Cerebral Visual Impairment: Another Way of Seeing
Presentation #3
Amanda Lueck, Ph.D.
Illinois AER Preconference February, 2016
Agenda for Today’s Sessions
Part 1: Introduction to Cerebral Visual
Impairment
Part 2: Multidimensional Assessment
Part 3: Assessment Tied to Intervention
Part 4: More on Intervention
Part 5: Questions and Answers
Pulling It All Together: How to Make Sense of Assessment Results
Results from the Three Tiers of Assessment Serve as Guides for
Instruction in basic visual skills
Accommodations or alternative compensatory strategies
Presentation modes to optimize performance
Pulling It All Together: Visual Information
Serves as guide for:
Eyeglass for refractive error and/or accommodation needs
Optimum size of materials
Level of contrast
Pulling It All Together: Visual Function & Functional Vision Information
Serves as guide for:
Best area of vision
Color
Illumination
Accommodations and/or training for visual skills
Pulling it All Together: Visual Function and Functional Vision Information
Serves as guide for:
Use of movement
Accommodations or alternative methods to assist with visual guidance of limbs
Alternative strategies to identify people, objects, shapes, pictures, words, or facial expressions
Alternative strategies to follow familiar and unfamiliar travel routes
Pulling it All Together: Combined Information
Serves as guide for:
Optimal auditory presentation modes
Build upon strengths of different sensory channels as well as cognitive and motor capabilities
Pulling it All Together: Combined Information
Serves as guide for:
Use of sensory channels to promote attention
Sensory motor skill interventions
Curricular and daily living activities
Assist with social-emotional concerns of student and family
Relationship Between Educational Assessment & Intervention
Continue to learn more about how the child functions so that intervention informs assessment.
Modify intervention as learn more about child
Modify intervention as child progresses or does not progress
Milliondelooks.com
Continuation of Assessment During Interventions
Assessment is Ongoing
Needs of children with cerebral visual impairment can be complex and can change with:
Performance improvements due to changes in the child
general maturation
experience
direct instruction effects
motivation changes
biobehavioral state e.g., (tired, sick upset, excited)
Different environmental conditions
Diagnostic Teaching
Combines assessment and instruction
Each process informs and ensures the validity of the other
Assessment Instruction
Important technique for children who have CVI
Diagnostic Teaching
According to Koenig and Holbrook (1993)
Diagnostic Teaching guides a teacher’s instructional practices as though each interaction with a student, whether instructional or not, is an opportunity to engage in integrated assessment
Koenig, A., Holbrook, M.C. (1993). Learning media assessment. Austin, TX: Texas School for the Blind and Visually Impaired.
Develop and Monitor Teaching Hypotheses
Need to develop initial hypotheses for teaching practices and monitor them for possible adjustments
Diagnostic Teaching: Example
For Ricardo, a 5-year-old with simultanagnosia (cannot see more than a few objects at one time) resulting from CVI
He does not want to ask for assistance and stand out from his peers
He needs help to find his coat on the coat hooks along the wall in his classroom when a lot of coats are there
Diagnostic Teaching: Example
Formulate Hypothesis
Ricardo will find his coat when he places his coat on the same hook every day. If he has trouble (e.g., someone moves it), he can search for his coat after most of the children have taken their coats off the hooks.
Observe Behavior/Environment
Collect Outcome Data
qualitative narrative timing of success in locating his coat for recess times and at the end of the school day
Refine Intervention as Needed
for learner and environment
Monitoring Compensatory Activities
Children with cerebral visual impairment often benefit from modifications to task requirements or task activities for successful task completion
Modifications to task performance require monitoring and revision as needed
Diagnostic Teaching: Example for Modification of Compensatory Strategy
Sometimes, compensatory strategies can be reduced or eliminated
Keiko, an 8-year-old with topographic agnosia (easily gets lost on travel routes) resulting from CVI
She loves her music lesson which is down a long corridor in her school from her third grade classroom
Keiko is very aware of the skills of her peers and does not want to stand out
Currently, she cannot tell when she nears the music room and wanders into other rooms until she finds it
Diagnostic Teaching: Example for Reduction of Compensatory Strategy
Formulate Hypothesis
Keiko will quickly find the music room by identifying a large, unique orange poster on the door to the music room. The doors to other rooms will not have any posters.
Observe Behavior/Environment
Collect Outcome Data
accuracy in locating the music room each day
Diagnostic Teaching: Example for Reduction of Compensatory Strategy
Refine Intervention as Needed
Keiko received training to identify the music room using a less-obtrusive method that does not require special materials or make her needs stand out.
She learned that the music room comes right after a bank of windows.
Her mobility teacher removed the large orange poster. Keiko is thrilled that she can use the windows as a landmark just like her peers.
