the repetition and the multiple exposures that is so important.

Do you find any difference between the regular picture communication, like a Mayer-Johnson versus the high contrast? Would you use the high contrast piece at all?

I don't typically use the high contrast. I have found those often sometimes difficult for a child with CVI to access. The typical Mayer-Johnson, what I typically will do is if I think a child, if for a specific child I'm working, if a certain symbol is too complex, if I know from their range, or what I know about them, that I look at that object, and think they're really not going to be able to access it, I will kind of go in there on my computer or even with a marker, and whether it's creating a border or screening for complexity and changing the color of the object. With children with CVI setting up these devices, it's often a lot more work intensive in terms of making sure each symbol is accessible. That's kind of where that piece comes in with children with CVI.

And signing, do you use signs at all, either formal ASL or kind of home signs, signed English?

I actually do not with the children that I work with. It's just [INAUDIBLE]

Fair enough. There was a question about that, and I knew you hadn't mentioned it. So it was about increasing visual attention when using sign. Go ahead.

OK. I mean, I can comment on it just knowing what we know about CVI and using these characteristics, if you are trying to bring more attention to your hands, you know, even putting gloves on your hands, you know, a certain color, or I even have actually have these light up gloves with lights, you know, I think it would be something you'd really have to think about it, and is it too much? I think that that could be something that could help with signing.

I guess as our last question, unless there's a short answer, but I think there won't be, a very important question that I'm glad someone asked, can you talk about your relationship with your students, TVIs, and how closely you're working with them, particularly around CVI since that's your topic, but in general what's your collaboration style?

Absolutely. So the setting that I work in currently is a private practice. So I have what I call truly the luxury of being able to collaborate with all of the professionals that work with the children that I work with, and I make that a really big point of what I do. For children with CVI, it's very important to touch base with the TVIs they're working with, whether it's in early intervention or someone that's school based. Depending on the TVI's experience with CVI, so some TVIs have not yet had the opportunity to really learn about CVI, and some know a lot, it depends.

So sometimes I serve more as a consultant, kind of a consulting role, and will kind of bring attention to what I've seen with the child, what has been successful since we're kind of collaborating and seeing what we can do to increase the specific child's success over all environments.

And with every child I work with, it varies. I have some kids that their TVIs will actually come here, maybe once a month or so, so we can kind of collaborate together, and that is something I really love to do so that they can see that communication piece of the feeding piece, the speech and language piece that I'm doing here, and use that knowledge that they see for me, and I can kind of see what they are doing, since my main role and my scope really is speech language and feeding, and the visual role that I play as the expert in CVI.

But there's so much more that I can learn from TVIs. So it's really no different than consulting with any other professional, but for children with CVI, it is really so important.

And thank you to the participant who reminded me I did not explain, that's a teacher of the visually impaired, is a TVI. So typically with a student who has a visual impairment, the TVI is often kind of positioned as the lead on their team. With a lot of kids who have CVI, as Jen has pointed out, may not have been diagnosed yet, or may not be what's considered their primary disability or where they need the most educational support.

However, we believe strongly that any child with a visual impairment, whether it's brain based or ocular, should have a teacher of the visually impaired, and then of course as much as possible the child's educational team, if that child has a CVI diagnosis, should also understand CVI as much as they can.

We did get a couple of questions from people, specifically those of you who are not coming from the visual discipline, asking about getting more training about CVI, and we do have more information on our website. I've reached out to a couple of you to get your email addresses specifically, and so I can give you some more pointed information rather than in this tiny box that I've been communicating with people with.

I'll give our email address as well, which is, I'm waiting for the captioning to catch up, perkins.elearning@perkins.org. If you are also interested in more information about this topic or other topics about visual impairment for kids on your caseload who have multiple disabilities, we can respond to those individually because we'd love to have you participate.

A lot of our content is free for you to use, like this webinar that will be recorded and provided later. Much of it, we encourage you to find a video to share with a family or part of your educational team, your district leadership if you feel that that's helping in an in-service capacity. We're happy to share that with you.

My colleague, Charlotte, reminds me, of course, of our communities of practice. These are sites that are also associated with our program, pathstoliteracy.org is the one that most of you may be familiar with, in addition to the links that Jenna has given. Also on our website, you'll find other, paths to transition is a great one that you might be interested in. We also have science as a topic. So come explore our website if you are new to this area of special education.

Well, thank you, Jenna. This has really been informative. We had a full room today and a lot of people who are looking forward to watching this tomorrow or later on. Any time we can bring other disciplines into this program, we are excited. Lots of thank you's coming in now to the Q&A.

So as I mentioned, the site tomorrow, we will have the presentation here available to download, as well as a recording of this event. We also have a webinar coming up next month that's based on a post that appeared on Paths to Literacy, which Charlotte just reminded me of, all about abstract thinking, and working with kids who have visual impairments on their abstract thinking skills, which often comes from incidental learning that they may have delays.

So now that you're subscribing to our webinar series, you'll get more information about that. So Jenna, thank you again on behalf of our team, Valerie Whelan, Dr. Mary [? Zata. ?] Valerie is reminding me that if you do want to earn credits for having participated in this webinar, we provide a tutorial version of it that has an assessment. You'll pass the assessment, and you can earn 1.5 continuing ed credits, including ACV REP credits. I think that is all the news. Anyone else sending me an instant message, no. All right, thanks, Jenna. Have a great weekend everybody.