Refraction and motor functions Orientation and lenght of lines Motion perception and VField Picture perception&recognition &

OUR GOAL to understand each child’s visual functioning

Children with CVI OUR GOAL: to understand -the quality of the image -the use of information in higher visual functions -the role of vision in development and education

The effect of visual impairment varies in different tasks. Visual disability is task dependent.

Visual Impairment affects four main areas: Communication Orientation & movement ADL, daily living skills Sustained near vision tasks

Four-leafed clover of VISION

Visual Impairment Basic questions: How does vision affect this function? How is vision going to affect development of this function? Does the child have compensatory techniques? How do I teach them?

Visual Impairment Basic questions: How does vision affect this function? How is vision loss going to affect development of this function? Does the child have compensatory techniques? How do I teach them? How do I help the child to develop compensatory techniques?

Refraction and motor functions Orientation and lenght of lines Motion perception and VField Picture perception&recognition

Visual cortex V1 & V2

Visual cortices posterior parietal inferotemporal frontal eye-hand coordination spatial awareness recognition

CVI Often a part of larger brain damage >> thus Cerebral visual impairment or Brain damage related visual impairment

Brain damage related VI Caused by: - lesions in visual pathways - cortical lesions, visual and other - subcortical lesions - leads to uneven profile of visual functions, some good, some poor important in assessment of children with intellectual disabilities

CVI - Behaviours - VARIATION in visual behaviour - effect of basic disorder - effect of medication, wakefulness - misunderstanding the functions easy to us, difficult to the child

CVI - Behaviours - VARIATION in visual behaviour - speech as compensatory function

CVI - Behaviours - VARIATION in visual behaviour - speech as compensatory function - plays with adults, not with children

CVI - Behaviours - VARIATION in visual behaviour - speech as compensatory function - plays with adults, not with children - clings to parents in crowded places

CVI - Behaviours - VARIATION in visual behaviour - speech as compensatory function - plays with adults, not with children - clings to parents in crowded places - uses colours for recognition

CVI - Behaviours - VARIATION in visual behaviour - speech as compensatory function - plays with adults, not with children - clings to parents in crowded places - uses colours for recognition - may learn letters early, only short words

CVI - Behaviours - VARIATION in visual behaviour - speech as compensatory function - plays with adults, not with children - clings to parents in crowded places - uses colours for recognition - may learn letters early, only short words - starts drawing late or never

CVI – Behaviours 2 - stops at thresholds and shadows - depth perception - perception of surface qualities

CVI – Behaviours 2 - stops at thresholds and shadows - does not look at, ”avoids eye-contact”

CVI – Behaviours 2 - stops at thresholds and shadows - does not look at, ”avoids eye-contact” - peripheral vision better, central scotoma

CVI – Behaviours 2 - stops at thresholds and shadows - does not look at, ”avoids eye-contact” - peripheral vision better, central scotoma - gets lost in familiar places

CVI – Behaviours 2 - stops at thresholds and shadows - does not look at, ”avoids eye-contact” - peripheral vision better, central scotoma - gets lost in familiar places - gets angry if objects are moved

CVI – Behaviours 2 - stops at thresholds and shadows - does not look at, ”avoids eye-contact” - peripheral vision better, central scotoma - gets lost in familiar places - gets angry if objects are moved - uses siblings and adults for help

CVI A list of typical behaviours does NOT help us to understand a child.

When a child has an unusual behaviour, describing it is not enough.

When a child has an unusual behaviour, describing it is not enough. Try to find out WHY the child has that behaviour. Consider other impairments. Consider the situation.

Fixation & accommodation

Length & parallel lines

Angle & cross Pen and spasticity

Parallel v. crossing lines

Eye-hand coordination

Cognitive visual functions Discrimination of orientation of lines Discrimination of size/length of lines Detection & discrimination of movement Perception of texture, surface qualities Object / background, Depth Recognition of faces, expressions Recognition of geometric forms Perception of pictures Spatial awareness, eye - hand coordination

CVI Diagnose and therapy: - team, transdisciplinary - tests are used by everyone - observation - structured play situations - repeated assessment

Transdisciplinary Diagnose In the assessment of children with brain damage related vision loss: - ophtalmologist: anatomy, refraction - teacher, therapist: observations, testing - neurologist: dg, neurologic impairements - neuropsychologist: cognitive vision video documentation

