Why do Students with CVI Continue to Need Services from the TVI?
Authors: Sara Kitchen and Lynne McAlister, TSBVI Outreach VI Specialists
Keywords: Phase III, Christine Roman-Lantzy, Christine Roman, CVI, Vision Services, Social Skills, Comparative Language, Salient Features, Cortical Visual Impairment, Literacy.
On March 10 and 11, 2017, we attended a training sponsored by the Perkins School for the Blind in Watertown, MA, called “Assessing and Supporting the Student in Phase III CVI”. The speaker was Dr. Christine Roman-Lantzy, who has been researching Cortical Visual Impairment intensely for a number of years. In 2007, her landmark publication, Cortical Visual Impairment: An Approach to Assessment and Intervention was released by the American Foundation for the Blind (AFB) Press. It provided a comprehensive approach to assessment and intervention that focused on 10 unique characteristics associated with CVI. A revised edition is scheduled to be published in the fall of 2017. Also in the works is Dr. Roman’s new book Cortical Visual Impairment: Advanced Principles, which includes information on assessment and intervention for students with CVI, particularly those functioning in Phase III. This new book is expected to be published in the spring of 2018 by AFB Press.
Cortical Visual Impairment is the most common form of visual impairment in developed countries that primarily use western medical techniques, and is a result of neurological damage or structural differences in the brain. Dr. Roman explained that individuals with CVI develop their visual skills more slowly over time. Part of the rate of development depends on whether their environment is conducive to building neurological connections. Their vision becomes increasingly “normal” over time. In the early stages of visual development the child is learning to see and act upon what they see. Dr. Roman refers to these stages as CVI Phase I and Phase II). Theoretically a child spends a limited amount of time in Phase I, in which they learn that visual targets exist but are not yet able to use their vision when there is competing visual or other sensory input. Dr. Roman refers to Phase I as ‘building visual behavior’. A child may spend a longer period of time in Phase II integrating visual information with other sensory information such as touch. Phase II is referred to as ‘integrating vision with function’. During Phase II, an individual must act upon and have an effect on their environment with opportunities to repeat actions. This cements neurological connections. The individual must also interact with enough environmental variance to maintain curiosity and support continued development. The brain’s dorsal stream, known as the “where” system, communicates between the eyes and brain about the locations of visual targets and is the first communication pathway to develop between the eyes and brain. This happens during Phase I and Phase II. The ventral stream, or the “what” system, helps the eyes communicate with the brain about the classification of a visual target. The ventral stream begins to develop in mid to high Phase II, and continues to develop throughout life. Individuals with CVI remain in Phase III, in which the vision system approaches typical vision, for the rest of their lives. The reason why the ten characteristics associated with CVI do not “resolve” completely is due to the fact that visual information is limited during early development, when a great deal of pruning happens in the brain. In Phase III, the focus is on looking to learn, which can be very difficult if strategies for using and refining the ventral stream are not being targeted. During her presentation, Dr. Roman enumerated skills that many individuals with Phase III CVI still need to develop. She also explained how to teach those skills.
What does Phase III look like?
Cortical Visual Impairment is apparent when individuals present with ten unique visual characteristics, as defined by Dr. Roman. These characteristics are expressed differently within each phase. The following describes how each characteristic of CVI is manifested in Phase III:
- Color: The individual may have been attracted to a particular color in the past, but is able to look at items that are of many colors. The preferred color may continue to serve as a visual anchor, making visual information easier to find. The need for highlighting using color never goes away.
- Movement: The individual may be very easily distracted by moving items or may need to move their own body or head to see better.
- Latency: Students may have a first answer of “I don’t know” as a strategy to accommodate for this characteristic: they may need to spend a little longer time to attend to, discriminate, or identify a typical visual target. If a child is having trouble responding to visual targets in Phase III it may be a sign that he or she is experiencing visual fatigue and needs a break. One good rule of thumb given by Dr. Roman is that the number of minutes on an intensely visual task should not exceed the child’s age in years.
- Fields: The lower fields are frequently less functional for tasks. The individual may have difficulty with stairs and may be confused in an environment that has changed, such as a familiar room that has recently been reorganized. Even if an eye report states that all visual fields are intact, consider that this may only apply in the quiet, uncluttered, controlled setting of an eye doctor’s office.
- If an object is too visually complex you may see task avoidance.
