O&M with CVI_1_0
Is O&M and CVI. Today's presentation by Alisha Waugh covers specific strategies and modifications to orientation and mobility specifically for students with cortical visual impairment, including their individual assessment on the CVI Range. Many of you have attended our webinars before. You know that your lines are muted.
We will be able to provide in Q&A box here in a moment as soon as we get started. Go ahead and post your questions as they occur to you throughout the webinar. We're going to try to collect like-minded questions together so that we can get as many of them in at the end of the presentation as we can. Alisha has kindly offered to answer questions offline in case we are not able to get to everyone.
Alisha Waugh is a licensed physical therapist. She is a certified O&M specialist and endorsed CVI. And the parent of a child with CVI who has devoted many years to learning about cortical visual impairment. Her consulting business, Fundamentals First, Incorporated is where she provides phone, video, and in-person visits to coach providers and family members on their interactions with children, to make sure they're as successful as possible in eliciting and promoting use of the child's functional vision.
Alisha has presented on CVI at both national and local conferences. She is also a board member of the Pediatric Cortical Visual Impairment Society. She chronicles her personal story on her website WhattodoaboutCVI.com. Alisha, this is really a pleasure, and welcome to Perkins.
First of all, I want to say thank you to Perkins, Mary and Robin for having me today to discuss this important topic. And thank you for Valerie for helping me with the PowerPoint and technical support. So thank you everyone for joining us, and I'm so happy you have an interest in this topic and want to learn more.
So we'll get started right away. And please forgive me if I rush. I'll settle in. I'm kind of a to webinars, so bear with me, please. So the objectives of today's webinar are to be able to identify differences in assessing and adjusting O&M-related areas for students with ocular visual impairment versus cortical visual impairment. To learn strategies to address and use the student's unresolved characteristics of CVI, as determined by the CVI Range. To encourage more reliable orientation and purposeful movement and mobility. And to be able to determine appropriate strategies to use with students in each age with CVI.
So we have a poll.
I'll go ahead and read these out for you, Alisha. We're always interested in knowing who is here in the room with us. So we have some choices that would best describe your primary role with students who have CVI. You may have many different roles, but are you primarily an O&M instructor, a teacher of the visually impaired, a speech language pathologist or other communication specialists? Are you an OT or a PT or some other kind of educator?
Perhaps you are a parent, guardian, or family member or some other kind of trainer or therapist, including a trainer of families. A program administrator or a paraprofessional. And as we predicted, you've got a great majority of O&Ms. This is a very hot topic in the field of O&M. About 50% responding in the O&Ms. And almost about 30% are TVIs. But we are seeing some other teachers, some family members, other trainers, and administrators. So welcome, everybody.
Great. So a lot of you have a background in O&M, so that is awesome. So a little background about me. We'll get the poll down. I began my professional career as a physical therapist first, working with adults and children, including early intervention in the 90s. And then 10 years ago I had my son, Griffin, and he was born extremely premature. So he was born at 24 weeks gestation, and he was diagnosed with CVI in his first year of life.
And that really brought the world of visual impairment home to me. So I became a certified orientation and mobility instructor. And I have become a lifelong seeker and learner of information about CVI. So currently Griffin is 10. And like I said, he was born at 24 weeks. He weighed just 1 pound 10 ounces. In the NICU, he got down to just 20 ounces. So literally he was the size of a soda bottle.
We got to addressing the CVI with specific strategies right away. And today he reads very well. He enjoys learning new things. He loves his LEGOs and the iPad. And he really is the inspiration of why I do this work.
Alisha, can we ask you to speak a little bit more loudly into the microphone? We've got a lot of folks saying they're having difficulty hearing. And I'd also say those of you in the audience, headphones will really help. Most computer speakers are not quite loud enough. But turn your volume up as loudly as you can. Thanks. Sorry to interrupt.
I wonder should I turn my volume up on my mic?
That may help. That may help just to give us-- don't turn it up too high because you'll start to distort.
How does this sound?
OK. Is this better. It's better for me, but I've got headphones on. Thanks everybody.
Well, everybody can give input. If it's too loud, please feel free to enter that in the chat room. So here the next slide. CVI is fundamentally different than ocular visual impairment, and therefore, its assessment and approach should be different. There should be an expectation that a student with CVI can develop greater use of their vision over time with the right approach and accommodations.
And this philosophy and approach comes from Dr. Christine Romans-Lantzy, who has written Cortical Visual Impairment, an Approach to Assessment and Intervention, published by AFB press. And her new revised version is coming out, I believe, in the next couple of months. So I would recommend that you have a basic understanding of the CVI Range when you work with students with CVI to guide your practice.
A lot of what we're talking about today is based on Dr. Roman's work. So if you are not familiar with it, I recommend you get her book or attend her workshops to give you more information. And Perkins also puts on courses about the CVI Range and learning how to administer and score it. And Dr. Sandra Newcomb has an upcoming course this spring through Perkins. That would be a great resource if you would like to learn more about the CVI Range.
So I love this cartoon. It's an illustration of a melting snowman with a suitcase, standing by a sign that says "Welcome to Florida," with the sun beating down on him. And he's saying, "I've got to find a new travel agent." And I guess the travel agent selected the standard, commonly preferred, warm-weather vacation without taking into account the client's specific needs. I think that applies well to the world of visual impairment and how we serve our students when we don't take an individualized approach.
So we may look at a student's orientation mobility skills through the lens of ocular visual impairment, and therefore not identify areas that need to be addressed for CVI. Or we may miss assessing a particular area that would be unique to CVI, and so we don't identify that need for intervention. Or we may identify a particular area of need, but we intervene in a way that is not meeting the unique characteristics for a student with CVI.
We don't want to automatically prescribe what we think the student with CVI needs based on what the student with ocular visual impairment needs, and vice versa. So we need to be very careful with our assessment and approach. And we're going to look at five different areas related to O&M. They are concepts in concept development. selecting landmarks, clues, and cues. Use of maps or physical representation to symbolize space around us. Cognitive representation or mental mapping, which basically means looking at something in our mind's eye, even though we are not in the physical space at the time. And social skills.
