Tammy and Ellen FVA Webinar
Welcome to Perkins eLearning's Webinar Series. My name is Robin Sitten. I'm program manager for Perkins eLearning. You are about to enjoy an episode of a multipart series on functional vision and learning media assessments recorded here on the Perkins campus. This webinar series will discuss how to administer quality and effective functional vision and learning media assessments for students with visual impairments and students with visual and multiple impairments, including students with diagnoses of CVI.
Administering functional vision and learning media assessments is a crucial component of a [? TVI's ?] role within the educational team. This is part one of this three part series. Tammy Reisman of the University of Massachusetts Boston will open this discussion with an introductory look at functional vision assessments for all students. Ellen Mazel will then delve into functional vision assessments for children with cortical cerebral visual impairments or CVI.
Later sections in this series will address an overview of learning media assessment with specific attention to LMA for students with multiple disabilities and for students with cortical cerebral visual impairment. When viewing this recorded presentation, you will find that headphones, earbuds, or external speakers give the best sound.
Tammy Reisman brings a strong background in education of students with vision impairments to her role as the Teacher of Students with Vision Impairments Program Coordinator in the Vision Studies program at UMass Boston. Her responsibilities include student advising, licensure coordination, and serving as a liaison between vision studies and the College of Education and Human Development licensing office. Ellen Mazel works as the CVI Program Manager for Perkins School for the Blind. She joined our administrative leadership team to create and oversee Perkins CVI assessment program. Both Ellen and Tammy teach in the UMass Vision Studies program.
Hi. I'm Tammy Reisman. And today I'll be talking to you about functional vision assessments for all types of students and learners. As we talk about functional vision assessments, our main objectives for this time is to review the purpose of the functional vision assessment, the components of the functional vision assessment, and also review a rubric that helps to really ensure a quality functional vision assessment that is performed and written up.
So let's start by talking about what is the functional vision assessment, what does it really entail. So a functional vision assessment is an assessment of the day to day skills and the use the vision of the individual who's visually impaired. It's often done in conjunction with a learning media assessment, though they are very separate assessments that you do. It is legally required for all students who are blind or visually impaired as part of the assessment process. It's considered often a supplement to the clinical vision assessment by an ophthalmologist or a low vision optometrist. And it's always administered by a licensed teacher of students with visual impairments.
The purpose of the functional vision assessment is to get to know the student in different environments. This includes looking at visual strengths and needs of the student, looking at the degree the visual impairment impacts both the core and the expanded core curriculum, looking at ways to increase the visual function, as well as looking at the need for further assessments, such as expanded core curriculum areas, like the assistive technology, O&M, or leg vision assessment, that also helps to determine eligibility for services as a student was a visual impairment.
The functional vision assessment is conducted always upon initial eligibility to determine that initial eligibility for every three-year re-evaluation that happens as part of IDEA, when there are vision changes. It can happen prior to any transition the student might be undergoing, following a low vision assessment done by the low vision optometrist, or when students move in from a different district.
The process of the functional vision assessment includes reviewing the eye report. And it's really important to get an eye report that's current within at least a year, doing observations and interviews of the student and of people that work with the student, including the family, assess the student directly, and then writing up the results in a report.
So as you start the functional vision assessment, you'll be reviewing the current eye report. And as I mentioned before, it's important to try to have one that's current within a year. It's really important to know the individual's medical visual information in determining initial and ongoing eligibility for services. It's really critical in really knowing what's been diagnosed, knowing how to interpret the eye report, looking at what the visual diagnosis means, as well as knowing if there are glasses that are prescribed and why they are prescribed is necessary as well.
So when you start with the observations of a functional vision assessment, you'll be looking at environment and material observation, as well as student observations. When you're looking at student observations, you're looking at how students complete daily tasks, how they're attending to different presentations, what distance they are from presentations, how they're moving through the environment, if they're wearing their glasses if they're prescribed, how they tolerate them, and if they're using low vision devices if they're prescribed as well, and just general observations that you might see throughout the day.
Here I just have a couple of examples of environments that you might look at. I always like to take a picture of students' environments to really get a clear sense of what they're looking at from their perspective, and often, I'll take the pictures from their seat so I can really get a good look. And here are three different environments to help you do that of three different students.
