Cortial Vision Impairment for Grace

CVI- Cortical Vision Impairment and Grace

By Grace’s mother

 This is my interpretation of CVI as it pertains to MY daughter. This is NOT medical advice for anyone else's situation. 

I have put it here on my daughter's website to get the information out to the people who work with my daughter. 

If you have stumbled upon this page, you can choose to read the information at your your risk.

Looking through Grace’s eyes with CVI

What do you see in these pictures?

 Pic#1

 Pic#2

  Pic#3

Spoiler Alert:
Pic#1 Dalmatian dog in center
Pic #2 Snowy bird
Pic#3 Bison drinking water, center

(Pictures from google images)

After reading the spoiler alert- You can probably see the objects in these pictures.

We can “dis-embed” the objects because we have “memory” of each of those objects.

Kids with CVI don’t know what they’re looking for because they have don’t have that memory piece developed in their brains. For Grace, what you first saw is what Grace sees and will continue to see unless we help facilitate for her vision. Grace can perceive/see information but cannot “sort” it out or categorize it.

 Another example: Grace may recognize her toothbrush (even in a good picture) AND she may recognize her toothpaste but she probably cannot separate the two items as in the second or third picture. (Pictures from google images, not endorsing any brands)

The CVI Range: The CVI Range measures visual function.

0 ______1_______2_______3_______4______5_______6______7______8______9________10

       Phase I (0-3)                                      Phase II (3-7)                                 Phase III (7-10)

Roman- Lantzy's Three Phases of the CVI Range

Phase I—The child is focusing on building visual behaviors, without yet incorporating visually guided reach. These children can only see when there are no visual distracters within a carefully controlled learning environment.

Phase II—The child begins to integrate vision into daily routines, including developing skills of visually guided reach. These children need environmental adaptations but they can visually attend amidst mild competing visual and auditory stimuli.

Phase III—The child progresses to develop and integrate more typical visual functioning. The child can see within a non-adapted, typical learning home or school environment

(Edelman, 2006; Roman-Lantzy, 2007)

Roman-Lantzy's CVI Range systematically tracks the 10 behaviors on the CVI Range. Following evaluation, Roman-Lantzy recommends specific intervention strategies and environmental adaptations to resolve systematically the child's CVI behaviors and symptoms (Roman-Lantzy, 2007)

Roman-Lantzy 10 Characteristics/ Symptoms of CVI (Adapted from Roman-Lantzy, 2007)

1. Color preference
2. Need for movement
3. Visual latency
4. Visual field preferences
5. Decreased visual complexity
6. Light-gazing & non-purposeful gaze
7. Decreased distance viewing
8. Atypical visual reflexes
9. Decreased visual novelty
10. Decreased visually guided reach

 Each characteristic is different depending where the child with CVI scores on the CVI Range.

CVI RANGE for Grace (8/2013)

CVI Rating I:   4.25

CVI Rating II:  7.0

Grace’s scores put her into Phase II

Interventions

The following chart, is a selection of recommendations from Roman’s book and from the workshop, I attended. This chart is a starting point, offering ideas and suggestions to help Grace use her vision.

Interventions for CVI must be incorporated within the routines and activities of Grace’s day and not used as independent activities. Integrating vision into all activities will give Grace repeated practice using her vision each day. Practice will help her improve her vision skills. The interventions are based on the characteristics/symptoms of CVI.

CVI Interventions Recommendations for Grace

General Recommendations

Within each routine: walking the halls, going to class, participating in class, playground, bathroom, therapy sessions, etc. integrate vision into the activity by using familiar objects, favorite colored objects, look first & touch, favored visual field (Right-1:00), among the other suggestions on this chart. If Grace doesn’t look at a presented toy or activity item, go back to a more familiar object to get her to look. If she looks, you are doing it right. If she does not look, simplify- (choose a favorite toy or item, favorite color), look to see if something else is wrong (tired, hungry, loud or humming noises). Before assuming that Grace can’t look at something, first ask, “What has changed in the environment?” You can first “practice” with familiar items and then move on to novel items, to prepare Grace’s vision. The goal is to get Grace to use her vision to learn about her environment and to use her eyes and hands together. Do this by adding her favorite color (BRIGHT ORANGE or YELLOW) to items, places, books that Grace will come into contact during her day. Wherever Grace is during her day, be sure there is something she likes to look at. Place something she likes to look at near her in the classroom, at therapy, in the bathroom, etc. Use a black or dark navy felted board as a background to items you want Grace to look at. Talk to Grace about her environment. Tell her what she can look for in her environment. Look for things that stand out in Grace’s favorite colors or that have a movement characteristic to them.