So when we are assessing students' concepts or schema that they already have mastered, we will present the materials differently, depending on the type or severity of visual impairment that they have. So if the student has an ocular visual impairment, our assessment may we presenting materials that the student can explore tactily and auditorily to determine what something is.
If the student has CVI, our assessment can be more visual in nature, assuming the ls are presented in a visually accessible [AUDIO OUT] for that student's phase of CVI. And we'll talk about these a little bit later. Even if the student is in phase 1, you can present carefully chosen materials visually in a noise and visually reduced environment to determine what they may be visually regarding.
And I have a table with nine different types of concepts that we use to make sense of our world for the purpose of O&M. They are body concepts, which would include body parts and how our bodies move. Shape identification. Understanding of size, understanding of quantity, understanding of position and spatial relationships. Color identification, texture awareness, sensing and identifying temperatures, and identification of visual patterns.
The assessment of the first five concepts in the table, which includes body, shape, size, quantity, and orientation or position, would apply to both ocular and cortical visual impairment. Again, keeping in mind the types of assessment materials you would use with the child for their exploration based on their available vision.
I put a plus and minus by colors, which means might or might not apply. Because if the student has severe vision loss, the color identification may not be possible. For students with CVI, color is a huge visual anchor and a clue to locate or identify things. So you would definitely apply that when you assess a child with CVI. You want to know the colors they recognize and regard.
I put a plus and minus next to textures, because if your student has severe vision loss, textures are hugely important in order for them to identify elements of their environment. But for CVI, we want them to use their vision before they touch. In other words, use their vision to guide their movement. So that may be an area that is not as important for this population, because our instruction will not focus as much on feeling textures to glean information from the environment.
Temperature I put exclusively in the ocular visual impairment category. Because that is a continuous experience that will give a student with severe vision loss more information to guide movement. For example, if they're feeling the sun on their right side as they're walking outside one morning in the spring, that would tell them that they're walking north. Or when they feel the cold metal material on the wall, that would tell them that they found the door.
So I put the concept of recognizing visual patterns more exclusively in cortical visual impairment. Because we are expecting those students to use their vision to glean more information about their environment. So stripes, dots, zigzags, et cetera, will help them identify certain elements that a student with severe vision loss or even low vision may not be able to perceive.
Continuing on with concept assessment, we went to that environmental concept understanding. What does the student do to understand common environmental generalities, like stairs, counters, windows, doors, tables, chairs, etc. And if they can, at what level of mastery? So your student with an ocular visual impairment may identify these environmental elements through touch, sound, and temperature.
The student with CVI will use their vision to identify these things, and you want to see how rigid or flexible the student is in their understanding. Do they have a mastery of understanding so that they can generalize environmental concepts to include variation in visual appearance.
I'll give you an example. Will they be able to identify a chair that happens to be a bar stool with just one base of support, even though it does not have four legs like most chairs do? Or maybe they learned what their chair at home looks like. They go to the library, but they can't identify the chair there because it's wooden and it's not upholstered like the one in their living room. Things like that. You have to take into account the CVI.
And we need to consider three levels of identification. So the first level, well, the highest level would be identification. Can they identify it if you asked, what is it? So if so, this means they can take the visual target in front of them and compare it with the Rolodex of visual imagery they have in their brain to retrieve the label on their own? Or do they need a label?
So in the recognition category, do they need a label like. where is the chair, to find it in their environment? And this may be necessary, because they may not spontaneously pull up the visual aspects of a chair in their mind or their visual memory. And this may indicate that they need more repetition of instruction or more explicit content development for teaching chair-ness. What makes a chair a chair?
On a basic level there's discrimination. And that would just be you instructing the students to find one like this. No label is involved. So this means that concept development instruction would need to occur. And there is likely no meaning behind that visual target itself. They won't have a visual memory of the visual target to use it in the future. So you need to keep those things in mind as you're assessing a child with CVI.
Another point I want to make is that we want to assess what attribute the student is using to confirm the identity of something. Is it based on fragile or solid information? So if they are using just one visual aspect to make an identification, that is a gradual level of identification. versus if they are using multiple attributes. And it could be partly auditory and partly visual for a student with low vision, but likely to be more visual in nature for a student with CVI.
So we have a poll.
We're interested in hearing from you about how often across your practice would you say you are administering the CVI Range? So not per student, but in the main, are you administering the Range more than once a month, about once a month, about once a year, or you do not or have not ever administered the range. It's really pretty evenly split.
It's really split.
Well, we are seeing a lot of people on this call who have not administered the range or don't administer the range as a part of their practice, about once a year practice wide is the next. And then about once a month. Fewer people saying that they are administering the range more than once a month with their children or students.
OK, great. That gives me an idea of people's experience with the range. Thank you, everybody. So the next slide we have focuses on selecting or using landmarks, clues, and cues. With ocular visual impairment, we want to assess what types of environmental information or landmarks are the students using to make it to their destination?
It could be that they're using wall texture, surface and elevation changes, auditory information. In the case of Braille users, Braille signage to help confirm their location in space. Is that student having any unintentional contact with obstacles or they're missing drop offs because they're feeling to use a landmark or their cane detection as a warning for upcoming danger?
With CVI, we also want you to assess the types of environmental information the student is using to make it to their destination. But we want to look very carefully at how they are making it to where they're going. Are they using visual landmarks that give them information about the space? Or are they using the context of the situation to tell them where they are?
And I'll give you an example. Maybe the secretary is always in the office, so the student just assumes when they see this person that they're at the office. Or maybe the student is aware of the time of day that the classroom goes to the library, so they know it's mid-morning and the class is walking to a new place, so it must be the library. So that's pretty fragile.
Is the student able to use any pictorial or print signs to give them more information? And oftentimes kids with CVI use the context of a situation to know where they are or who someone is rather than using their vision to analyze the situation. And that may be that the environment is too complex at the time in a visual or auditory way for them to use their vision to tell where they are. So time of day and specific conditions in the environment are important considerations when you assess a child with CVI.