I also might say in the back of a classroom like right here to also see what their environment looks like, and it helps me determine what tools or accommodations they may need to help them access what's going on. I also look at, if you look at the far right, how a student is using her video magnifier to access the presentation on the board.
Here are some materials that you might look at, a student with a tabletop adjustable [INAUDIBLE] with a worksheet. There's another picture that shows another worksheet looking for the letter C, and then finally a student's pad communication notebook and looking at how it's been modified and seeing if there's anything else that we need to do to help her access it.
So as well as the observations, you'll also be conducting interviews, and that can include, or it should include parents and caregivers, teachers, students, if possible. You're discussing concerns, the current accommodations, and any of their observations. And it's really, really important when possible to get the student's perspective and to see what they know about their visual impairment and about the accommodations that are in place for them.
So once you do all the observations, and you conduct the interviews, then you start your direct functional vision assessment with the students. So it's really helpful if you have a template that you've developed for yourself to help you record different components that you assess. This also really helps provide a framework for your written reports. It's always necessary to make sure you have an assessment kit and selecting materials based on what you've learned in the observations and interviews. You might have a standard assessment kit that you use, but it's also nice to grab items that might be preferred by the student or that you know might grab their interest.
I always make sure that the materials that use our age appropriate. You don't want to be using Sesame Street characters with a high school age student, even if a student is at that developmental [? learning. ?] And you want to make sure, especially when you're working with younger children, to be aware of choking hazards, and like I said, it's good to have your own kits, but you can also use them in conjunction with the kids that have been put together by American Printing House for the Blind.
So here I just have a few examples of some good functional vision assessment kits. From APH, or American Printing House for the Blind, we have the new tools and activities for use with functional vision in learning media assessments. It's called the [? New ?] [? T. ?] And it comes with a range of pictures and items to read and some acuity charts to use as part of the functional vision assessment. There's also the tools for assessment and development of visual skills, so that comes with puzzles and other kinds of pictures and different tools that you might use. And then the FELMA Practitioners Guide book, the functional vision learning media assessment book that has come out from APH as well, that has a lot of nice forms and sample interview questions that you could use.
About a month ago, Texas School for the Blind and Visually Impaired came out with a nice resource guide as well, called the Essential Tools of the Trade-- A How-To Guide for Completing Functional Vision, Learning Media, and ECC Assessments. So that also is a guide book. It has a lot of considerations to make, a lot of observation forms, interview questions, and some report writing templates that really help you guide the process, which it's worth checking out as well.
So when you start your direct functional vision assessment of students, you'll look at the appearance of their eyes, how their eyes are aligned, visual behaviors, and awareness of lights. You might look a little bit at the pupil response to light, and this could be important, because you're looking at how do they function when there's a change of lighting, when the lighting increases or decreases, when there's a lot of glare, how they're moving around in their environment. You're looking at how they're fixating on different targets and different visual stimuli, and that could have implications of tactile accommodations or needing verbal instructions as well, and also eye preference, which will help with presentation of materials.
So here's a few materials that you might use in your functional vision kit. There's a kaleidoscope, some really fun finger puppets, a slinky, which, you know, preschoolers through high schoolers love slinkies. I also make sure, like I had mentioned, to have age appropriate items in my kits. You know, I've had one student that loves to cook. So I have a cooking magazine in my kit. And we look through that. Another student loves nail polishes, so I got a kit of all different colored nail polishes when I was doing some color assessment, and then other students love cars. So it's just really, really important to have an assortment of different items that could be used.
You're also looking at convergence, the ability for eyes to work together at a near distance and visual tracking. You know, it's still important to look at visual tracking because there are several implications that might happen with learning and the environment. There could be safety considerations during PE class or on the playground and playing sports. It's important to keep an eye on that, because we need to, as [? TVIs ?] recommend for an orientation mobility assessment.
There might be other supports that they need, whether they're on field trips or in different activities around the school. And they might need items such as line guides to help them keep their place when reading. We're also looking at the shift of gaze. And possible implications from that might be needing a line guide, as I mentioned, or some kind of other place holder, having a copy of notes. So if teachers are presenting notes at the front of the class, they may need an actual copy of the notes right in front of them.