Color Preference	BRIGHT ORANGE & BRIGHT YELLOW (& bright Red can sometimes work) Grace especially likes the grocery sacks from the Grocery Outlet. Even when not rattled, the color catches her attention. Use these preferred colors in routine activities throughout Grace’s day. Add preferred color to direct Grace’s attention. Highlight/Outline specific items in picture books with orange or yellow. Add preferred color to give Grace’s visual information- (Ex. #1- Point out and teach Grace bright-colored landmarks around the school to orient her to where she is. Ex. #2- Add preferred color to line pictures on worksheets or in books to help her interpret black & white pictures) Use a preferred color spoon, cup, mat, object, toy, etc. Add orange or yellow tape to the door jam of the resource room or add a large yellow or orange circle shape- anything that can help Grace ACT on her environment Stick with colored toys with only 2-3 primary colors. Introduce new colors by adding a movement quality to them. (Ex. Show the green Christmas tree by shaking it slightly as you talk about the tree and its properties.) Try also shiny Orange or shiny Yellow or shiny Red
Need for Movement (Shiny and reflective materials are considered to be of the movement characteristic.)	Use shiny materials on switches to encourage Grace to look before activating. To encourage Grace to attend to an object at a distance, move the object (Ex. To get Grace to look at the flag, wave the flag for her) If you show Grace a toy and she doesn’t look at it, try moving slightly. If you want Grace to look at 2 different objects- slightly move each one alternately, so she looks at each one. Make a picture book using Mylar or bright shiny shapes to get Grace’s attention on the book.
Visual Field Preference	Grace prefers her RIGHT visual field at approximately 1:00-2:00. (as on a clock) Present items here to grab her attention. Present more complicated toys here. Present faces here and novel items, here. Left Visual Field: more difficult for Grace. Present highly motivating toys here. And simple, preferred color or shiny objects here. Lower Visual Field: May need to add more movement and bright colors here. Could also use a slant board to present objects a bit higher in lower visual field. Use favorite toys/items when Grace is in a challenging postural position.

Visual latency	GIVE GRACE TIME TO LOOK. Wait, wait, wait, wait, wait, and wait. After speaking about an item, Be quiet. Give Grace time to look. or Present an item and wait. Give Grace a chance to look. You can move the object slightly to encourage looking. Looking is not automatic for Grace. She may very well see but she may not be processing for learning or acting upon. Present the object and WAIT. Don’t continually tell Grace to look with her eyes. Just add movement or simplify the environment or the task even more.
Light-gazing and non-purposeful gaze	Give Grace another visual target when she is staring at the lights. (Ex. Use a preferred colored balloon or ribbon wand or something to distract her attention. Put light source behind Grace, so light shines on the activity and is not a distraction. This includes putting Grace’s back to the window. Never encourage looking directly at a light, a flashlight, etc. Light should only support the activity. You can use light to direct attention to an object, a picture, etc. Use a flashlight from behind Grace & point it on the item. Turn off overhead lights as necessary Try using a light box to if it helps Grace improve the use of her eyes and hand in looking and reaching. -A light box can be used as a stage to illuminate objects from behind -A light ox can be a big motivator for Grace to look & where to look *There is a lot more about light boxes & you can ask me for more information if you’d like to look into using a light box  further
Difficulty with distance viewing	Use bright, colorful, naturally occurring landmarks in the hallway to help Grace know where she is and where she is going. Explain to Grace what to look for in a complex environment. This simplifies the task for her. (Ex. Look for the red poles in the cafeteria. Talk about the poles, the red color- compare the red color to a favorite item that is red, etc.) and the feel, and height, etc. Give her descriptive words. If the teacher has a book at the front of the classroom or the circle, that she is sharing with the class, give Grace one at her desk to look at up close too. Here you can also point out distinct items to look at or use a black cardboard window viewer to minimize the details on the page.