While the poster worked well, it was important to Keiko that used a strategy that was also used by her peers.
Summary of Diagnostic Teaching
Needs of children with CVI are evaluated in initial assessments
Instructional solutions are based on initial assessments findings
Performance and outcomes are monitored continuously in order to revise and improve intervention methods
Diagnostic Teaching Works Well for Independent Living Skills
Skill: organization
Task: taking homework papers out of backpack
Effects of VI/CVI: difficulty seeing items and reaching for them
Functional Observation: unable to locate loose papers in backpack
Suggested Intervention Approaches: place papers in bright yellow folder in separate compartment
Outcomes of Intervention Hypotheses and Revision: initial visual discovery of yellow folder & subsequent reach for folder via touch
Bruce
Children with profound
visual impairment due to CVI
Assessment
Tier 1
Gathering more information about ocular vision needs related to refractive error, accommodation, visual acuity, visual field, eye movement
Tier 2
Gathered information about salient/preferred stimuli primarily from interview, observation, earlier reports
Tier 3
Gathered information about functional tasks and environment from interview and observation
Case Story: Bruce
Background
Bruce was 14 months old
born with most of the lower back portion of his cortex missing and has no corpus callosum
recurrent myoclonic-tonic seizures that did not respond well to medication
reduced vision diagnosed as a result of cortical visual impairment and optic nerve hypoplasia. His vision reportedly had not improved over time
cortical hearing impairment which was reported to be improving
non-ambulatory and non-verbal
lives with his mother in an urban area in California
receives services from a vision impairment specialist from Blind Babies Foundation as well as physical therapy, occupational therapy, and feeding therapy
Bruce’s mother was assisted by an in-home nurse who provided care for Bruce.
Case Story: Bruce
Ophthalmologist’s Report
Bruce fixated and followed
visual acuity of approximately 20/2000 based upon the Teller Acuity Cards
horizontal nystagmus
variable and intermittent esotropia
pupils were sluggishly reactive to light
Case Story: Bruce
Observations
fixated on objects but did not follow them as he did for the ophthalmologist.
shift gaze very slowly to objects directly in his line of sight that did not require major head movement. reduced ability to control head movements seemed to severely restrict ability to shift gaze.
With head support, fixated for longer periods of time and shifted gaze more readily.
A fixed head support did not appear to change inability to follow objects.
mother and home counselor reported vision functioning appeared to vary depending upon levels of seizure activity and medication.
appeared to attempt to reach for objects based upon visual cues, showing movement of his hands and fingers even when he physically could not make the arm movements to reach desired objects.
Case Story: Bruce
Observations
mother reported that Bruce will reach when “gotten started”because the physical act of reaching was difficult for him.
Bruce was noted, however, to reach directly for a penlight with a “monster”cap during our evaluation without any assistance.
in a sitting position, Bruce sucked on his fingers and brought his head down to his hand rather than his hand to his mouth.
once his head was down, Bruce had difficulty raising it
displayed understanding of cause and effect- moved his hand repeatedly to bat a favorite toy that made animal sounds when pushed.
Case Story: Bruce
Observations
Bruce smiled when he heard certain sounds
stilled as he heard his mother’s voice when she was out of sight on many occasions
appeared to be less alert in the supine as opposed to sitting position
appeared to display preferences by looking, reaching, or making hand motions.
when seizures were under control and medicine did not overly-sedate him, Bruce was alert and interested in people and objects in his surroundings
Case Story: Bruce
Determine repertoire of behaviors
Skills acquired, when/where used, motivators
Skills likely to be acquired
Skills that need refinement
Skills acquired but could be applied to specific tasks or a wider variety of tasks
Case Story: Bruce
Intervention goals focused on areas of high priority areas to family
Infused within daily routines at home
Complete meaningful activities as independently as possible
Use positioning in which child is most responsive
Use activity pace matched to child’s pace
Use materials of high motivation
Fade to the use of less intrusive adaptations as soon as possible
Case Story: Bruce
Mother wanted him to follow her visually when she was in the room
Functional goal to follow an object of interest from left to right
Wanted to try to encourage Bruce expand his skill to reach for objects
Functional goal was to reach for favored object (Mardi Gras beads) within arm’s reach and directly in front rather than an object he did not favor. Beginning step to making choices using vision
Case Story: Bruce
Intervention Hypotheses
Bruce will be able to fixate and follow a favorite toy moved along the squiggle template on an illuminated light box for longer distances over time (3 months) and this training will transfer to non-illuminated light box
Measured pre and post 15 weeks of training with illuminated light box.
Bruce will choose his favorite Mardi Gras beads from a translucent shape of the same color when presented on an illuminated light box more frequently over time (3 months), and this training will transfer to non-illuminated lightbox.