Nowadays, if teachers are-- and we'll talk about this a little bit later. But if they are projecting their notes as well, you might be using some screen sharing devices. There also might be magnifiers that students are using that help them to view items at a distance from the board. And you know, another thing that might come into play is when students are taking tests, sometimes you have a separate answer key for students to write on and just having the students write their answers right on the test and not having a separate answer key for doing that.
We're also looking at visual scanning, needing to scan worksheets and textbooks, and especially as kids get older, there's more and more to manage with that. You're seeing how they're functionally scanning to find materials in all their environments, trying to reduce visual clutter, looking at high contrast, looking at the number of items that they need to scan and finding out how you can reduce them if needed, and if possible, and just reducing their area to scan, so really looking at kids' working environments and how you can facilitate the way they're scanning in their immediate work areas.
So as part of the direct functional vision assessment, there's some other items that you might use. The I Spy books are great for really looking at how kids are scanning and finding images within a book. File folder games are really terrific, especially matching ones, where you have to match maybe a letter and match it with another piece on the folder, using things like pompoms or Cheerios, you know, keeping in mind the food allergies, but using those to have them scan their area to find different colors or different pieces of them can really be helpful as well.
Another area when you're doing the direct functional vision assessment is the peripheral visual field. Possible implications, again, might be the need for getting an orientation mobility specialist involved. You might need an assessment. Kids might miss things out of the corners of their eyes or from their sides, using visual cues may really help them such as marking stairs and the corners of tables or at the edges, preferential seating to help them take advantage of the widest visual field, looking at how they're accessing PE or recess time, and just teaching kids to scan their environment before entering different environments, whether it's the classroom, the cafeteria, the gym, other classrooms as well.
And some tools that you might use for conducting a peripheral test could be, again, slinkies, some mylar pom poms, some windup toys. There's a lot of really fun pens and pencils out there that have little heads and shapes on top of them that kids love, regardless of the age, pinwheels, and Koosh balls are always a favorite as well.
So next, we're looking at the near visual acuity and print comparisons, how those students currently complete near activities, does a student have the best optics in place, will a slant board help relieve some of the neck and shoulder strain. Very often, you'll see students really hunched over at their desks trying to get close to their work. And how can you help alleviate some of that, because what I have found is that the older kids get, their posture worsens. So trying to find a way to make sure that doesn't happen is really critical and important. And looking at a large print or some kind of assistive technology is really important. And that's what you look at here as well.
There's a really good tool that's come out from American Printing House for the Blind called Decision Making, and it really looks at acuity in near print, and it helps you really decide what makes the most sense for students. And most likely with many, many students, some students still really like the large print, but with many students now, we're moving towards more technology to help magnify and access a lot of the print that's out there.
It's important to measure the objects that you're using, and that will help give you an idea, when you look at different acuity comparison charts, and we'll look at one in a second, it'll help you know what size pictures and what size font to use for kids as well. With distance acuity, when possible, you'll want to use an acuity chart to assess distance. Often, I really try-- hopefully you have a current eye report and using the doctor's results from that. But when you can, it's great as a [? TVI, ?] if you can do that test as well, and you incorporate observations of the distance viewing in different environments, because students use their vision differently in different environments. It's really critical when possible to just try to see that.
Looking at the use of vision in a school based functional vision assessment can be very different from a clinical vision assessment, and it's really important to kind of work through that, even though you're reading your report, and an optometrist or an ophthalmologist might have said, oh, we could get the student to see up to 20/80 20/100, it's really important to know how to explain the differences that you might see in a functional vision assessment with that clinical assessment to the family, because really, the task itself could be different. The environment itself, whether it's familiar unfamiliar, how motivating the task is for the student, and the environmental conditions.
Often in the eye doctor's office, the room has been darkened, you have an illuminated screen, so it's much easier for students to see that one letter that's being illuminated on the screen. And then when you get them in a classroom, it's very, very different. And they're just not able to see much that's going on. So here's one of the acuity charts that I talked about.
This one was developed by [? Tod ?] [? Topfer ?] in 2004. It looks at the size of an object that you might measure and from what feet that student might be able to see it, how it corresponds to different visual acuities. And you'll see that a quarter inch object shown just two feet away really corresponds to a 20/200 acuity, which is considered legally blind. That's a legally blind measurement.