Difficulties with Visual Complexity

Use non-shiny black background (Ex. black felt board) or at least a solid- colored background. If Grace does not look at a toy or person-, look at the environment or simplify the task, visually. (Ex. There are many ways that a task can be too complex for Grace, including: too many toys out at a time, sounds, lights, movements, being asked to perform a motor task while looking, other people, distractions, etc.) Use favorite objects when working on motor skills. Review goal of task: Is it motor? Being quiet? Looking? If task is difficult, make the visual demands easier. Reduce complexity in visual tasks by presenting only one object at a time on a plain background. Be aware of the background, even your own clothes or what is behind the teacher. Reduce complexity by having Grace in a very supported position when you want her to look or especially look and reach. Verbal cues are ok if information is also provided. (Ex. “Look, the ball is red.” This gives Grace more information than a command that she look- now she will know what she is to look for.) If motor demands are high, make vision easier. Reduce complexity by limiting background noise: conversations, music, hums of machinery, etc. If using a mirror, watch for complexity within the mirror image. Reduce complexity by explaining what is going to happen next, to prepare. Simplify picture books by using a piece of black cardboard with a cutout window to highlight specific portions of the picture or text. Reduce amount of information on a page to reduce visual clutter. Keep Grace’s workspace simple & free of visual distractions Encourage Grace to look at your face. You may speak to get her attention, then be quiet and wait for her to look. Then speak again. Think about what is behind you when asking encouraging her to look at you. Ex. Place a plain background behind the sink to help Grace attend to the faucet. LIMIT HAND-OVER-Hand prompting. If an adult moves Grace’s hands, she does not look at what she is doing.

Difficulty with visual novelty

Introduce novel toys or objects that are similar in color & properties to the toys Grace consistently looks at. If you present a new item and Grace is not looking at it, go back to a more familiar item to get her to look and then try the new one. Present novel objects that are part of routine activities. Repeated use will make the object familiar and help Grace look at it. Familiar is easier to look at. Limit novelty. Give practice with the things Grace does like to look at. (Grace’s brain is learning to use vision information and things that are familiar are easier for her to look at. She will not get bored. Use the same objects in each routine activity.) Allow Grace to touch and hold novel items to help her learn about them and visually attend.

Absence of visually guided reach

Be sure Grace looks at an object before she reaches. Remember to use color, movement and patience to get her to look rather than commanding her to look.(You can explain what you both are going to do but then be quiet and give Grace time to look.) Refrain from talking to Grace during this action. Try not to be super excited when she does touch the item. After she has looked and touched then you can give quiet encouragement. The reward should become intrinsic in Grace that looking gives her something. When the whole activity is over, then you can uber-praise Grace. You can say, “Quiet hands” or “waiting hands” or “hands on tray/table” or “hands on belly” so Grace will look first then reach. Allow for latency and use movement to encourage Grace to look before touching. Grace still has a little of this from Phase I- She will look, look away, look again pattern before reaching out to touch. It’s ok, let this happen. If Grace gets distracted by this pattern, use movement of the items to regain her attention. Teach by example. Play a game where you must look before looking and reaching with Grace. Take note of what toys Grace does look at and reach.

How to use the chart: CVI Interventions Recommendations for Grace

 You may be thinking how in the world, can you incorporate all those recommendations into Grace’s school day. Here is a way to simplify and begin to incorporate some of the suggestions. Try just 4 times a day at first: Think of 2 separate activities in the morning and 2 activities in the afternoon that you can incorporate CVI interventions.

Three things for planning: 

1. Time of Day  

 2. Activity at that time 

 3. CVI adaptations to the activity

Use the CVI Planning Table

Daily Schedule: time and activity	CVI Characteristic	CVI adaptations for this activity
8:05 AM- getting out of van at handicap parking space	Distance viewing, color, complexity	Teach and learn the fire hydrant as a landmark upon arriving at school
10:00 AM-traveling around the school	color, complexity, visual field, distance viewing	-Teach & learn landmarks like the red poles at the cafeteria, -highlighting the drinking fountain by adding an orange post-it note near it or on it. -Placing an orange or yellow flower by Mrs. Sinnet’s window. -Talk about what to expect & what to look for.
10:30 AM- diaper changing/toiletry & self-help hand washing	color, visual field, latency, complexity, novelty	-present toilet paper on black background in preferred visual field until learned, then move it around, same with soap for hand washing, -put black background behind water faucet -present paper towel on black background -talk about what Grace can see when hand washing & playing in water - show Grace her diaper on against a black background before putting it on -add shiny orange/yellow color to the tiles by changing table
1:00 PM matching items	latency, complexity, visually guided reach, color, visual field	-offer one object at a time on a black background. -encourage looking at both items independently by slightly moving each one independently -offer the “wanted” match in the preferred color & visual field -give verbal prompts before & after looking, not during viewing
1:30 PM Physical therapy maybe a different day- it could be ride the bike & hold the handle	~nothing today~ color, complexity, visual field	Today’s goal is to stand. Vision will remain simplified Consider making the bike handles yellow or orange and/or put a black background behind them.

More Resources for CVI:

Paths to Literacy
Perkins elearning
CVI Teacher

My CVI Pinterest Board
Pinterest- search for CVI