Introduction and Assessment

Cortical Visual Impairment (CVI), also sometimes referred to as Cerebral Visual Impairment, refers to visual impairment due to damage to the visual cortex, the posterior visual pathways or both. Groenveld, M. (n.d.). Children with Cortical Visual Impairent. Retrieved November 3, 2008 from aph.org/cvi/articles/groenveld_1.html

CVI is a visual impairment that occurs in the brain, rather than in the eyes themselves or the optic nerves.

The degree of neurological damage and visual impairment depends upon the time of onset, as well as the location and intensity of the insult.

It is a condition that indicates that the visual systems of the brain do not consistently understand or interpret what the eyes see.

CVI: child may see a visual image, but cannot interpret it accurately. Ocular: child has difficulty obtaining good visual image, but can process and interpret image accurately when enough information is present. Some children have both.

Vision is a learned behavior. Vision and hearing are distance senses. 95% of all learning is through our distance senses.

80% of learning is through vision. 90% of learning is incidental.

Leading cause of VI in children in the western world. Likely to continue to increase due to advances in medicine.

1. Brain injury 2. Normal eye exam which does not explain why the child is not using their vision 3. Unique CVI characteristics are present

Asphyxia damage depends on severity & duration. Some causes: placenta previa, prolapsed cord, delivery complications.

Hypoxic Ischemic Encephalopathy too little oxygen (hypoxia), too little blood flow (ischemia), irritation of the brain (encephalopathy). Results from asphyxia. Seizures common.

Cerebral Vascular Accident-(stroke) blood capillaries in the brain rupture, damage depends on extent of bleed, more common in full term male infants, mostly affects left side of brain, seizures common.

Intraventricular Hemorrhage Occurs in premature infants w/in 1 st 48 hours. Severity grades I-IV. Premature babies can develop an ocular visual impairments as well – ROP.

Periventricular Leukomalacia (PVL) something, such as trauma, occurs and oxygen does not get to the distant areas of brain. These cells die and the space is filled w/ fluid (sometimes called cysts in the brain. Can cause CP, developmental delays.

Infection-viral and bacterial (TORCH)=toxoplasmosis, rubella cytomegalovirus, herpes/HIV. Also meningitis. Syndromes

High Myopia or hyperopia, ROP Optic nerve disorders Cataracts Strabismus (eyes not aligned) Stage 1 ROP Will not result in the child being “blind”.

Three Gates: 1. Medical History – file review, neurological assessment is best. 2. A normal eye exam which does not explain why the child is not able to use their vision 3. The unique CVI characteristics are present.

ColorLight Gazing Visual NoveltyVisual Motor Complexity Visual Field Preference MovementVisual Reflex Response LatencyDistance Viewing

Drawn to highly saturated colors. Parents report that kids have a “favorite” color. Most commonly reported “favorite colors” are red and yellow.

Children prefer familiar items over novel items. May ignore something that is novel. Very different from ocular impairments in which something new will attract attention.

Toys which are visually too “busy”. Toys against a complicated and confusing background. Competing sensory impute – such as toys which make noise and light up.

Complexity of array. Complexity of sensory environment. Complexity of target / object.

Objects viewed have movement or reflective property A way to jump-start visual system.

Delay in directing vision to a target when new object is presented or new activity begins.

Non – purposeful gaze toward light. Attentive to lights and ceiling fans.

Look Turn away Reach

Strong Preference for looking at objects when presented in specific positions of peripheral and / or central viewing fields.

No Blind in response to touch and / or visual threat.

Often problematic for children in early phases. May be result of increased complexity of visual array.

Early resolution: light gazing, and visual reflexive response of blink Mid-Resolution: color, latency, visual novelty, visual reflexive response of blink to threat, and movement

Later Resolution: visual fields, visual motor, complexity, and distance vision It is always important to remember that CVI can seem to vary from minute to minute and from day to day.

Children with CVI are visually inattentive and poorly motivated. All children with CVI will have cognitive deficits. CVI is not a true visual impairment.

Treatment is EDUCATIONAL - not medical. CVI may range from severe ( with difficulties in all or most areas) to mild ( with many of the characteristics resolved or resolving). CVI gets better or it gets worse.

Intervention centers on the resolution of the CVI characteristics through experiences that are supported by “environmental engineering” specific to the student’s/child’s characteristics.

The first three years of life are the most critical for permanent change…. but change continues long after if the environment is set up optimally to allow opportunities for visual behaviors/ functioning to develop.

1. Interview 2. Observation 3.Direct Evaluation

1. Parents are the experts on their child’s visual behaviors. 2. Many parents are not aware that the same injury or condition which caused the child’s CP or developmental delays also caused the CVI

Remember that parent’s have hopes and dreams for their children. Educators who can help facilitate functional vision will help facilitate improvement in every aspect of these children’s lives. It’s a unique opportunity and privilege for educators to do this work.