So I mentioned this a little bit previously with the functional vision assessment, when you're looking at [? distance ?] print functioning, you might also want to look at screen sharing apps, using a tablet or a computer, a video magnifier with distance capabilities, providing copies of notes, preferential viewing, maybe having some them sit with a peer to have the peer help, looking at binoculars to access information, and just notifying the teachers that the students may not be able to see anything from a distance, including facial expressions, or the details from what's being put up on the board.
We're also looking at color perception. So there's a couple of great vision tests that are out there, Color Vision Testing Made Easy. There's an easy test to use, but just using different toys have you sort colors and going to a place like Home Depot or Lowes and finding paint samples that have different shades of colors is another great way of determining color identification. You might need to label crayons and markers, adapt maps and graphs that are colored to with symbols, looking at the keys. Teaching color concept specifically might really be necessary.
Avoid using directions that are color dependent, because if the student is unable to directly state what different colors are, you don't know if there could be some cognitive or other reason for them not being able to determine the colors. You want to stay away from that. And increasing illumination, making sure the lighting is very strong is important as well.
So contrast is another area that we'll look at, using high contrast trades or backgrounds, highlighters, trying out different kinds of pencils and pens will really help, placing a solid material under a clear wheelchair tray will be important to help provide contrast, and indicating a contrast preference, black on white, white on black, or some other combination. And it's really interesting, a lot of kids, you might think that they own the you know just a white background with was black or something else, but a lot of students actually prefer the black background or the yellow background with another print and picture contrast.
We're looking at response to lighting and the possible lighting and glare applications, looking at task lighting, do you need to have extra lighting from what's available in the classroom, making sure kids have sunglasses, having them avoid facing windows. Preferential seating away from different light sources are important for some students, providing copies of any overhead activities, and eliminating and reducing extreme changes in illumination. And a lot of classrooms nowadays still have a fluorescent ceiling lights, though many are changing to LED lights. With those fluorescent lights, they can really provide a huge glare for a lot of kids. So if possible, getting light filters to help them adjust to that.
Looking at visual clutter and complexity is another big area, presenting materials on solid services, we talked about that a little bit, to provide high contrast as well. Depth perception and visually guided reach is another area that we look at, putting color cues on the edge of stairs, putting treads on stairs, having a trial that provides high contrast with different materials. Sometimes you don't really know until you try different things, and just emphasizing areas, so students know where to work. So for example, when a student's doing writing, you might highlight the lines so that they know what to write.
Visual discrimination and recognition is another part of the functional vision assessment, looking at the ability to recognize details in visual images, recognizing the likeness and differences of different shapes and forms, which can include letters and words, colors and positions of objects, people in printed materials, identifying matching and sorting and classifying objects. And if the student uses a picture or object communication board or system, looking at how they're using it. Are they successful? Are they able to access the pictures in the way that it's set up?
We're always also looking at-- even though we're not doing the orientation mobility assessment, we're looking at how the student's moving through their environments and making recommendations as needed. It's important to know that as [? TBIs, ?] we should not make recommendations specifically for O&M. Just write down your own observations and make sure you recommend an assessment or a consultation with the own O&M specialist if there's already services in place.
So finally you get to the final process of the FVA, writing the report. So you make sure as you're writing, you're writing for all audiences who may read the report. Could be parents and family members, classroom teachers, paraprofessionals, different therapists, the low vision specialist, the ophthalmologist. There could be a multitude of people working with the student. It is a professional document and should look like one. It should be in a report format and not just a checklist.
And there really isn't a page limit. Some people feel like you should just get your whole report into two to three pages. And it's important that we document everything, even if there's the thought that only the summary and recommendations will be read, all students, they really deserve a full, thorough report. And that's how it should be written.
Be specific. Be factual. Be applicable. Avoid a lot of jargon. Always define different terminology that you write in your report. Include implications of the visual impairment and the various visual skills in the summary. Include a practical and specific recommendations. And just be careful of cutting and pasting from existing reports. You'd be surprised how many reports go out there where you might forget, someone has forgotten to change a student's name or keeps the he when it's a her. So really be careful of that. And just thinking about service delivery.