So we can help them use their vision by making specific adaptations. And we will talk about that in a little bit. Because we want the child with CVI to use their vision. Because the more they use their vision, the more visual pathways will be developed in the brain.
Another point I want to make is to not assume that absence of unintentional contact with obstacles equates to safe travel. When a student with CVI is moving around, they're likely using their dorsal stream vision, which is their peripheral vision, that detects form and light. It's the non-detail vision. And so that is what they're using to avoid contact with obstacles.
But they may not be using their ventral stream vision, which is the detailed central acuity vision to tell them about important cues that there's a potentially dangerous situation ahead. And so depending on the time of day or level of complexity that is present when you assess them in that environment, it could look totally different the next time.
If the child is more visually fatigued later on than when you assessed them earlier that day, they could have traveled around without difficulty with you but experience a lot of difficulty later on. Or maybe you assessed them when it was particularly quiet in the hallway, but now they're trying to travel the hallway during the transition time, with busy class changes, and they become disoriented. And they don't pick up on the visual features in their environment due to this increased complexity.
When you assess that child CVI, you want to observe if they consistently visually attend to the same types of features. Do they always attend to objects in the same visual field, or only attend to visual targets that are highly familiar, or that they have very explicit, meaningful experience with? And that will help you know what specific characteristics of CVI are still present and interfering with their use of vision.
This will also help you determine what types of landmarks and what types of conditions the student with CVI needs to achieve visual access in their environment. And I made a note that Dr. Roman's CVI range rating 2, which is the Within-CVI Characteristics method, will help you determine what characteristics are still present, and to what level of interference, which then helps you choose appropriately landmarks and conditions to present those landmarks in for that student to visually regard.
So we have another poll.
Great I'm getting some feedback from the audience, Alisha. If you are able to slow your pace just a little bit, you're presenting some pretty complex ideas and people are just asking if you could give a little slow down just a little bit.
I will definitely tray. Thank you.
Thank you very much. To the members of our audience, if you are aware of the phases that your students are in, we're interested in whether you see students in phase 1, phase 2, phase 3? Do you have some students who have not been assessed on the range for whatever reason? And sometimes that may [AUDIO OUT] the have not been diagnosed officially, but you may have some suspicion that there's a cortical issue at work.
So answer any of those that apply. And we're seeing the largest group in phase 2, but pretty evenly distributed across all three phases.
So the largest group phase 2. Great. And we will get into each individual phase and how you would attack landmarks in concept development and materials and that kind of thing in a little bit.
The next area related to O&M is understanding maps or physical representations of space and what they mean. So if you have a student with ocular visual impairment, the learning media assessment results will help you determine the type of map to use. So you might choose the tactile map, an auditory map, high-contrast map, things like that.
Once you have that determined, you can present the type of map that is appropriate and assess whether the child can interpret it. Does that student have an understanding that this mark on the map represents where something is in actual space? And if that student does not, that's an area of need to address. They need to learn how to use maps to plan their travel and understand space without the use of vision or with limited vision. And by using a map, this will help them develop a mental representation of space that they can access without a map or without being in the actual location.
And I have found that students who are not congenitally blind, those who have had at least partial vision during their early years, do fairly well with interpreting maps. That they do have visual memories to access, which helps them understand space and spatial relationships between features and locations.
For a student with CVI, you can use a CVI range rating 1, which is the Across-CVI Characteristics method. And that will help you determine the type of map and the conditions of map presentation you should use to assess the student's map-reading ability.
I found in familiar spaces, typically sighted children at fairly young ages, often by the age of six or seven, are able to understand simple maps. So if that student with CVI can't tell you where they are on the map when you give them like a reference point, that means this is an area of need.
And I have found that children with CVI often have difficulty understanding maps and what they symbolize. So therefore there needs to be a lot of repetition and explicit teaching to help them learn to read maps. And you have to keep in mind that these children have had the impact of CVI their entire life. So they don't have the benefit of solid visual memories through which to develop a strong visual spatial sense. So keep that in mind.
Moving on to assessing cognitive representation of space. For students with ocular visual impairment, you may ask them how they know when and where to change directions along a familiar route. You might look at their accuracy in knowing and using compass directions. You'll look at their understanding of temporal relationships. For example,
what landmark or location comes first, second, and last, and so on.
With CVI, we want to look to see if that student is aware of important features in that space. If you give them a simple map and no reference point, can they position landmark [AUDIO OUT]? Have they developed an accurate mental map of the space in their head without having to be there? Do they have a sense of temporal relationships? That from the front door of the school, the office is closer than the gymnasium, for example.
Do they have enough visual memories of features and locations within a specific space to have developed mental imagery to inform their travel? Or do they have to actually encounter the landmark in the actual space to know it exists? And addressing this may just be going in with the smaller steps of learning and becoming visually aware of the important salient features of a mini route within the classroom or room in the child's home. So it may not be traveling from one room to another room. It may be getting from the back table to the seat in the classroom.
In order to create a visual memory, visual regard has to happen, and meaning has to be created around that visual feature. So this may be your starting point for cognitive representation down the road. That would be like a baby step. Get them to notice those salient features so that they can start having visual memories about that to use it to plan their travel in the future.
The last area we will talk about for assessment is social skill-related areas. So the CVI children may or may not work directly into other people's faces. And that face is highly complex, so it's difficult to interpret all the details. Especially when the person talks, it can become more difficult for someone because they have to take in the visual and auditory input at the same time. And that can be very difficult when there's brain injury as there is with CVI.
But I want to know when they see someone in real time, do they know who that person is? So you want to assess that. And if they are accurate in knowing who it is, how do they know who it is? What is it that they use? Do they use fragile or solid information? Do they use visual or non-visual information? It may be voice recognition that they're using. So can they identify that person if the person does not speak? Can they identify that person if they're not in their normal location in the school?
