CVI TVI Webinar 1 - Matt T
OK. I think we're ready to begin. And my name is Mary Zatta. I'm the director of professional development at Perkins School for the Blind. And I've had the pleasure of planning this event with Yvonne Locke, Peg Palmer, and Ellen Mazel over the course of the past year. The idea for the series was actually brought forth by Peg and Yvonne as one way of continuing to meet the needs of professionals serving children with CVI.
Currently, there is a weekly call for parents, and Peg and Yvonne thought that if professionals would benefit from a similar event. So we sent out a survey this summer. We got a huge response supporting this idea. And at this time, we are planning a monthly webinar on a range of topics, which will provide opportunities for professionals to interact with experts in the field of CVI. The topics we have planned were gleaned from the survey information you provided, so we thank you so much for your feedback.
And we hope this is beneficial for all. We have folks joining us today from Dubai-- wow, which is great-- North Dakota, South Carolina, Connecticut, Hawaii, Canada, Seattle, Washington, North Carolina, Kansas, Texas and, of course, New England, just to name a few. Today's moderator is Ellen Mazel, and she will introduce Matt and introduce the series for you today. OK, Ellen.
Good afternoon, everybody. Welcome to our monthly presentation and discussion around the topic of CVI. We're calling this CVI for the TVI, but of course, all professionals are welcome. My name is Ellen Mazel. And today's presentation, the "CVI Umbrella" with Matt Tietjen, will begin in just moments. Perkins eLearning webinars are presented throughout the year on a monthly basis.
You can register to attend live at no fee or view the recorded webinar at any time and place that suits your schedule. The webinar series is just one of the offerings of our professional development program, which includes publications, e-newsletters, webcasts, online and in-person classes, and self-paced study. You can see our entire listings at our website, Perkinselearning.org.
On today's call, we're talking about the shared and common ideas of CVI from major theorists. These ideas are more alike than different. Thank you for joining us for this event. We appreciate your feedback and any topic suggestions. And now it's my sincere pleasure to introduce today's speaker, Matt Tietjen.
Thank you, Ellen. I just have a quick question. I don't want to take up all the time. I want to leave some time for questions at the end. Should we go a little bit longer, or are we stopping right at 4:00?
I'm looking to Mary for an answer for that. Hold on a sec. I would just go ahead and start, and I'll try to get it-- yes. Mary says yes. Mary says yes.
OK, great. All right. Thank you very much, everybody, for joining me today. And thank you for waiting, too. I'm really excited to have everybody here and to have this opportunity. I know it's the beginning of the school year for a lot of people, and you're probably even more busier than usual. So I especially appreciate your time, this time.
My goal today is to share with you a little bit about my own journey in learning about CVI and how an integrated understanding of the variety of ideas that are out there about CVI has really helped me tremendously in serving my students. But before we go further, I need to ask a question that's going to be very divisive. Here we go, and there's going to be a little pop-up field for you to type in your answer.
OK. What color is the dress? So everybody should be seeing there-- right in the corner there, a little pop-up survey where you could choose black and blue, gold and white, or other. OK. Oh, wow. It looks like it's neck and neck right now between black and blue or gold and white.
So it looks like we're-- I think that's all the results in. We've got about-- whoop, a couple more. So about 43%, about 17 people, said that they saw black and blue, 20 people, gold and white, and three people other. Thank you. We can move the survey. That's pretty cool. So we have a pretty even split there between black and blue, and gold and white.
I think it's really amazing that we're all looking at the same dress. The raw data that our retinas are sending back to our brain when we look at this dress is the same for each of us. But our brains are choosing to interpret it differently based on the same set of cues. And that brings me to this quote by David Eagleman, who is a neuroscientist.
He says that "Despite the feeling that we are directly experiencing the world out there, our reality is ultimately built in the dark in a foreign language of electrochemical signals. There is no single version of reality, but rather each brain tells its own truth." And then my favorite quote about vision, also by David Eagleman-- "Seeing is never anything but electrical signals streaming into the darkness of your skull."