Nowadays, with IDEA and the regulations, we don't write specific service delivery in the report itself. That's a team decision, and we talk about it as a team. But it is important to document that services will be discussed at the team meeting. A really good resource for conducting FVA, this is the Essential Assessment Rubric for Students with Visual Impairment that was developed with Karen Blankenship, and it has a really nice group working there for knowing what components to include in the functional vision assessment. So it's really worth checking out. Teaching Visually Impaired, that website is also a great resource, and it has a lot of functional vision assessment samples that you can look at. It just has some guidelines as well.
When we look at a student with CVI, and we want to determine a functional vision for the student with CVI, this is addition to what Tammy was mentioning about a functional vision assessment for a child with an ocular impairment. So we'll take a look at the similarities and differences here. Just a definition of CVI. It's a visual impairment due to damage or disorder of the visual pathways and the visual centers of the brain, including the pathway serving visual perception, cognition, and visual guidance of movement, and it may co-exist with anterior visual pathways anomalies.
And this comes from Vision and the Brain by Dr. Dutton and Dr. Amanda Lueck. We start as we would start with any functional vision evaluation. We really start with gathering the information. We want the medical information about the eye health and vision function and the low vision clinic information, ophthalmology, and always ask for neurology reports, too. I think it's important to remember, that we're thinking about CVI in the context of what's gone on with the visual brain, so that neurology report comes just as important as the eye report.
Want to take a look at student files. I often find even though that teams don't understand cortical visual impairment, they understand their children. And the student file can be filled with very, very good information about how that child uses their vision or what kinds of problems that child is having with their learning. So I really like to look through student files. The parents are an extremely valuable bit of information about their child. They have that visual history of their child's visual development. They have across the day information and different environments, information about how that child's operating at a crowded mall or operating in church. They have all that wonderful information that we want to make sure that we capture when we're taking a look at a child's functional vision. And of course, all the other team members, too, bring new information to our understanding of how that child is using their vision.
Functional vision is the job of the [? TBI. ?] And there's a difference between functional vision in vision function. So vision function is really that collection of data that an ophthalmologist or an optometrist can do. Those are things that can be measured. So contrast sensitivity, acuity, those sorts of things that can be measured. When we think about functional vision, as our job as TBIs, that's a collection of observations across multiple settings, multiple environments, and really getting at how that child uses their vision. And this is very, very important when we think about children with CVI, whose functional vision really can change depending on the environment that they're in.
We want to remember when we're taking a look at children with CVI and taking a look at their functional vision, that acuity is not the measure of functional vision for children with CVI. And we'll just do a couple of examples. So here is a case study of some twins. Our twin student L has a neurological history of a bilateral interventricular hemorrhage at grade 1 or 2. And her acuity is measured as 20 over 160. But it takes 30 minutes in order for the optometrist to get that measure. It's extremely difficult to get this child's visual attention.
When I do the CVI range, I get a score of 5. So she's using her vision, but her attention is intermittent. She doesn't always recognize what she sees. She's very distracted by movement in the environment. Let's take a look at her sister, twin A. She has a neurological history with a much worse brain involvement. She has a bilateral interventricular hemorrhage of grade 4. But her acuity is much better. It's 20 over 63. It takes only five minutes to get her acuity measure. But on the CVI range, she's a child not using her vision very reliably, very, very difficult to get her visual attention, and she's scoring a 3.5 to 4 on the CVI range.
So just taking a comparison of the two, actually the child on the left, student L, has much better visual skills, but yet, acuity is far worse. Student on the right, her acuity is gathered quickly, and it looks much better. But this child is very, very, very visually impaired. We want to make sure that we don't rely on acuity when we think about children with cortical visual impairment, or cerebral visual impairment.
The brain based visual issues need to be the things that we look at in our functional vision assessment, not the ocular criteria. So when we think of people that are using criteria for brain based visual issues, Christine Roman-Lantzy is talking about color preference or a child's reliance on color to identify things or reliance on color to find things that distance, their reaction to movement or the impact of the environmental movement around them, attention to light or how light can support them, reduction in visual reflexes, to touch or threat, difficulties with the complexity of objects, difficulty with complexity of array, the number of things that are laid out in front of them, difficulties with sensory complexity, having sound or being touched, or not having solid seating would all come under sensory complexity, and difficulties with facial complexity, whether it's looking at faces or looking at faces, but not understanding who they're looking at.