If they're using visual features, are they using hair style, hair color, body size, body shape, certain kinds of clothing that the person might wear on a daily basis like a certain coat, shoes, or jewelry? For typically sighted children, they're using facial feature details to recognize people.
But for children with CVI, oftentimes they're using less detailed information like hairstyle and color, or body type. And then you can look at facial recognition in photographs versus real time with the person present. That's a much more complex task. And the photographs give you less information than someone that's standing in front of you.
And then lastly, does the child seek to find out who that person is if they cannot recognize them? This is an important thing we need to teach them to do in order for them to be more successful in self-determination and with their social interactions.
Versus with the student with ocular impairment, you will want to check that they are able to recognize others around them, but you may ask, who do you hear? It may not necessarily be the person's voice. It could be their cadence of walking. It could be how they move or how they smell. Things like that. And like students with CVI, you want to see do they clarify if they don't know who is around them. That is very important.
There are several social skill assessment tools out there, like the Social Competence Assessment, or the Social Skills Assessment Tool for Children with Visual Impairment. I would recommend referencing those types of tools to help you determine what areas of social interaction the student needs instruction in developing. And then that would be an area that you've might identified as a need to address.
Now we're switching gears from assessment to approach or intervention. And there are differences in how we would teach a student with ocular visual impairment versus one with cortical visual impairment. So with a student who has ocular visual impairment, we're going to teach part to whole. Since they have limited visual access to the world, we will cover each part, and then help them put it all together to develop a comprehensive understanding.
We may try to take advantage of teachable moments that come about in our lessons, which means that we were not planning on teaching a concept specifically during the lesson, but an unexpected opportunity arises and provides the chance to offer insight to our student. In our instruction, often we teach with an increased focus on tactile, auditory, tactile, and olfactory attributes.
When working with a student who has CVI, we may start with the whole and move to a more detailed part analysis. Because oftentimes those kids start out using their dorsal stream vision, which means that they are visually aware of form, light, and color. However, they're not noticing specific internal details that the ventral stream central vision detects.
So we want to teach concepts that will be encountered during lessons beforehand, with materials and instruction conducive to the child's specific phase of CVI. We might try to take advantage of random teachable moments that arise. However, this can be disorienting or without meaning to that student with CVI, so we need to be very cautious of that.
The novelty of an unexpected moment can be very difficult for the brain to interpret. And we want to teach with an increased calling of attention to visually accessible key attributes or salient features, as Dr. Roman likes to call it, for the concepts we are providing instruction in.
Next slide goes over use of landmarks, clues, or cues, and you know we select those for a student with ocular visual impairment. So access to your vision allows you to perceive things from afar, and gives you immediate confirmation of where you are in space. The students with ocular visual impairment will have an increased use of less immediate perceptual senses like touch, sound, and smell to provide clues and cues for confirmation of where they are.
And they may use magnified or high-contrast visual targets and landmarks to provide orientation information. The high-contrast colors and the magnification allows the eyes to take in the information with improved clarity. And if a visual target is magnified or more contracted to improve its quality to a level within their visual threshold, then they're aware that it's there so that they can perceive and interpret it.
Oftentimes, auditory information can supplement tactile and visual information, so that addition of auditory input is helpful for the student to know where they are in space. That's with an ocular visual impairment. For a student with the CVI, we also want to encourage use of their vision to access landmarks, clues, and cues. So we might as color, movement, or light to an existing environmental feature to provide a learning visual information for that student with CVI to become more likely to visually attend.
[INAUDIBLE] landmarks often unrelated to size that appeal to the students unresolved CVI characteristics. If we choose a larger target for a landmark it may be to reduce complexity, because it's the most prominent visual element among other things in their visual field. But it's not to make it bigger so that it's clearer. We want to elicit the student's visual attention to a particular detail or target so that they may perceive it and then interpret it.
So we're calling their visual attention to a detail so that they will then get into it and interpret it. So unlike a student with ocular visual impairment who may not know something is there, a student with the CVI may, in fact, know it's there, but not be able to visually attend to it or dis-embed it from its surrounding elements.
And extraneous noise in the environment can be distracting and disorienting and may not add anything for that child in terms of being better oriented to where they are in space. For a child with CVI to access vision, quiet may be the preferred condition, depending on their phase.
And here I just have a photograph of an orange-colored flag outside of the cafeteria. And again, it may be color or the movement quality that will attract a student's visual attention to that doorway.
When it comes to addressing maps with ocular visual impairment, you may be teaching tactile, graphics, different textures, or use of tactile overlays to provide relevant information. If the child has partial vision, you may use high contrast to distinguish different areas on the map. Auditory information can be added. You may choose to include more extensive information to form the most comprehensive map, whether it's in a single map or a series of overlay maps, or in a separate legend or key.
For a child in phase 1 CVI, you want to use a three-dimensional object, an object cue. You may use an actual object to signify something in the location they're going to end up to. And for something for them to match in the environment. And it has to be simple and single-colored if possible. You need to present it against a plain background-- for example, an InvisiBoard or a tri-fold presentation board, before they encounter it in the actual environment.
You will have presented this three-dimensional object, again, something that is ideally an actual object that they can find in the location that they will be going to. Presenting it multiple times in a quiet environment will help them develop visual access to and understand the object before they encounter it in a more complex setting.
So looking at the swing set photo in this slide, without any prior visual teaching of swing-ness, on the actual playground it would be very difficult to actually dis-embed the swing from background elements outside. I also have a photograph of a yellow sling seat swing by itself, presented against a plain black background. So if I had a student in phase 1, I would review its salient features with the actual object against a plain background in a quiet environment.
I would verbally review the visual features, then present the item, staying quiet during their viewing. And then I would take the object away and verbalize the salient features again. So in this example with the photograph on this slide.
For example, this is a swing that has a flat surface on the top, it's curved like a banana, for instance, if they know what banana is and banana is meaningful to them. They have long chains that you hold on to when you swing. And you sit on it on the playground.
