Visual efficiency toolbox by Diane Sheline

Encouraging Efficient Use of Vision in Students with CVIEncouraging Efficient Use of Vision in Students with CVI
The following are suggestions to use with infants, young children, and students who have Cortical Visual Impairment (CVI) or who are suspected to have a brain damage related vision loss.  These suggestions are intended to encourage students with CVI to use their vision more efficiently.  These suggestions correlate loosely with functioning levels/Phases described in Dr. Christine Roman’s book, Cortical Visual Impairment – An Approach to Assessment and Intervention. The reader is encouraged to read through all suggestions, as some students functioning in Phase III might still benefit from suggestions in Phase II or even Phase I, students in Phase II might also benefit from suggestions in Phase I and Phase III, etc.  Use the suggestions, especially in Phase I, in conjunction with regularly occurring activities in daily life such as feeding, toileting, grooming and amusement activities.  These are general guidelines; no individual student with CVI will ever fit into any one category.
Students Functioning in Phase I
Students in Phase I are generally functioning at a level where they are just beginning to alert to light and objects with movement. The focus in this phase is the building of visual behaviors.  Environmental complexity and distractions need to be strictly controlled.  Sound can sometimes be used to initiate visual attention, but should be discontinued as soon as the child visually locates the target.  Often, the auditory learning channel is the strongest and if a sound source continues longer than necessary, the child may look away to attend to the sound.  When the child looks away, he/she discontinues learning through the visual channel and discontinues building the neurological pathway that helps the child make sense of what he/she sees.  The same applies to tactual input.  The child at this stage may notice visual targets up to about an arm’s length away (24” to 36”).  Some suggestions offered in Phase II and Phase III may also be applicable to a child functioning in Phase I.
Considerations

• Interview parent or caretaker; learn about most frequently viewed targets and situations when student most frequently uses his/her vision; knowledge of what the student likes/dislikes should be built into his/her learning activities
• If visual learning occurs away from home, use familiar toys or visual targets from home
• Be aware of prescription medications the student takes; some may cause student to be drowsy or have visual side effects
• Watch for signs of visual fatigue, overstimulation, and/or stress.  Signs include vocalization, eyes closed or sleeping frequently, hand or leg muscle tension/twitching, yawning, and “fading” behavior such as light gazing.
• Allow for intermittent break times
• Plan activities during the time of day when student is alert, ready to learn
• Proper positioning will be crucial.  If the child is not in an aligned or supported body posture, he/she will have difficulty attending to the visual target, focusing, and using efficient vision in general.

Environment

• Reduce auditory distractions when visual learning is taking place – turn off the TV, turn off the radio, move away from neighboring students who are very vocal/loud, turn off cell phones, encourage quiet from other adults/caretakers in the room
• Reduce tactual distractions when visual learning is taking place – resist the temptation to give a rub on the back or a pat on the arm as a “good work” gesture; Care should be taken not to bump into a wheelchair or bed. When there is a need to encourage the student to touch something, use hand-under-hand technique – more information at: “The Language of the Hands:  Hand-Under-Hand Technique” http://nationaldb.org/NCDBProducts.php?prodID=47
• Reduce or eliminate visual distractions that may interfere with visual attending behavior (i.e. sudden movement off to the side) – Use a 3 panel curtain or block from distractions by use of positioning
• Work surface should be free of visual clutter
• Use a white or black cloth to cover distracting background items
• Walls and bulletin boards should be simple and free from clutter
• Carpets should be plain, no pattern
• Turn student away from sunlight streaming through windows or blinds
• Care should be taken that no sparkling jewelry is worn, distracting the student from the visual target
• Reduce or eliminate use of perfume, cologne, or other strong odors/scents
• Maintain a comfortable room temperature

Near Visual Field

• Present visual targets in preferred visual field (usually left field or right field, generally not central and rarely lower)
• Often, students have difficulty detecting targets in lower visual field – raise targets up
• Use of a custom made slant board, reading stand, felt covered tri-fold board or angled dry erase board are helpful in creating contrast in near visual field
• Teacher or caretaker should wear plain colored clothing that creates contrast behind the target being presented; black smock or apron works well
• Use of a black cloth or white cloth also helps to create contrast
• Use a “CVI Den” to help with contrast and to reduce visual distractions

Visual Target

• Use of objects with a single color, especially red or yellow, but sometimes other bright primary colors including orange and purple
• Present visual targets against plain, visually quiet backgrounds (black felt board, white cloth, black cloth) again, attention to contrast will be important
• Place targets no further than an arm’s length away (about 24” to 36”)
• Pair visual target with movement (slinky), especially in the peripheral fields; sometimes moving the object helps the child to see it better
• Use visual targets with light qualities (colorful light or blinking light)
• Use visual targets with reflective qualities (mylar)
• In some cases, pairing visual targets with sound will initiate looking behavior
• In some cases, pairing visual targets with a touch cue will initiate looking behavior
• May turn head to one side or the other when reaching for object; appears as if they are looking away from the visual target, but may be using their peripheral vision
• Use real objects whenever possible.  When using an Anticipation Calendar, use real objects that the child has had a meaningful experience with (see http;//www.tsbvi.edu/Outreach/seehear/archive/Let Me Check My Calendar.htm) For example, use a real cup rather than a picture of a cup.  Relate what is being seen to function, whenever possible
• Present real objects against high color contrast (light colored foods against dark plates with a contrasting background color)
• Watch for subtle response cues to visual targets including; shifts of gaze or body positions, changes in breathing patterns
• Use color
  • Keep color of common objects consistent until association is established (if student is attracted to red, use a red cup during meals; at school and at home)
  • Encourage looking at mom by use of bright colored lipstick
  • A bright yellow colored pom pom might encourage reaching behavior
  • Bright, primary colors are best; red, yellow, purple, and orange work well