Distance viewing is very difficult for children with Dr. Roman's 10 characteristics, that the children are not really looking at things at distance really due to complexity. And when I think about functional vision for children with CVI, I'm really looking at where's the visual curiosity, because the place the child's visual curiosity is where they can learn incidentally. They have increased latency for looking. May take a long time to get their visual attention, or once they are looking, it takes them a long time to understand what they're looking at.
They have reduced visual motor skills, difficulty with new things, with visual novelty, and visual field preferences. When we take a look at some of the work of Dr. Gordon Dutton or Dr. [? Else ?] Ortibus, they're also talking about visual field differences, difficulties with visual attention. We've heard that a lot in our case study of the twins, impaired perception of movement, not understanding the direction of movement, not understanding the speed, not understanding how movement around them is operating, so lots of difficulty crossing streets, for instance.
Difficulty handling complex scenes, difficulty with visually guided movements. And in this case, they're talking about not only eye hand, but eye foot, where am I putting my foot that's safe. Behaviors in crowded environments, so they're really taking a look at some of the behaviors that you might see in a child with CVI based on the fact that the child has difficulty with complexity and understanding what is being looked at, how do they understand what's around them, what's being looked at.
So the components of any tool that we use for functional vision assessments of a child with cortical or cerebral visual impairment really begins with a parent interview, where you're really getting that rich information about how a child has used their vision in the past, how they use it in different environments, how they use it across the day, invaluable in all three of the tools that we've discussed.
The observations in familiar and unfamiliar environments, I can't tell you how many times I look at a child in a classroom, and they're moving around completely smoothly, and then we go on a field trip, and it's a completely different story. They're using their vision in a very different way in that unfamiliar environment. And Dr. Roman-Lantzy really uses that direct assessment where you're really setting up an environment with little distraction, with the highest environmental supports, and seeing what the best visual behaviors you can get from the child. And those three pieces of information can really give you some functional vision for that particular child with cortical visual impairment.
So when I really base the assessment on that student profile, it can really help me drive educational programming. It helps drive what kinds of materials, what kind of adaptations need to occur to materials in the classroom, helps me document any changes in vision that the child is having, and helps me help to adjust the environmental supports for that particular child based on their areas of need.
So let's take a look at another case study, where this student, Peter, in the ophthalmologist, the eyes are completely healthy. Perhaps it's delayed visual maturation. The optic nerves may be pale. It's hard for the doctor to really be definitive about that. The child is sent to a neurologist, because the eyes are healthy. There's nothing wrong with the eyes. Yet there might be a history of brain damage. And there is a strabismus, so the eye doctor does pay attention to the strabismus and will deal with that as an ocular issue.
So if I take that information from the eye doctor, and I don't understand cortical visual impairment or don't understand the right tools to use in order to assess this boy's vision, I find that the child has completely typical looking eyes, might hold his eyes to the left at times, has an alternating exotropia, no eye contact, no tracking, no scanning, no response to visual field testing, no blink reflex, and no light sensitivity. So I've gotten very little information using the ocular assessment. And because I don't have the information that's based on the problem, which is the visual brain, I get information that leads me to only think about using the child's compensatory skills.
And it leads me to believe that those visual skills are fixed and limited. So I'm not even thinking after this assessment that I need to challenge this boy's vision at all. When I take a look at the same student through the lens of the CVI functional vision assessment, I do find visual behaviors based on the problems that are happening in a visual brain, attention to certain colors. Movement of materials really helps to keep and gain and keep this boy's attention. He'll fall asleep in busy places. Those behaviors can tell us an awful lot about what's difficult for children. Limited visual attention, in general. And when he does look at something, it takes him a long time to find them and a long time to understand them perhaps.
He might locate materials faster in his left visual field when it's at eye level. So that's important information for me to know when I'm thinking about functional vision for this child. He visually locates best in simple environments, when they're quiet with non-complex backgrounds, and if he's solidly seated. Again, valuable information, functional visual information for me as a teacher of students with visual impairment. He will stare at light sources and can look very, very visually inattentive.