After multiple presentations in a controlled environment like this, I would take the student to the playground and review the swing's salient features on sight with the child right there. And then I would give them an experience on the swing to help them develop meaning for its function and use so that they could attach that experience to the visual of the swing.
For phase 2 and phase 3, CVI, you'll start using a map instead of object cues so you can more two-dimensional to represent physical space. And you just want to use one map or representation. You want to use highly saturated colors only on the important aspects of the map that the student really needs to visually regard. And you'll want to design the map based on the CVI phase visual accessibility guidelines we'll go over in a few minutes.
You want to limit the information provided on the map to reduce visual complexity. Because remember, the more elements on the map, the more the brain has to visually process through, and that can become confusing. Consider pairing an actual image of the feature or landmark with its corresponding icon on the map. So
On this slide's photograph, we have a photograph made from foam on a lightbox. I made the template from black art form and placed it on the lightbox. I'm using three-dimensional different-colored balls to mark three Landmarks in the space that is being represented by the map.
So for example, if that center orange ball marks the location of a water fountain, I would have a photograph on my iPad of the actual water fountain and show the student that this orange ball on our map represents this water fountain on my iPad. And then ultimately we travel the route and find the actual water fountain in real space and pair it with the iPad photo of the water fountain and an iPad photo of the map.
When you're working on map understanding it's important to have the student square off in front of the landmark you're viewing in the actual space and draw their attention to where they would be on the map. And draw their attention to the icon on the map that represents that landmark. You can use a separate marker. I like to use the smiley face sticker to represent the student's location on the map in relation to the landmark marker on the map. And this helps them develop their spatial relationship understanding that is needed to use a map to plan travel.
This is an example of a Wheatley map, and it just has three landmarks on it represented by the orange squares. And so again, I don't have a lot of landmarks marked, but I have the walls of the building. And this would be something I would use with a student in late phase 2 at the earliest. Probably more like phase 3. If I were going with phase 2, I would put it on backlighting. I would take a picture of it on my iPad and use that. Backlighting supports the student in phase 2's visual attention.
This is something I found that using with students in phase 3. This is a photo of a design-your-own marble maze virtual reality activity by Seedliing. And you can make your own map of a space with the maze materials. And then you scan that into your phone, and once you put it in your phone, you can play a game and travel through the space, the maze that you made. You can import photos of landmarks and add it to the maze and the space that you're mapping. This is the actual three-dimensional maze that they give you. And then this is it scanned into an iPhone.
And then on the next slide, this is when you're traveling it in the game on the iPad. You can see that they're plain walls, plain floor. So if you want them to notice a certain landmark, or be aware of where it is in that configuration of the map, you can actually import the photo and put it wherever in the map that you want. So here's a side view of it and then here is a straight-on view.
And when you're playing the game, say there's a green door you want that child to get attend to in their environment. This appears in the game. So you take a picture of that door in the actual environment. You import it into the game, into your maze, and place it where you want. And then they can find it as they're playing the game.
And then they're working on that cognitive representation of space, because they're having to figure out what direction they have to go. There's a start and a finish, so maybe you make the start the front door of the school and finish the gym. You can take those pictures of salient features along the way to the gym and import them into the map. It's really cool.
I jumped ahead of myself. Now we're moving on to cognitive representation of space. And for ocular visual impairment, this may develop through distance-time relationships. So how long does it typically take me to travel from point A to point B? And if I haven't done my landmark or destination within a certain period of time, then I'm probably off route. That distance-time relationship helps the student with ocular visual impairment develop a mental map of space.
Also, they will use tactual exploration through perimeter, grid, line, and reference strategies, which is O&M terminology. If you're not O&M, you may not know it, but it's a specific systematic way of exploring space. He'll learn certain locations of textures, environmental elements that have specific auditory feedback-- doorways, hallways, by counting from a reference point-- to help develop that cognitive representation of space.
And oftentimes kids with ocular visual impairment may achieve spatial orientation by comparing the flow of information they perceive through their touch and hearing with their memory of landmarks in order of expected encounter along a route.
So this oftentimes means that they have an egocentric frame of reference, which means that they are developing their mental map through their position in relation to objects in their space, although an allocentric frame of reference can be taught. An allocentric frame of reference is an overall understanding of how the spatial relationship of multiple elements within an environment relate to each other separate from your own position in space.
With CVI, development of a solid cognitive representation of space will require you to call the child's visual attention to landmarks. And you need to do regular review of these landmarks to integrate them into their visual memory. Ensure that the children landmarks are presented with materials conducive to the student's phase.
And very importantly, provide language support to help the child interpret the landmarks and visual displays. For example, describe the landmark's location, shape, size, quantity of key elements, so that the child's brain can make sense of the vision the visual scene in front of them.
Tactual exploration like trailing a wall, which commonly is used by those with severe vision loss, may interfere with the student with CVI being able to visually regard landmarks at the same time. So it may mean that you stop and look at the landmark, but you don't touch simultaneously.
Distance-time relationships may not be understood. So using a timer may help the student develop a sense of time it takes from traveling point A to point B. And time comprehension is a highly visual, spatial-related skill, so that can be difficult for students with CVI.
Predicting a sequence of landmarks along routes can be difficult as well, due to weak visual-spatial working memory. So it's important to address this by working on that order of encountered landmarks. And that's an important part of instruction. You can play games by putting iPad photos in order of encounter along a specific route, things like that. You can be very creative, but practice that sequence of encounter.
As we all know with ocular vision impairment, social skill development does not occur incidentally. Social skills have to be taught as part of the expanded core curriculum. And if a child has severe vision loss, this may be apparent for others to notice. And therefore others may more readily accommodate for this and inform the student of what is happening around them, who was around them, and provide more specific instruction to walk them through multi-step tasks.
With CVI, social skill development also does not occur incidentally. And oftentimes other people assume that facial recognition has occurred because the student may look at their face. But as we talked about in the assessment slide, recognition may be based on fragile or changing visual information.