Measured pre and post 15 weeks of training with illuminated light box
Case Story: Bruce
Intervention method and some results: Following black background with squiggle cutout on lightbox with large translucent bead
Dramatic improvement in following responses during final non-illuminated light box and increase in following beads halfway:
79% following responses in final lightbox trials compared to 14% of initial light box trials…but only 37% in total training trials
Case Story: Bruce
Intervention method and some results: Following black background with squiggle cutout on light box with large translucent beads
Improvement in following responses across the entire squiggle template from initial non-illuminated trial to final non-illuminated trial after training (from 0 to 29%)
Interestingly there were no following responses across the entire squiggle template during training sessions
Lessons Learned: Bruce
Bruce’s performance may have increased at the end of training due to
return to the non-illuminated light box moving his attention away from the riveting light and back to the toys within the squiggle cut out
Reduction in dosage of seizure medications after his last hospitalization resulting in heightened general alertness
Lessons Learned: Bruce
Bruce benefitted from intervention despite great gaps in training periods due to hospitalizations related to major seizure activity
Intervention related to visual skills may have been successful with Bruce but this could have been more related to management of the visual environment and generalization of skills already acquired to other situations
Multiple dimensions of training were successful with Bruce grounded in collaborative assessment and systematic intervention that occurred during teacher directed training activities and reinforced in other aspects of Bruce’s daily routine
Case story: Jack
Walking in unfamiliar area
Reading
Walking past familiar person without expecting her along the way
Case story: Jack
Interventions
Use of Kurzweil for reading with key phrases highlighted
Mobility to familiarize Jack with concepts about environmental patterns
One on one aide
Arrange seating so that para can redirect Jack back to his work easily
Family is considering placement at school for the blind so that Jack can have more focused attention to his needs
Case Story: Isaac
Case Story: Isaac
Background
6 years old, twin (fraternal),1st grade
Respiratory syncytial virus (RSV- a respiratory virus) in first week with CPR to help regain normal breathing
Referred for reading difficulty and reduced vision with diagnosis of bilateral amblyopia and moderate refractive error (farsighted) in right eye
Case Story: Isaac
Screening
slightly reduced acuity OU (20/40) with single Lea symbols with difficult naming symbols so Isaiah pointed to symbols that matched
slower responses on Lea line acuity chart
full visual fields
contrast sensitivity in normal range
color vision normal
appeared to have difficulty with crowded symbols at near (Lea Near Acuity Card - crowded and uncrowded)
difficulty with some items related to figure-ground, visual memory on Motor Free Visual Perception Test
reversals and writing outside lines
no issues noted with movement around house and outside
Case Story: Isaac
Results
Referred for binocular vision and perceptual skills evaluation
Moderate farsightedness; ocular health and eye alignment normal
Distance visual acuity with Lea Chart 20/20-2
Near visual acuity with Lea Chart 20/30
Significant visual memory weakness
Decreased visual processing speed
Visual sequential memory weakness
Visual figure ground weakness
Reduced rapid automatic naming skills for numbers, symbols, and colors
Case Story: Isaac
Recommendations
tactile writing methods
continue speech and language therapy and work on automatic naming skills
extra time to complete tasks
break tasks into manageable portions
receiving handouts in advance
reduce clutter and visual overload
enough time to complete work
lined paper for writing
play games that promote visual-spatial intelligence
reference strips when handwriting and encourage to practice writing
video games to build hand-eye coordination and laterality
Play individual sports to encourage spatial awareness of body
Reconsider reading program that relies on good visual processing skills to trains auditory processing
Case Story: Isaac
FOLLOW-UP - Isaac’s father writes…
Understanding Isaac's visual experience has been invaluable in helping him in school. Isaac's best friend in school this year is a boy named Ted. Ted is an amazing child: bright, affectionate, personable, and athletic and an excellent reader. He and Isaac have been independently meeting at lunch time so Ted can "teach Isaac how to read." Somehow this has worked. Isaac has quickly gone from being a non-reader to a happily compulsive reader, although he still has issues. He now has a large collection of Star Wars books. I work in Isaac and Zaida's classroom on Friday's and I once listened to Isaac and Ted reading. They would take turns, and Ted would help Isaac when he got stuck. I began to notice that when Isaac got stuck on a word, Ted would spell it to him and then Isaac would get it. So it would sound sort of like this Isaac: The Jedi knight could see the . . .
Ted: m-o-o-n
Isaac: moon rise over the hill and he . . .
Ted: r-a-n
Isaac: ran home.
Later Ted told me that Isaac "can spell better than he can see."Amazingly, he's right. Isaac's teachers have been making him an assortment of typoscopes, and that does seem to help.