Assessment of functional vision - basic information from the eye hospital structure of the pathways, refraction, glasses (under- or overcorrection?) VA, VF, CS, CV, VAd, motor functions

Assessment of functional vision - basic information from the eye hospital structure of the pathways, refraction, glasses (under- or overcorrection?) VA, VF, CS, CV, VAd, motor functions - testing of all visual functions in play and teaching situations, effect of other impairments and disorders

Transdisciplinary assessment

School assistant

Assessment of functional vision - basic information from the eye hospital structure of the pathways, refraction, glasses (under- or overcorrection?) VA, VF, CS, CV, motor functions - testing of all visual functions in play and teaching situations, other impairments - effect of posture and facilitation in children with severe motor problems

Influencing factors

Four children Prematurely born girl with problems in recognition of faces + other impairments Boy with severe CP, poor head control and poor oculomotor functions, good VA, CS,VF Girl with extreme hypotonia, insufficient accommodation, slow hand movements Boy with deletion syndrome, central scotoma, hearing problems, delayed development

Recognition of faces Re-cognition: - the facial features are seen - a template is formed in memory - the face is seen again - template is found and matched

Periventricular leukomalasia Next to ventricle loss of white matter PVL

Matching pictures

Recognising pictures of faces

Photophobia due to optic atrophy Glasses are tested both outside and inside

Photographic memory

Severe hypotonia no functions without good support

Spatial concepts eye-hand coordination good when supported

Correction of reading distance accommodation insufficiency

Early developmental level

Strabismus

Testing in play situations

Findings A rare deletion in chromosome 2 MRI not yet possible, anesthesia dangerous Optic discs greyish; hearing =? CAI? Good orientation in space, explores Reaches for and grasps Notices grey on grey Strabismus LE, does not seem to alternate Seems to fixate at hair line > central scotoma RE –3.0, LE – without cycloplegia Vision for communication in lecture V.

Four children Prematurely born girl with problems in recognition of faces + other impairments Boy with severe CP, poor head control and poor oculomotor functions, good VA, CS,VF Girl with extreme hypotonia, insufficient accommodation, slow hand movements Boy with deletion syndrome, central scotoma, hearing problems, delayed development

Severe multihandicap Highly individual Difficult to assess, formal tests may not function - detection tests do not measure form perception Pleasure of seeing may be lacking - no drive to look, learning through vision does not occur Directing attention; comprehension; memory No prior confirmation with mouth and hands The child may be blind; hearing/ tactile/ haptic - Try with very high contrast visuo-tactile toys, not too long.

”Levels” of CVI There are no general ”levels” of CVI Each cognitive visual function needs to be assessed individually

”Levels” of CVI Each cognitive visual function needs to be assessed individually We do not assess all functions during the first examination, repeated assessments needed

”Levels” of CVI Each cognitive visual function needs to be assessed individually We do not assess all functions during the first examination, repeated assessments needed Accept variation in results in CVI, try to find out the causes of variation

”Levels” of CVI Each cognitive visual function needs to be assessed individually We do not assess all functions during the first examination, repeated assessments needed Accept variation in results in CVI, try to find out the causes of variation Train to improve weak functions, find compensatory strategies, build on strong functions.

”Levels” of CVI Each cognitive visual function needs to be assessed individually Do not believe that you have assessed all functions during the first examination Accept variation in results as a norm in CVI, try to find the causes of variation Train to improve weak functions, find compensatory strategies, build on strong functions Never generalise, children with CVI are highly individual in their functions and experiences. Consider other impairments. Consider techniques of blind people.

CVI Impaired cognitive vision is most often part of brain damage related visual impairment that involves also motor functions and/or hearing. When CVI occurs without other neurologic problems, it is often wrongly diagnosed as ”autistic features” or the child is said to see ”when (s)he wants to see”.

OUR GOAL to understand each child’s visual functioning

Four-leafed clover of VISION

Visual Impairment Basic questions: How does vision affect this function? How is vision going to affect development of this function? Does the child have compensatory techniques? How do I teach them? How do I help the child to develop compensatory techniques?

Vision for Special Education - consider ALL areas of functioning at preschool and school age not only - vision for academic subjects

Vision is a learned function

Learning to see Hands (to midline and into mouth) Mouth (a reliable source of information) Tactile information, tasting, smell Vision (confirmed by other modalties) Multimodal memory Recognition

Finding hands

Because vision is a learned function start early intervention early!

CVI Cerebral visual impairment Brain damage related visual impairment