I know that this boy also only looks at things when they're very close, between 12 and 18 inches away, and that he essentially never reaches out to anything in the environment, doesn't seem to know items are there, doesn't seem to know how far away they are, so is not really accessing and reaching out the environment, so much richer visual information based on the kinds of visual behaviors that you find in children with cortical or cerebral visual impairment. You might recognize one or two items according to parent report. And when I use those items, he's able to look at them faster and seems to sustain his attention longer on those things.
I also can notice in my assessment that he uses peripheral vision, that he seems to note things and is using his peripheral vision long before he turns and uses his central vision. So I need to provide that wait time in order to get him to be able to know that something is around him. When I check his blink reflexes, he has a delay to touch and absolutely no reaction to visual threat at all.
So once I've done this assessment that's based on the problems of children with cortical or cerebral visual impairment, that leads me to really gain real functional vision information. And to focus on those skills, it leads me to use the compensatory skills, but also consider vision in that service to that child. And because it's cortical or cerebral visual impairment, I know that there's a possibility and an expectation of improvement of visual recognition skills and that visual recognition is the issue that we're thinking about when we're thinking about cortical or cerebral visual impairment.
Peter, over time, did improve. He moved from the Christine Roman range score of phase I all the way to high phase II. His visual recognition of things improved over time. His visual attention improved over time with the adaptations in place, and he was able to use a backlighted TOBII eye gaze system to communicate.
In our next case study, we have John, who goes to the ophthalmologist. Send this boy has seemingly very good vision. So he's passing, let's say that, passing all kinds of vision function tests that an ophthalmologist will do. He does show a slight astigmatism and strabismus. So he's prescribed classes, and from the ophthalmologist's point of view, then the issue is solved. This boy does have history of a brain based difficulty. So we do want to check for CVI for this boy.
If I did not check for CVI, and I used only the ocular assessment, I would determine that he had typical looking eyes, a little esotropia, that he seemed to look at faces with no problem, he had good fixation, good tracking, as long as it was moving slowly enough, he has good scanning, he has good responses to all visual fields, he has us a little bit of a slower blink reflex, he has no light sensitivities in his visual fields using light we're full with confrontation testing.
It would lead me to believe if I use that ocular assessment. It would lead me to believe that this boy, John, only needs the glasses, that his issue is solved, and that we don't have to think anything about how this child is using their vision, and it would lead me to believe that his vision was completely effective for learning. In fact, because this boy does have some issues of brain damage, I'm checking for cortical visual impairment, and I do indeed see that there's preference for certain colors, that there's need to use color in order to identify things at distance, that he might be asking his mom to wear a certain color when she comes to pick him up at the end of the school day, because he can't figure out who she is by her face.
Movement of materials really distracts this boy at distance and in complexity. He can't tolerate the all school meeting at the end of the day with everybody moving around. It's completely exhausting and completely overwhelming to have that movement in his environment. He has difficulty recognizing things if they're too close together. If they have a spacing between them, he has no problem, but once they're too close together, they begin to look like another new thing to him. He doesn't understand what those are. So understanding his problems with simultanagnosia is very important.
He still needs extra time to locate things against complexity and certainly at a distance. And at distance, I'll have to name the color for him in order for him to find it. He needs extra time to look at new things that he sees, so he doesn't immediately understand something that you show him. He can't link it to something he already knows as automatically as he should. He has difficulty in new places, in fact, would keep his head down completely on vacation, for instance, in a novel environment, and his lower visual field very much is impacted functionally.
So we saw in his vision function that he had no problem at all in any of his visual fields, but functionally, he really does have a lower visual field problem, and he would go off of curbs, have difficulty on stairs. His visual understanding is optimal when the environments are simple and quiet with non complex backgrounds, and if he's solidly seated. Backlighting really really supports his visual attention, and it reduces the visual fatigue for him. His distance for learning is four feet. But remember, it's back to that visual curiosity. Anything beyond that is not really very well understood. He doesn't really even pay attention anything beyond four feet.
So it's the place where incidental learning drops off after four feet, and that's important to know in a classroom is what's he missing. What's going on beyond four feet that needs support for his learning?