- Salient features need to be identified to help the student build visual memory. (See next section)
- Complexity of Array: If too many objects are presented, the individual may not be able to pick out an object. In the classroom, preferential seating may help to decrease competing visual and auditory information. In certain settings it may help to dim lights or use spot lighting on visual targets. (Note to TVIs: When all of the APH complexity cards have been completed, this equals a score of 7 on the CVI Range.)
- Complexity of the Sensory Environment: You may see light gazing, fatigue, rubbing eyes, changing the topic, a tantrum, or seizures if instruction is not modified by giving breaks or making the environment less stimulating.
- Faces: Individuals will still have difficulty recognizing people by facial features alone and may rely on the face, body shape or voice to recognize a person. Eye contact does not equal facial discrimination.
- Light: A focus light may help the individual find or maintain focus on a visual target. Hazy days may affect vision as objects stand out less in diffused light. A backlit display like a tablet or computer screen may help to draw visual attention and make looking easier.
- Reflexes: Protective visual blink reflexes could be typical at this phase, or slow or intermittent. A blink to threat response can be latent or intermittent if the individual is fatigued. This characteristic is the only one that may “resolve” completely and not interfere with visual performance.
- Novelty: Visual curiosity is seen at Phase III, though just the ability to look at new materials does not mean that novelty is no longer interfering with vision. Individuals must learn to look for features of visual targets that are familiar. What is it similar to? What makes it different? What could it be? (See section below on Comparative Language.) Processing novelty requires an ability to access a visual library, which in individuals with CVI must be developed through strategies and intervention.
- Visual Motor: Many times individuals with Phase III CVI are able to look at and act upon an object simultaneously. Characteristics such as novelty or complexity may affect this skill. An individual builds sensory concepts based upon multiple experiences of physically interacting with objects.
- Distance: An individual with Phase III CVI may continue to have trouble identifying objects and people in complex environments such as crowds or when distance results in increased visual clutter. Distant visual targets may not be recognized due to this interference.
Building a Visual Library and Strengthening the Ventral Stream
Dr. Roman refers to two informational streams within the brain that require development through organized, mindful intervention for an individual with CVI. The first to develop is the dorsal stream, or the “where” system. Typically this is the dominant informational stream in Phases I and II. The dorsal stream alerts a person to where an item is in space and does not discriminate details about the object. Initially the individual may just become aware that something is there. The sense of exactly where an object is in space develops next during Phase II. Last to develop is the ventral stream, or the “what” system. This enables an individual to enlist visual memory to recognize, discriminate, and then eventually to identify visual targets. Guided practice is required to bring attention to elements that make an item recognizable, then discriminable, and finally, identifiable. Teachers and parents may help an individual with Phase III CVI view internal details using modifications, discussing internal details, and comparing them with familiar visual items.
Identifying salient features and comparing them to familiar objects utilizes an individual’s ventral stream. This results in a faster and more efficient visual process. When the ventral stream is faster, less work is required to access the visual library and identify objects. Visual processing becomes easier.
Salient features are the distinctive and recognizable visual elements that define an item such as internal details, shape, color, pattern, etc. What visual features do animals have? Four legs and a tail? Do all dogs have floppy ears? Do all cats have pointy ears? Individuals with CVI may need help directing their attention to these types of details. When targeting an item, encourage the individual to use their own descriptors to identify salient features; for example, a picture of a coiled snake might look like a rolled up garden hose the individual has had direct experience with. Joint attention is required for discussing salient features. Both the adult and the child must be looking at the same feature. It is best to follow the child’s lead as this reflects their current understanding and visual perception of the salient feature. Salient features that somebody else perceives as important about the item may not even be seen by the child. As you follow the child’s lead, assist them in choosing two or three visual descriptors and consistently use those to help them remember what the important details are. Team members should be aware of which visual descriptors the child has chosen for a targeted item and be consistent in using them to provide the child with less confusion and more time to practice.
Comparative language is the way to talk about salient features and establish joint attention. Using comparative language encourages the analysis of visual targets to discover how certain features make them the same as or different than items that are already in the individual’s visual library. Joint attention is required for understanding what items are foremost in an individual’s visual library and what may be missing. After new visual items are fully understood, they can be added to the visual library. As the visual library is grown and accessed more, the ventral stream is strengthened. We use comparative language to discuss, practice, and cement visual memories and tie new information to those visual memories.