Lighting

• Provide additional, supplementary light shining on target of interest; 100 LED bright flashlights work well
• Shine light on target of interest without attracting student’s attention to the light source
• Care should be taken to avoid glare
• Do not shine a bright light into the eyes of the student
• Use of plug-in, natural desk lights work well to shine on targets and workspace (but you are restricted to the length of the power cord)
• Use of Light Box (with a Swirly Mat) and other lighted toys/targets are beneficial
• Care should be taken when using blinking or flashing lights (this sometimes sets off a seizure)
• When using a supplementary light shining on a target to encourage visual attending behavior, dim the overhead lights and reduce natural light coming through windows
• A small number of children with CVI experience photophobia (light sensitivity)

Positioning

• Ensure that the student is in a comfortable, secure position when use of vision is the goal
• Do not try a new stander or chair (or other new position) when working on use of vision
• Work closely with the PT or therapist to determine the best position to help student feel secure and comfortable
• When a child’s head rolls to one side, the visual field involuntarily shifts; provide appropriate head support
• Try a variety of positions to determine which one supports visual attending behaviors

Routine

• Repetition, repetition, repetition: use the same objects and the same process each time to provide familiarity, reduce latency period, and shorten “warm up” time
• Same individual working with the child in the same way, again and again
• See, “Steps for Incorporating Activity Routines into Your Practice at:

http://www.tsbvi.edu/Outreach/seehear/fall02/activity-routines.htm

• Repetition and practice is how a child with CVI learns to integrate new knowledge, remember it for a future session, and put it to use

Familiarity

• Use objects that the student is familiar with and uses on a daily basis; use of objects that are familiar often result in increased visual attention
• Objects used in the classroom setting should also be used at home (and vice versa)
• Familiar objects often include bottle, cup, spoon bowl, plate, comb, washcloth, noisy or musical toy, and diaper
• Work with the student in a familiar environment, when possible (this includes when you meet a new student for evaluation; try not to take them to an unfamiliar testing room)

Pacing

• Slow down presentation of visual objects and targets
• Allow student time to process what is being seen and respond to what is being presented

Mobility

• Use lights to encourage reaching behavior/movement
• Use mylar pom poms and other reflective toys with light shining on them to encourage reaching behavior/movement
• Present targets against a contrasting color

Students Functioning in Phase II
A student functioning in Phase II is using his/her vision more consistently, but often not efficiently.  The teacher and caretaker will want to work towards encouraging the child to use their vision during daily routines and activities. Generally, students at this stage are able to visually attend to targets up to about 4 or 5 feet away.   Many of the above considerations may still apply and some suggestions in Phase III may also apply.


Considerations

• Interview parent or caretaker; always the best source of information
• Be aware of the prescription medications the student takes; some may cause student to be drowsy or have visual side effects
• Providing a routine and structure/sameness continues to be important
• Use of cues, signals and symbols might be considered at this stage (see “Non-Verbal Communication: Cues, Signals and Symbols” at; http://www.tsbvi.edu/Education/vmi/nonverbal.htm
• Encourage students to learn by being active (see “An Introduction to Dr. Lilli Nielsen’s Active Learning” at

http://www.tsbvi.edu/Outreach/seehear/summer99/nielsonintro.htm
Environment

• Reduce auditory distractions – turn off the TV, turn off the radio, move away from neighboring students who are vocal/loud, turn off cell phones, encourage quiet from other adults/caretakers in the room
• When an auditory cue is used/needed to encourage looking behavior (and develop language), use the following suggestions
  • Explaining what to look for and where to look often helps a child with CVI see better
  • Use descriptive words about the object or visual situation
  • Use voice intonation that matches the word used
  • Use “Verbal Cuing” (the ball is by the light)
  • Use an interesting noise or a few words of praise, along with a visual target, to increase looking behavior (crunchy/scratchy noise when you shake a mylar pom pom)
  • If possible, try to establish looking behavior first, then give verbal praise or description; make sound a “reward” for looking behavior
  • Reduce tactual distractions when visual learning is taking place
    • Resist the temptation to give a rub on the back or a pat on the arm as a “good work” gesture
    • Avoid grabbing a hand to help student touch something
    • When a tactual cue is needed to encourage looking behavior, use the following suggestions
      • Touch the object of interest to the child’s hand to direct visual attention
      • Run the object of interest down the side of the child’s arm to his/her hand, to direct visual attention
      • Reduce visual distractions when visual learning is taking place
        • Sunlight through the window or light from a lamp may be a distracter
        • A moving ceiling fan may be a distracter