So it's important that we teach the student the salient features of people that are unchanging so that they have a better chance of achieving facial recognition for peers and adults they see on a regular basis, like their classmates, teachers, family members, et cetera.
This strategy also helps when meeting a new person. So by describing a person's facial features, the child may be more able to look at a new person's face. I have found that.
Other people may assume that if a student with CVI does not actively participate, or they refuse an activity, that they're just not interested in it. But it may just be that they haven't had any explicit instruction on how to perform the activity, and so therefore they can't visually process what it's all about to even go over and approach it or engage with it. So please keep that in mind.
And with visual latency, there is a lot of difficulty to follow along with multiple-step activities, even if an interest exists. So pre-teaching activities step by step, with materials accessible for the student's phase of CVI, is an important consideration, rather than just throwing them in the activity.
So think about gym class and they are learning something new. Has the child with CVI ever have any previous exposure to it? That may be a good time for you to pre-teach whatever they're doing before they get to that gym class.
If the student doesn't acknowledge their peers, people may think that they're just not interested in having a friendship, when really it may be that there is a barrier to recognizing peers. So peer education is extremely important. I believe we should teach peers to introduce themselves when they approach our students with CVI, and teach peers to be specific about what they are doing, where they are going, et cetera, if they want that child with CVI to engage with them and join them in their activities.
So don't just say, oh, we're going over here. Say, we're going over by the slide. Give them more specific information. Because even though they look sighted in some cases, especially once they get into phase 3, they are not usually processing through all the elements in the environment.
So as I mentioned, a lot of information I'm presenting is based on the CVI Range, which was developed by Dr. Christine Roman-Lantzy. And I have a photo here of her book cover. Published in 2007 by AFB Press. But like I said, her revised version it's coming out in the next couple of months. So I recommend getting that if you'd like more information about CVI, the range, the specific characteristics, and the three phases.
I have the 10 characteristics listed there. Those characteristics are color preference, attraction to movement, visual latency, field preferences, complexity difficulty, light gazing or attraction to light, distance difficulty, novelty difficulty, difficulty with visually guided movement, and atypical or absent visual reflex responses.
Now we get into the visual accessibility guidelines for CVI. In phase 1, we're working on building the student's visual responses. So you will want to use three-dimensional objects. Keep it simple, without pattern, single color, plain background. Show only one item at a time. Be aware that likely there will be no visual imagery generated in the student's mind's eye, even for familiar objects. Out of sight, out of mind. If there's no mind's eye visual imagery, it's hard to use that information for the future that has yet to be stored in the brain.
In phase 2, the student is starting to integrate using their vision with function, you want to have avoid using two-dimensional materials, unless you're presenting it on backlighting, like an iPad or a lightbox. If you're using two-dimensional materials, use photographs of actual objects instead of abstract illustrations that are much harder for the brain to interpret.
You can start using multiple-colored items, but limit the patterns. Limit the number of items added at one time. Be aware that visual imagery in the mind's eye may be generated for routine objects and landmarks, but not for novel or less-known concepts. And you may need to use a tangible prompt in order to get the student to record the visual imagery that they have stored in the brain.
So, they may not remember that they had gym class today, but if you ask them, did you do any exercise, that may be enough of a cue them, oh, I do have a visual memory of an experience I had, and we were doing jumping jacks. So keep in mind that tangible prompts are very important in phase 2, and actually in phase 3 as well.
In phase 3, we're looking at further progression and improvement of the CVI characteristics. But it is highly unlikely that there will be full resolution of all the CVI characteristics. So please keep that in mind. It isn't something that is cured. You can start using two-dimensional materials with color highlighting on significant salient features for the child to visually attend to. Make sure that you don't highlight the entire object, because then it's not clear where the child needs to visually attend.
You want them to use their central detail vision in order to analyze salient details within the image. So you can use abstract illustrations, but check to make sure that it's accurately interpreted by the student. Matt Tietjen, who is a Perkins Roman Range CVI Range-endorsed, has a framework where he assesses this in a progression from realistic to more abstract images. And also it goes from color to just black and white two-dimensional pictures. That's good to keep that in mind that you're showing them this picture and with an illustration they may not be able to interpret it.
Extremely familiar visual imagery of objects, landmarks, and experiences may be generated in the mind's eye without the actual visual information being present. But the student may have difficulty generating and recalling less familiar visual imagery without verbal or visual prompt to cue them, like I had mentioned before.
The next slide mentions the [AUDIO OUT] Complexity Framework. And this is a great tool developed by the TVI I mentioned, Matt Tietjen. It's used to help decide if you need to change the environment or the task complexity in order to create success within an activity for a child with CVI. Perkins e-learning offers a seven-week online course to learn how to use the tool. So I highly recommend that. And this too will help you decide if you need to modify activities or the environment in order to make a task more visually accessible for a student with CVI.
And I know I'm running out of time. So now we're going to talk about each individual characteristic of CVI and how you would use that in O&M if it's still present in the student that you're working with. So we'll go over the three phases, and how it may look different depending on what phase your child is in.
So the first characteristic its color preference. And in phase 1, you want to choose landmarks that are in the student's known preferred color. Preferably, it would be single-colored, because as you add color on top of color, that visual becomes more complex. And in phase 1, that is not accessible.
In phase 2 you may choose landmarks along routes that are not of the student's preferred color, but you might mark the selected landmarks with the student's preferred color using bold masking tape or something of the like.
In phase 3, you may not modify the actual landmarks on a route at all. But you may do a photo preview of landmarks that you are to encounter on the iPad. And you can use an app to add color to highlight the selected landmarks in the iPad photos.
Then you would walk the route looking for those landmarks that were previewed on the iPad. For example, that's marking say that would be a phase 2 accommodation that the child need to find the toilet. As a landmark, you know they're in the bathroom. You could use, if orange were their preferred color, you could use bright orange masking tape and mark the back of the toilet so that they are more apt to visually regard and pay attention to it.