Visual literacy media could include objects, pictures, or letters and words. In order for an individual to be able to use letters and words, they must show that they are not only able to identify, discriminate and produce phonemes, but also to identify visual details. This signals that the ventral stream has begun to work. All the components of reading should be taught including phonemic awareness. Letter-sound production and recognition must be intact in order to make words and letters have meaning. Photographs of real objects and settings taken with complexity considerations can continue to serve to support memory, just as pictures in books support memory and understanding for a typical learner. The whole alphabet does not have to be known before literacy instruction with letters and words begin, in fact, letter drilling should be avoided. Teaching literacy should be child-guided and fun. Make use of all four approaches to literacy: phonics, personal experience, participation, and whole words. Each approach contains important components that support reading competency.
Most fluent readers look at the shape of a word while reading instead of looking at all of the letters. Even if a word is degraded, a fluent reader can fill in the blanks and determine the correct word fairly quickly. Individuals with CVI benefit from instruction in word shapes. Start by picking two words that are important to the child. These two words should differ greatly in shape and be able to be discriminated easily without any of the internal details, or letters. Words should be outlined in the student’s preferred color. The shape of the word can be discussed, comparing parts of the word to familiar items. Encourage your student to come up with the language to describe the shape, such as “orange” starts with a ball shape. An orange is also ball-shaped. As you begin, use lower case letters as they are easier to interpret.
Often students in Phase III have many negative associations with reading due to lack of success. High interest words that have been identified by the child and that are visually different will be easier for them to recognize and discriminate. This will provide the student with a sense of accomplishment with reading that they may never have felt before. Have them match the shape with the cut out shape on a piece of black paper, like a puzzle. As the child begins to more easily identify word shapes according to the student-identified salient features, begin to embed the words in short and simple connected text about the high-interest word. Ask the child to pick out the familiar word shape as you read the other words. Now you are reading together.
The Impact of CVI on Social Skills
In Phase III, CVI characteristics such as difficulty with visual novelty, complexity, and detecting information at a distance can affect an individual’s perception of social behavior. Social behavior is communicated largely through subtle facial expression, body language, and group action. Social skills are learned through imitation of these behaviors. Social Behaviors that are not perceived cannot be imitated. Factors that put children with CVI at risk in the area of social skills include:
- Difficulty with discrimination of faces, facial expression, and mood
- Learning from visual imitation may be challenging
- Inability to deal with new, unfamiliar visual materials
- Busy and unfamiliar environments can’t be understood or safely negotiated
- Activities occurring at a distance are missed
Mediated playgroups or play buddies may help children develop social skills. In these settings complexity may be reduced by having fewer participants. The children should be encouraged to play together and work out their issues without the adult. The adult may help by describing what other kids are doing and may be more of a facilitator, but not a play partner. A social assessment and curriculum may be used to address specific social skills. Goals and objectives in the area of social skills should be considered a necessary targeted area on the IEP.
Tasks that require the use of vision throughout the day to learn content, such as reading and writing, navigating environments using visual cues at a distance, and learning social skills will continue to be challenging for an individual with CVI functioning at Phase III. Much guidance is required at this phase for students to have success. A knowledgeable professional can provide this guidance for areas In which CVI characteristics continue to interfere with learning. This person can also work with the team so that they can begin to understand the impact of CVI, which may be invisible to many, and provide necessary accommodations such as pre-teaching, sensory breaks, preferential seating, reduced noise in the environment, a study buddy, etc.
Interfering visual characteristics are the least obvious in Phase III CVI as compared with the other Phases. The student’s vision is used throughout the day and in many different environments. However, these characteristics continue to interfere with vision and visual fatigue is significant. Unfortunately, the services of a teacher of the visually impaired are often reduced for these students. Appropriate interventions for literacy and social skills require highly specialized knowledge and skills. It is suggested that services from a TVI should be maintained rather than decrease for a student in Phase III CVI.
TSBVI Outreach is pleased to announce that Dr. Roman-Lantzy will speak at the Texas Focus 2018 Pre-Conference on March 1 about Phase III Cortical Visual Impairment (CVI). She will present two sessions during Texas Focus Conference on March 2nd. One session will provide participants with a view into Dr. Roman’s new work. The second will be a question-answer session with Dr. Roman.