So really, our eyes-- the analogy that I like to use when I'm doing CVI trainings for my student school teams is that the eye to the brain is really like a flash drive to a computer. The flash drive contains the raw data, which in and of itself doesn't really make any sense unless, maybe, you're a computer programmer. But once you plug that flash drive into the computer, that computer takes that raw data and builds meaning out of it.
Similarly, our eyes are really capturing the raw data that gives us information about the world out in front of us, and sends it back to our brain, and that's our brain's job to build meaning out of that otherwise meaningless raw data. Whoops. It looks like I lost my-- I lost the PowerPoint on my screen. Let's see. It's coming back. There we go. Thank you.
So I was using that analogy for years. And I would always ask myself and wonder, what does that raw data look like? You know, how can we conceive of the raw material that's being sent back to our visual cortex from our eyes? And I was really excited when I saw these images from the visual scientists at MIT. This is part of the Project Prakash that they're doing, a study over in India, on how the brain learns to see.
And they say that if you look at the image on the right-- here we see a full-colored image of some girls in a dance class with a bagpiper in the background. If we look at that image, they say, what our eyes are giving to our brain is something-- looks something like the image all the way to the left. If we look at that image to the left, we see this black and white sort of array of just scattered visual information, scattered data points.
And what that represents, the scientists from MIT tell us, is really every little change in light, every little shadow, edge of an object, corner of an object, every little parcel of that visual scene that's out in front of us, every little individual data point. And amazingly, our visual brain is able to take each of those separate data points and decide which of those belong together to form arm, which belong together to form leg, or bagpipe, and so on.
And it's really a monumental computing task that our brain is charged with to make sense of our visual world. So when we think about-- when we ask ourselves that question, what does the world look like for our kids with CVI, I'll often show teams these two pictures and ask, let's imagine what the world might look like between these two images.
Because really, if we think about the image on the left being the unprocessed raw data that our eyes send to our brain, and the image on the right being the fully-formed product of a healthy, functioning visual system, then it would make sense that if you have an impairment of that visual system that the image of your world is going to fall somewhere in between those two images.
Now, as we know, most kids with CVI can see color. The color in the brain is preserved. So we might imagine that their visual world as being somewhere between a color version of the image on the left and the fully-formed image on the right. And so how do we know where each student is? There's no simple answer. I think that we can't know for sure, but we can certainly try our best to imagine.
So if we think about our journey, our journey in learning more and more about CVI so that we can better serve our students, I really like this quote from Gordon Dutton. He says that "I now like to think of vision as effectively being an ever-changing mental representative construction of the external environment, the nature of which is dictated by the character and processing capacity of the brain.
It is the true nature of this mental image that practitioners need to envision for each affected child so that they can inhabit their visual worlds in a manner analogous to virtual reality and see out through the affected child's eyes." So I think that's the challenge that each of us feel when we work with our students. And the more we learn about CVI, the better we'll be able to do this.
And if we think of that as our journey-- I'd like to start off by telling everybody where I started on my journey. It actually started-- my journey learning about CVI actually started on Peg Palmer's porch. She's one of the people who organized this call and came up with the idea. And I was a first-semester student at UMass Boston training to be a TVI. And I was interviewing Peg as the veteran TVI for one of my assignments.
And I remember sitting on her porch and just listening to Peg talk so passionately and with so much enthusiasm about working with kids with cortical visual impairment, how rewarding it was to watch their vision improve as they went through school. And I remember asking myself two questions in my head while she was talking. One was, how can I get in on this? This sounds amazing. I really want to work with students with CVI. How can I be like Peg someday?
And unfortunately, my second question, I'll be honest, was, what's a cortical? You know, we haven't gotten to anything on the brain yet in my classes. We had just started to look at some of the diagrams of the eyes. So I was thinking, what's a cortical? And in my imagination, I started to pull up that diagram of the eye with the retina. And I'm thinking-- you know, as Peg's talking about teaching kids with CVI, I'm thinking, maybe the cortical is part of the retinal pigment epithelium.
It's got a lot of layers in there. I don't know. Maybe it's something like that. You know, maybe it's somewhere near the zonules of Zinn, and I was hoping for that because it's so much fun to say. But then, of course, I got home, and I googled cortical, and realized, of course, that it had nothing to do with the eye, but that it referred to the brain's cortex. And that was sort of the beginning of my journey.