On the next slide we discuss attraction to movement. In all phases, if this characteristic is present, you may want these naturally moving landmarks like a flag, for example. And if there are not any naturally moving landmarks to use, adhere shiny reflective material, like Mylar, onto a landmark to create the illusion of movement.
So in phase 1, the student may need a movement activity before asking them to use their vision. And this may be swinging or going on a walk. OTs are great at coming up with those kind of movement activities, so you may want to confer with an OT on an appropriate activity. Movement helps to activate use of vision, because our vestibular or our movement and body detection system is closely connected to our visual system.
In phase 2, the student may need the landmark to have movement qualities in order to notice it at distances greater than a few feet away. And in phase 3, the student may need movement qualities within the landmark to notice something greater than 10 feet away.
Next slide talks about visual latency. And in phase 1, a student may not even achieve either landmark fixation. So keep that in mind. The latency may cause the landmark to go unnoticed, because of the processing time required. So give extra time to visually process. Don't move away from the landmark too quickly.
In phase 2, the child may achieve [INAUDIBLE] landmark fixation, but not actually interpret the landmark. And in phase 3, the child may need more time in verbal mediation or basically narration of the salient details to interpret novel landmark in a less complex setting. So a quieter setting, and not so much movement around. Be sure that it's not too loud and that there's not a lot of visual distractions.
In phase 3, they may still need more time to process familiar landmark if the setting becomes more complex with a lot of noise and movement. I like to describe latency with an example that people with typical vision can relate to. So I really like the photograph here on this slide, because it depicts it well, I think. It's an image of a campsite by the water, and a man is looking up into the sky at the stars. And he knows a whole lot about constellations, he can look up at the sky and may fairly quickly identify multiple constellations on a clear night. But if he knows nothing about stars and constellations, he could not do that.
So if I had spent a lot of time studying constellations and I narrated to him the different positions of the stars, pointing out what's salient, his brain could start interpreting the constellations with my help. And it's the same visual without my narration and drawing attention to the specific aspects of the sky. But his interpretation is facilitated by my narration.
That is why salient feature language is so important when we talk about introducing novel landmarks. Getting the child to understand how this novel landmark is like an already-known landmark that they are familiar with, and how it is different. Also, this allows them to form a new concept for this new landmark and retain it in their brain. So that language support is extremely important.
The next one goes over visual preferences. In phase 1, I would only use landmarks for orientation purposes during map travel that are located within the student's preferred field. So I would know what those fields are, and the CVI Range would help me determine if that characteristic is present.
In phase 2, you could begin using landmarks that are very motivating and familiar, but are located in less preferred fields. And in phase 3, if you're pointing out or wanting to use landmarks that are not as familiar, be sure to select those that share characteristics with already-familiarized, well-known landmarks. So it may share the same color. It might be the same shape and size, for example.
Also be aware that the location of more novel landmarks should be positioned within the student's preferred visual field. So in this picture, for example, if the student needs to approach the double doors in the back of the room on this photograph, and they tend to not notice things on their left, but they notice things on the right, I would pick the bench as the landmark versus the elevator. Because it's on their left, and that is not a preferred visual field.
Other considerations to be aware of. Be aware of lower field issues and address by teaching cane technique to detect drop-offs and obstacles in less-regarded fields and less familiar settings. So in those novel settings, you want them to use that cane, because they can't anticipate what's coming up.
Protective techniques should be [INAUDIBLE] decreased effort field regard to protect the student from unexpected upper-body producing obstacles in less-known known settings as well. Keep that in mind.
The next slide goes over difficulty with complexity. There are four components to complexity. One is the target itself. Another one is background array behind the target. Third is the sensory complexity of the environment with noise and movement. And lastly is a human face and the complexity here in the human face.
So in phase 1, you want to use single-color, three-dimensional, non-patterned landmarks for the student to regard. Make sure there is no clutter around the landmark. Familiarize the student to routes during periods of quiet and absence of pedestrian traffic. So class change time is not a good time, obviously.
In phase 2, you want to use three-dimensional landmarks with minimal pattern, minimal clutter around the landmark, and teach that during periods of quiet and low pedestrian traffic. And in phase 3, you can use two-dimensional landmarks with some pattern. If it's a highly familiar setting, background clutter may not have as much impact. But sensory complexity often continues to interfere with the student's visual regard and processing of landmarks.
Comfort level in navigating environments in varying levels of sensory complexity needs to be considered. So when noise level increases or a class enters the hallway, the student may freeze en route. Or they may just charge through. But likely you're going to get a change in behavior with the change in complexity.
The next characteristic is like gazing or attraction to light. In phase 1, you might need to shine a flashlight or light source onto an adaptive landmark, for instance one with Mylar adhered to it, for the student to visually regard it. And if possible, with the lights dimmed to reduce the background array complexity.
In phase 2, the student may benefit from choosing light-emitting landmarks like windows or message boards, pop machines that have backlighting to them, things like that. Or add a light feature. You can add a light feature onto a landmark by using a clip-on LED reading light or a pop-on light, and attach that to the landmark for the student to notice.
In phase 3, you may just use natural light-emitting landmarks if a student needs to visually regard to catch their attention from a distance.
Next characteristic is difficulty with distance viewing. Students in phase 1, they need to be within a couple of feet of the landmark in order to visually regard it. A student in phase 2 needs to be within 5 feet to regard it. And a student in phase 3 may visually regard a landmark from a distance of approximately 10 feet, but beyond that may need some kind of adaptation in order to notice it.
Next we're talking about novelty difficulties. So in phase 1, you will need to allow multiple presentations and exposure to a landmark before a student will visually regard it at a later time. In phase 2, novel landmarks may go unnoticed, even with an unfamiliar environment.
And in phase 3, novel landmarks may be noticed within a familiar environment, but likely only if it shares something meaningful with an already well-known concept. In order to recall novel landmarks for later use, there needs to be familiarization and concept development instruction done about that landmark. So salient feature and comparative instructions of pointing out likenesses and differences between already-known concepts and new targets is important to address.
