Presenter: Gregory Santamoor, MS, TVI

Content Overview of Session and Participant Learner Objectives Introduction to Cortical Visual Impairments (CVI) Interventions and Teaching O&M O&M Students with CVI in EVS Applying strategies based on student needs O&M Instructional Approaches Integrating Learned Activities

Introduction to CVI → Your understanding Definition Terminology/Diagnoses New Developments Causes Incidence Educational Challenges Teaching Approaches for children with CVI

Definition 1 “Cortical Visual Impairment is a temporary or permanent visual impairment caused by the disturbance of the posterior visual pathways and/or the occipital lobes of the brain.” Ref:

Definition 2 “Cortical Visual Impairment is a neurological disorder, which results in unique visual responses to people, educational materials, and to the environment.” Ref:

Definition 3 Cortical Visual Impairment refers “to a visual loss caused by some disturbance to the ‘posterior visual pathway’ or ‘visual cortex’ which encompasses difficulty in processing and interpreting incoming visual information.” Ref: Teaching Exceptional Children Plus article Volume 4, Issue 5, May 2008

CVI – AKA… What Is and Is Not CVI Is CVI Cortical Visual Impairment Cerebral Visual Impairment Neurological Visual Impairment Is Not CVI Hemianopia –damage to optic nerve/tract Absolute Scotoma –specific blind area Functional Blindness –possibly psychological Visual Agnosia –inability to recognize common object Visual Neglect Ref:

New Developments American Printing House CVI Advisory Group in 2008 and ongoing efforts to recognize CVI as a separate visual impairment to receive Federal Quota Funds. Creation of CVI website through APH Inclusion of CVI through Familyconnect.org (NAPVI) CVI included and recognized by NYS Department of Health as one of the most common visual impairments

According to Dr. Roman-Lantzy… “Experts do not agree whether cortical visual impairment, neurological visual impairment, brain damage-related to visual impairment or some other term will ultimately be chosen.”

More from Dr. Roman-Lantzy… “Cortical visual impairment is more commonly used in North America, while cerebral visual impairment is generally used in Europe.”

Causes 1 Hypoxia –lack of oxygen to the brain Encephalopathy –damage to the brain Intra-ventricular hemorrhage Peri-ventricular leukomalacia Cerebral vascular accident Central nervous system infection Structural Abnormalities Head/brain trauma

Causes 2 Microcephaly Hydrocephaly → Shunt malfunction → Intracranial pressure Hypoglycemia Meningitis Epilepsy Poisoning/Drug exposure

Related Neurological problems Cerebral Palsy Seizure disorders Cognitive impairment Hearing loss Memory dysfunction

Incidence Cortical visual impairment is considered to be the PRIMARY cause of visual impairment in First World countries. In the United States the top four (according to the NY State Department of Health Clinical Practice Guidelines in Visual Impairment): Cortical visual impairment Retinopathy of Prematurity Optic Nerve Hypoplasia Structural Abnormalities

Incidence continued… The most common cause of visual impairment in children WORLDWIDE is ________?__________.

And the answer is… Ulceration (or scarring) of the cornea, secondary to Vitamin A Deficiency.

According to the American Foundation for the Blind, 30-40% of children with a visual impairment have CVI

Educational Challenges Signs and Symptoms Variable visual responses Visual Latency –delayed responses Use of peripheral vision rather than central vision Visual Novelty –prefer more familiar objects over novel objects Visual field restrictions Poor Depth Perception Absence of visually guided reach Better visualizing moving target than motionless

Educational Challenges Signs and Symptoms continued… Figure-Ground Perception Compulsive Light Gazing/Photophobia Color preference (color may act as anchor) Lack of sensory nystagmus vs. presence of motor nystagmus Non-purposeful gaze Difficulty with Visual Complexity Pattern on surface of an object Visual array within surrounding environment Complexity of sensory environment

What is it like for a child with CVI? Akin to looking through Swiss cheese Imagine trying to find one person in a football stadium while standing on the 50 yard line Like looking at modern art Similar to looking at an unfinished jigsaw puzzle Continuously playing “find the hidden object”

Visual Pathways Cross Section

Damage to Optic Nerve and tract

General Teaching Considerations Allow for intermittent breaks Child should be positioned comfortably Avoid challenging a child with CVI with a visual task and other fine or gross motor task Work in a simple uncluttered visual environment Use familiar objects Repetition is important Use vibrant colors such as red, yellow and orange

Teaching Considerations cont… Use toys and materials which are motivating to child Pair visual tasks with other sensory systems such as audio or tactile (to support visual task) Use verbal descriptions of materials Arrange optimal lighting – preferably from behind child Move the target you want him/her to see Utilize different visual fields for optimal responses Allow for additional time Ref:

Additional Suggestions from Teaching Exceptional Children Plus Use boundaries or borders around target when possible Use technology (changing settings on PC/laptop) Recognize that behaviors (i.e. maladaptive) may be a way child is communicating Start sessions at levels child can achieve Consider less inclusion – What is the best LRE for the child? Keep team members informed

Role and Approach of O&M Instructor Connect and consult with TVI Connect and consult with rest of team –including family!! If possible, take part in Functional Vision Assessment and Learning Media Assessment Review Functional Vision Assessment, if you do not participate in the process Get updated eye report Agree upon approach and strategy with team members that is consistent and that meets student’s needs Be flexible as your approach may need to be changed to better suit the student