And due to the simultanagnosia, he's really going to he's really going to struggle in crowded scenes. He's going to understand familiar items and events faster, because he can tap into that visual prediction better. So on vacation, for instance, he might really want to be in that hotel room, because he's got an understanding of what hotel rooms contain, and he can visually protect what the items will appear in that particular environment. But you take him outside, and everything is new, different, and completely visually overwhelming for him.
This boy does show a blink to touch and a little bit weaker blink to threat. He has a lot of difficulty with visual recognition and facial expressions. He just does not understand facial expressions. He also struggles with pictures. He reads at grade level, but asked to identify the picture on the page, he does not understand the picture. The more symbolic they get, the more difficult they are. So real pictures are better than cartoon like photographs or images for him.
In new places, he gets very quiet, puts his head down, and uses his vision much less. And he's hugely impacted by the visual fatigue and we'll ask to go someplace quiet to recharge. So because I've done the assessment that's based on the characteristics of a brain based visual impairment, that leads me to really identify that boy's functional vision, what is and is not accessible for him. It leads me to focus on those brain basic visual skills, not on those ocular skills, which he's able to do.
It leads me to consider his compensatory skills, but also understand how much of the time he's using those compensatory skills to support his visual understanding, much more than another child with typical vision. And it leads me to expect his visual recognition to improve and defines what kind of support I need to give that child to help that visual recognition improve.
So when I'm doing a correct functional vision assessment, and I'm thinking about the context of children with CVI, it's really going to allow me to get at what the issues are for brain based visual impairment, what are the functional areas of need. The goals and objectives that I create are going to be based on the correct areas of need. The environmental adaptations will be based on that child's accessibility needs. Materials will be based on that child's accessibility needs, and the teaching methods for accessibility will also help to lead to some visual recognition improvement.
I can begin to explain behaviors in the context of the CVI lens. So why is it that he can't go to the all school meeting on Friday afternoon and keeps asking to go to the bathroom. If you understand his difficulties with complexity, this behavior becomes clear, becomes understandable. I can caution people about how much vision can mask his cognitive skills. So if he's not able to process the picture, any testing done with those cartoon like pictures is going to lead the teacher to believe he doesn't understand the material, where in fact, that material was inaccessible to that child.
I can also caution teams about the diagnosis of autism or ADHD, or distractability or cognitive impairments that are masked for this student because of his visual impairment, and lead them to understand how a crossover is between some of those behaviors, like the lack of visual attention to faces can look like autism. The over attention to movement around them can look like ADHD, and distractability can also look like ADHD, where in fact, it's an over attention to movement for a child with CVI.
And I can also instill in a team that idea of the belief in functional vision change. And this boy has changed over time, so just helping them to understand how the supports are geared towards improving, again, the idea of visual recognition, because that's the issue when we have a child with a brain based visual impairment.
We often have children that have both cortical or cerebral visual impairment and ocular issues. So Tammy talked a lot about the assessment of children with ocular issues. We have to use both. We have to use the tools that are available for an ocular functional vision assessment and use information from the cerebral cortical visual assessment. For the tools for CVI, we can use the CVI range. We can use Dutton's survey. We can use the [? Else ?] Ortibus Teach CVI materials, and Matt Tietjen's "What's the Complexity?" framework to take a look at specific brain based issues of the visual brain.
And for the tools that we need for the ocular assessment, I think Tammy has covered those very completely. So some of the ocular issues that are coexisting often are eso or exotropia. You see pale optic nerve. There are children that have poor contrast sensitivity that we need to think about what supports we need for that, children with refractive error issues, nystagmus, for instance. There are many coexisting ocular issues that we find in children with cortical or cerebral visual impairment.
Our sincere thanks to Tammy Reisman and Ellen Mazel for opening this series, which will also feature [? Ann ?] [? Spitz, ?] teacher of the visually impaired and frequent contributor to the Perkins eLearning program. Perkins eLearning webinars are presented throughout the year. And while school was out, our colleagues were generous with their time to record these presentations with us for your professional development.
This is just one of the offerings in our program, which includes publications, e-newsletters, podcasts, online and in-person classes, and self-paced study. You can see our entire listings at our website www.perkinselearning.org. Please let your colleagues and the families you work with know about the Perkins eLearning Video Library. Professional development credits are available for this series when all sections have aired. We'll see you next time.