And if we think about all of our-- this collective journey on going from, what's a cortical, to CVI competence, we know where I was starting off. And it was definitely at the very beginning. So what did I have by my side as I went on this journey? I had a lot of great books and resources that I'm going to share with you today, and then some wonderful mentors, as well, many of whom will probably be on these webinars in the upcoming weeks and months.
So the first leg of my journey, I was very excited. Maybe another couple of semesters into my time as a graduate student when, for one of my classes, I was asked to order Cortical Visual Impairment, an Approach to Assessment and Intervention by Christine Roman-Lantzy. And so I was really excited. I started reading it any chance I could get. And then another one of my professors handed me the article by Gordon Dutton.
It wasn't this exact article, but this is a very good one. It's called "Types of impaired vision in children related to damage to the brain, and approach towards their management." So I was very excited to read that. And I'm reading both of these resources any chance I could get. And as I was reading these resources, I was getting more and more excited for my student teaching, when I could go out there and start working with kids with CVI and applying what I was learning.
But there was also this question that was sort of nagging at me that I couldn't really resolve, and it was this. So as I'm was reading Christine Roman-Lantzy's book, I'm hearing a lot about 10 characteristics. As I'm reading the Gordon Dunton article, I'm reading the terms ventral stream and dorsal stream quite a bit, but nothing about characteristics. In Dr. Roman-Lantzy's book, I'm reading things like, difficulty with visual complexity of object, of the array, of faces, sensory environment, and so on.
And then in the Gordon Dutton article, I was reading terms like simultanagnosia, prosopagnosia, object-form agnosia, et cetera. And as you can probably guess, the biggest difference that I noticed was that CVI in Dr. Christine Roman-Lantzy's book meant cortical visual impairment. And CVI in Gordon Dutton's article was referred to as cerebral visual impairment.
So even though I was so excited to be kind of getting further ahead on my CVI journey, I was very confused about what the-- how these two bodies of work related to each other. So I felt a little bit lost in the fog early on. And I want to share some of my initial misconceptions and stumbles as I look back on them.
So one of my first thoughts was, maybe these two resources are totally unrelated. Maybe they describe two totally different visual conditions-- cortical and then cerebral. Another misconception that I had was that maybe Dr. Roman-Lantzy's book is describing impairments of more basic early visual functions, and Dr. Dutton's article is dealing with higher level visual functions, like dorsal stream and ventral stream dysfunction.
And then finally, as I started to go out and student teach later in the semester, it seemed that most of the characteristics in so many of my students were resolving, and I was scoring a lot of kids at the 8 and 9 range on the CVI Range. So I was a little lost. But then a watershed moment early in my career happened, and I felt like the fog was lifting.
And the watershed came because I did two things. The first was that I attended a week-long CVI Phase III Boot Camp with Christine Roman-Lantzy in Maryland. This was in the spring of 2013, and it was an amazing experience. We stayed-- myself and dozens of other TVIs from around the country stayed at a conference center together with Dr. Roman-Lantzy, and with children with CVI, and their families for a week.
And we were each assigned in small groups to work with the child with CVI, complete a CVI Range assessment, come up with an educational intervention plan for that child in cooperation with his family. It was an amazing experience. Well, about two weeks before I left for that month for the boot camp, I got a book in the mail. And it was the red book by Dr. Gordon Dutton called Visual Impairment in Children Due to Damage to the Brain.
So this was like an amazing CVI retreat for me. I was attending Dr. Roman-Lantzy's workshops during the day. I was catching up and reading my new Dutton book at night. And really, a lot of things started to occur to me. And I felt like I was really advancing in my own understanding of CVI. So some of the things that I was learning-- the first, which I learned in the boot camp, was that the CVI characteristics rarely resolve, even in phase III.
They just present differently and more subtly. And spending the whole week with a child in phase III and his family really drove this home for me, and I got better at picking up how the characteristics present more subtly in phase III. I also was learning that the CVI Range covers both basic and higher level visual functions, like dorsal and ventral stream dysfunction, which was very contrary to that initial misconception that I had.