Characteristics of Cortical Visual Impairment Checklist Children with other types of visual impairments may exhibit some of these characteristics. CHILD’S NAME_____________________________ AGE________ DATE______ RESPONDENT’S NAME & RELATION TO CHILD________________________________ A child may be suspected of having a cortical visual loss when the extent of visual loss is unexplained by ocular abnormalities. Etiologies may include cerebral palsy, asphyxia, intracerebral hemorrhage, and meningitis. Please check any areas below that pertain to the child. APPEARANCE ___Does not look blind ___Blank facial expression ___Lack of visual communication skills ___Eye movements smooth, but aimless ___Nystagmus (rapid eye movement) rarely seen

VISION FUNCTION ___Visual function varies from day to day or hour to hour ___Limited visual attention and lacks visual curiosity ___Aware of distant objects, but not able to identify ___Spontaneous visual activity has short duration ___Visual learning tiring ___Closes eyes while listening ___Balance improved with eyes closed ___Look away from people and objects ___Consistently look to either side when visual looking ___When visually reaching looks with a slight downward gaze ___Turns head to side when reaching, as if using peripheral fields ___Uses touch to identify objects

MOBILITY SKILLS ___Occasionally "sees" better traveling in a car ___Difficulties with depth perception, inaccurate reach ___Unable to estimate distances ___Difficulties with spatial interpretation ___Avoids obstacles, but unable to use vision for close work

IMPROVED VISUAL PERFORMANCE ___When in familiar environments and when using familiar objects ___When told "what" to look for and "where" to look ___When objects are held close to eyes when viewing ___When objects are widely spaced ___When looking at one object verses a group of objects ___When color is used to assist in identification of objects or shapes ___When objects are against a plain background and paired with movement and sound K. Appleby’s compiling information from article by: Jan, J.E., Groenveld, A., Sykanda, A.M., Hoyt, C.S. (1987) "Behavioral Characteristics of Children with Permanent Cortical Visual Impairment." Developmental Medicine & Child Neurology, 25,

O&M suggestions for children with CVI The follow suggestions are based on the Texas School for the Blind presentation on March 31, 2012 by Lisa Colaci, COMS and Ruth Ann March, COMS

Color Preference Wear student’s favorite color Mark key locations with the student’s favorite color Consider using AmbuTech red and orange ball and roller tips Use tape in a student’s favorite color to mark the placement of hands (or the lower bar) on a pre-cane device Point out red lines on sides of aisles (grocery store) Direct focus to overhead department store signs also often in red Incorporate preferred color in maps for student’s use

Attraction to movement Mark key points on route - helium balloons (favorite color) tied to weight Use Mylar pompoms to mark key destinations Use hand motions to direct attention or provide directional cue

Visual Complexity Avoid wearing overly busy clothes Expect the student to have difficulty recognizing faces; provide verbal prompts in social settings Provide opportunities to practice recognizing faces by using photos of key people seen regularly Spend ample time familiarizing to new classroom/school prior to beginning of year before teachers begin decorating Schedule at least one lesson after teachers have returned Provide ample practice the first few days of the school year after students return

Visual Complexity cont… Try to limit visual complexity when choosing training sites, especially when teaching a new skill Use of telescope, binoculars, digital camera or cell phone may help control for visual clutter (as well as be a motivator) Cane or pre-cane device may help student focus on what is ahead Looking at the cane as it moves may help cut down on visual clutter by decreasing array Cane movement may attract student, promote use of vision, but distract from awareness of other key visual information

Visual and Environmental Complexity Because of difficulty attending to more than one source of sensory input at a time, try to limit auditory prompts as they tend to interfere with vision Use physical prompts, especially those that involve movement

Visual Novelty Very connected to visual clutter Use sequence of photos with increasing complexity to introduce/familiarize to new landmarks Preview planned destinations with your student Give student pictures of desired items when teaching shopping or how to find a landmark on a new route When introducing a new route, make picture book with the student present in pictures, of key points on the route Use preferred color for background

Visual Novelty cont… Keep it visually simple; put only one picture to a double page Use the picture book to review route before practicing again On any new route, allow time for exploration, perhaps initially with a guide, so the student can become familiar with new surroundings and you can point out key areas Expect cane skills to temporarily decline when working in new area until the environment becomes more familiar

Visual Novelty cont… Introduce new cane skills in familiar environment to help avoid visual distractions Watch for evidence of visual and/or physical fatigue As vision resolves, tactile and visual exploration will occur more simultaneously, but only when child is ready Allow for delay between first seeing and then acting upon a visual target Know visual field preferences

Lighting considerations Not the classic photophobia The presence of shadows creates complexity. Teach student how to recognize shadows and what causes shadows to change Or avoid times of day when shadows are present Reflections from windows, standing water or shiny surfaces may distract and cause changes in performance Attraction to reflective surfaces can be utilized to mark landmark or promote visual field expansion

Good News Increased support and understanding of CVI including State and Federal changes Children with CVI can improve their skills and use of vision with the right approach(es) The brain has plasticity and for children with CVI, this could mean additional improvements Recognition that LRE for children with CVI does not necessarily mean inclusion Team approach works wonders Presence of CVI does not always mean cognitive impairment Your lessons can be simplified for children with CVI

Resources → characteristics-of-cortical-visual-impairment-checklist → cortical-visual-impairment-an-overview-of-current-knowledge → →

This presentation is dedicated to the memory of Dr. Harvey H. Mar, Developmental Psychologist ( )