Used with all ability levels & with infants–21. Assessing both the presence of the behavioral characteristics of CVI and the degree of impact that each characteristic has on child. Scores the degree of CVI on a 0-10 scale.

Phase I (Ranges 0-3): Building visual behavior Phase II (Ranges 4-7): Integrating vision with function. Phase III (Ranges 8-10): Resolution of remaining CVI characteristics / moving into 2D educational materials

actSheets/StrategiesCorticalVisualImpairment.p df

The CVI Resolution Chart

What is the best way to do this? How do we ensure our recommendations are followed? Vermont Report.

Is it our responsibility to add vision goals to the IEP? Modifying and accommodating or measurable goals….?

“ For Children with CVI, it is important to determine where they are on the continuum of possible impact of CVI, to identify in this way what they are able to look at or are interested in looking at, and to give them as many opportunities to look as possible by integrating motivating activities and materials into their daily lives. The goal is to facilitate looking.” C. Roman Latsky

Focus your adaptations on the identified assessed characteristics, Consider using: A lighted box, special seating or positioning. Head support is OK. Presentation of objects – use familiar /real objects

Allow for intermittent “break” times. Use child’s typical routines as “vision time” Keep verbal cuing simple.

Visual performance is affected by health, medication, alertness, emotion, stress, fatigue, situational demands, etc.

Given that Cortical Visual Impairment is the result of damage to the brain, could the child’s ability to process sounds and words also be impacted? Assume a hearing impairment. Auditory Processing Disorder.

Children who are deaf-blind have both hearing and vision loss. Although most are not totally deaf or totally blind, the combination of hearing loss and vision loss impacts the child’s ability to access information, communicate, and interact with other people.

Children and youth identified as deaf-blind are a unique group of learners who require intensive and effective early intervention and educational programs from infancy through young adulthood.

Intervention can not be RANDOM, Or they will not work.

Students in Phase 1 are generally working on building their visual attention and looking behavior.

Parameters…….what are some ways we can adapt and modify items or activities to develop/encourage social interactions with significant adults, siblings or peers in their lives?

What can we do to help the child locate and identify people in the environment? Brain storm appropriate activities which will promote visual attention and looking behaviors? Phase 1, 2 & 3 Search for ideas on line –share

Total Communication Total communication is using any means of communication -- sign language, voice, fingerspelling, lip reading, amplification, writing, gesture, visual imagery (pictures). Brain storm ideas & share

ASL + CVI – making the issigns more visible.

Have child eating/sitting with peers during snack and lunch times but use light box as table. Place saran wrap x2 over light box. Put juice in a clear cup or bottle- add holographic paper ring to it. Move target.

Total Communication The sign language used in total communication is more closely related to English. The philosophy of total communication is that the method should be fitted to the child, instead of the other way around.

Learn or create your own name sign to use with a student. Learn and teach one high frequency word to class.

How can I help with the calendar goal? Calendars provide context in which students with CVI can develop meaningful communication and time concepts. Calendars and calendar discussions also support CVI children through the security that comes with anticipation of upcoming events, knowledge about changes in routines, and trust in an adult’s commitment to follow through on scheduled activities.

How can we use all residual senses including tactile? What about Braille labels? Ideas – please share.

Co-actively help child mix colored soft drink mix or jello powder into a clear glass of water and watch the color develop. Snow globes adapted.

Social activities continued…. 1. How do we increase the number and quality of interactions and relationships for the student? 2. How do we develop opportunities to improve the ability to initiate meaningful and socially appropriate self – directed activities during free time ? Ideas?

Social activities continued…. Trace outlines of make believe characters / action figures to make pictures of them, then use picture to tell a story. Use red or yellow highlighter to color only the salient feature in the story. Use the light box on the child’s wheel chair (facing the child) and tell a story around the child’s chair (small group activity). Includes the child

Behaviors – are closely tied to sensory access and communication. Often the result of coping with situations that seem confusing or threatening due to lack of information available from others or from the environment.

It can also be a result of frustration about being ineffective in communicating important topics in a more socially acceptable way. The student’s difficulty in recognizing, trusting, and bonding with others can have an impact on behaviors.

Also need to simulate or regulate sensory input? We can: Improve the student’s ability to communicate ideas and concerns in a more socially acceptable manner. How? Provide the student with more understandable information about activities, surroundings, & expectations.

Sensory breaks. Snoezelen rooms. Add scent to Experience?? Quiet!

CVI can affect the child’s ability to know where they are, and how to go from place to place. Children receive less information about the environment, and have lower motivation to explore.

Students need more orientation to environments, and strategies to gather information about their surroundings.

Utilize the child’s communication system during instruction. Work with team to provide adequate information for the student to establish a destination and recognize a particular route ( use communication system to establish a destination, use of the calendar conversation, additional time to explore the salient part of the route.

How can I enhance the visibility of our playground equipment? Gym equipment? Hallway to student’s room? Entrance way of classroom? Other ideas? Flags?

Orientation to new spaces – Peripheral room exploration