And I just love this photo. I took it in Target, in Target's food aisle. And my son, who is in phase 3, he still has difficulty with novelty, but I have used comparative language and salient-feature language with him so much, he has developed this framework on his own to analyze new images. And so he noticed it, and he said, look, that looks like a Pac-Man eating pellets in a maze, which it does.
What it is is a pineapple slice with a wedge cut out and a row of eggs. But to him it looked like Pac-Man eating pellets, because Pac-Man is extremely meaningful to him. So he made that association. And that's what we want our kids with CVI to start being able to analyze new information by taking what they already know and comparing it.
The next slide goes over difficulty with visually guided movement. And in phase 1, you should not simultaneously move by a target while looking at it. Visual regard of the environment is a challenge in itself without additional movement demands. So you need to stop close to the target and allow the child to view it separately from moving.
In phase 2, have the student stop en route and visually regard the familiar landmarks. Because movement will likely continue to interfere with simultaneous visual regard. And in phase 3--
We are at about five minutes max.
OK, I think I'm almost done. I can't believe it.
Great!
The child may be able to regard landmarks simultaneously while moving if they're highly familiar. So you want you to encourage purposeful movement by noticing more distant landmarks. So you're teaching them to guide their movement choices by using their vision.
And lastly is atypical visual reflex responses. Phase 1, there will be no reflex response. Or if there is one, inconsistent. Phase 2, it may be inconsistent. Phase 3, they will likely have intact reflexes, but it may be delayed if they're tired, they had a seizure, or they are ill. And please be considerate. Potentially dangerous environments with fast-moving threats and make sure to use protected techniques to increase safety.
This is my final slide. Well, almost final. I really appreciate this quote from Oliver Sacks. It says, "The brain is more than an assemblage of autonomous modules, each crucial for specific mental function. Every one of these functionally specialized areas will interact with dozens or hundreds of others, their total integration creating something like a vastly complicated orchestra with thousands of instruments, an orchestra that conducts itself with an ever-changing score and repertoire."
I think this describes our brain. Our vision is constantly changing, and vision is a function of our brain. And it requires cooperation and integration of so many different parts, not simply acuity. And so vision must constantly readjust with the changing environment. And with CVI, use as active vision as possible with the just-right challenge.
So that's why it's important to have a careful assessment and approach to help our kids learn to see, and how to navigate their world. Thank you all for all of your attention. If you have any questions, please feel free to reach out to me. I have my email on the last slide there.
Thank you so much, Alisha. I know you are going to have to drop off. I have a couple of questions I wanted to address. Can I ask if you can turn your speakers off? Just because I'm getting feedback from my side.
You need me to turn my volume down?
Yeah, would you mind would you mind?
Sure.
Please respect the seven-second delay. Thank you. We did get a number of questions that came through that I wanted to address specifically around O&M. You talked a lot about cuing, different ways of cuing with students to find a landmark or learn a route.
At one point, you talked about using what we might call CVI-friendly colors. A lot of kids have a preferred color. Do you advocate finding what that preferred color is, and using that as cues?
Yes, so you would do the CVI Range and determine if there is a color preference. And asking parents. Parent interview is part of doing the full Range. So asking their parents if they notice that there's a certain color that the child seems to choose best. Or if you look at the toys they do look into, or the objects they do attend to, you might find that there's a certain color that repeats.
So I would definitely take that and use that with my landmarks and try to pick landmarks that are of that color or landmarks that leads to places with that particular color.
Thanks. There's also a school of thought surrounding using terms like look and see with our kids with CVI. And rather than you certainly attend, getting them to attend to something. In speaking with the student, what words or instructions do you use rather than [INAUDIBLE]?
What I would do is point out the salient features. And I would use my finger to direct visual attention. So I use the [INAUDIBLE] or I would use attraction to movement that also help. And point out specific details of the objects or the landmarks. And then describe what it is by shape, or color, or size, or quantity of something to try to get that looking, rather than say, look.
I've certainly said some things like, find. See if you can find the stop sign or find the curb.
Yes, see if you can find. That's perfect. I do that a lot as well. And I know one thing is just don't ask them to look, look at my face. Because if they could look at your face, they would. Watch
I wanted to repeat the name of the maze app again. There was a lot of questions within the Q&A box. That was the maze by Seedling.
Yeah. It's a newer product out. If you Google Seedling design your own marble maze virtual reality. That would pull it up.
And just while we're on that topic, would you advocate using the same sort of cues in the tactile map or maze? Say, for example, you showed a red block at the end of the route. Would you then use that red block on the actual item as some kind of matching cue while you're learning a route?
I would. I think that's a great idea. You're making that association. And if you can keep things as similar as possible, you want to do that. That's going to help the brain make sense of it and compare the two to understand that they are the same thing, just different representations. One's a concrete representation, one's an abstract representation.
There are two other questions from the people who asked them online. I'm going to give them to you offline, because they're more complex. But one is specifically asking a parent about advocacy. I think that as both a parent and a professional you might be able to comment. So specifically advocate [INAUDIBLE] services when perhaps the school or program can't understand why a program's vision [INAUDIBLE]. So we'll take that offline.
And another one was we did have some colleagues sitting in today from the UK, where Dr. Roman's CVI Range is not as well known and not as used. So I wanted to acknowledge that we didn't address that in depth. But I did share some links with those participants to break down what the phases are, and how they're defined. We'll make that available, along with your PowerPoints as well.
Great. Thank you.
You're welcome. Thanks for participating. I wanted to make one last plug, and if I'm [INAUDIBLE] post it here on the site, The fourth annual Perkins CVI Symposium will take place here on the Perkins campus in April, April 13, 2018. That's a Friday. If you are able to come to the New England area and you would like to participate in that, we'll have that on the page as well. But it's Friday, April 13, Here on the campus.
All right, thanks. I'm going to have to call that a day. Appreciate those of you staying over. Thank you, Alisha, for staying over. On behalf of the elearning team, my partner Valerie, and Dr. Mary Zatta, we thank you all for joining us. We'll see you all next month.