The third thing I learned, and this was coming from both Gordon Dutton's book and Christine Roman-Lantzy's materials, is that CVI is really, in so many ways, about visual complexity, difficulty with visual complexity. I was noticing from the boot camp that many of the 10 characteristics revolved around visual complexity. And then when I was looking through Dr. Dutton's inventory of questions in his red book, I noticed that about 21 of 51 questions were really centered on visual complexity directly.
And finally, what I was most excited about was that for the first time, I was seeing so much overlap and so much agreement in the literature on cortical and cerebral visual impairment. I was seeing so many connections, and it was helping me already understand my students better. So before we get going further into this idea, am I saying that cortical and cerebral visual impairment are the same thing? No, not exactly.
We know that sometimes the terms are used interchangeably based on geography. So in Europe, it's more common to say cerebral visual impairment, and the term cortical is more common in North America. Sometimes these terms are used more precisely to describe two different visual conditions, sometimes based on anatomy.
So trying to separate out what are visual dysfunctions due to damage to the earlier pathways in the visual brain versus those due to visual processing later in the visual brain, such as dorsal and ventral stream. And then sometimes these two definitions are parsed out based on functional behavioral characteristics, as well. And I think it's an interesting debate, and it's important. But I'm not a good person to-- I wouldn't be able to add anything to that debate.
So that's not what I'll be talking about during this presentation. Instead, I want to turn to the words of Lofti Merabet, who is a CVI researcher at Harvard University. And he says, of the terms cerebral and cortical, "These terms are not mutually exclusive." And that it's "not unusual for students to have elements of both."
And then he kind of jokes in one of his webinars that maybe we should call it CCVI to show that there's both cortical and cerebral aspects for so many of the kids that we work with. And to continue, Dr. Merabet says that "There is a limit to parceling and labeling things. Even though that might be important in some ways, we can't be dwelling on all of these titles. At the end of the day, we need to be taking care of the kids."
And that really resonates with me. I've found that by really absorbing myself in both schools of thought, cortical and cerebral, and by taking an integrated understanding of the two, it's really allowed me to feel more competent in my ability to go into the classrooms, and take care of my students, and support their families and their teams. And also, before we get going further, I should say, too, that my approach just represents my own personal approach.
So I'm just one TVI, and this is how I've come up with a specific way that I have learned to integrate the two kinds of schools of thought. The CVI Range and the 10 characteristics by Christine Roman-Lantzy are my home base and my foundation, and I have a lot of reasons for that, which are beyond the scope of this webinar. But it's really sort of like the bedrock of my understanding of CVI.
And then what I do is, as I'm reading the literature on cerebral visual impairment, is I integrate what I feel to be the most closely corresponding ideas and strategies from that literature into the framework of the 10 characteristics. And certainly, my way is not the only way. But that's sort of the approach that I'll be sharing during this webinar. So let's get started.
Going along with this idea of taking the 10 characteristics and integrating the ideas from the cerebral visual impairment literature into them, let's start with difficulty with visual complexity. And we know from the CVI Range that Dr. Roman-Lantzy has broken this characteristic out into subcategories. In one of those subcategories is difficulty with complexity of objects.
So we know that many children with CVI have difficulty with complexity of the object or the target that they're looking at. And here's a common misconception that I run into, and it's one that I had before the CVI Phase III Boot Camp. My misconception was that this characteristic involves only the ability to look at different types of objects.
But in reality, this characteristic involves difficulty with complexity-- I'm sorry, this characteristic of difficulty with complexity of objects also encompasses the ability to interpret-- the ability to interpret objects, images, symbols, letters, words, numbers, and so on. And really, when I have a child who's in mid-phase II or beyond, I'm much more concerned with the question, can the child interpret versus can the child look?
So when I read about difficulty with visual complexity of objects in the cerebral visual impairment literature, the most closely related term that I see is visual agnosias. And what that means is just the inability to interpret visual information-- agnosia coming from the Greek word, for lack of knowledge. And there are several types of visual agnosia that I feel are really closely related to difficulty with complexity of object, and they really encompass the ventral stream impairments.
And here's a list of some of the types of visual agnosias. I'm not going to go through each of them, but I think it's so interesting that we've found that people who have difficulty interpreting what they're looking at can have difficulty doing that in a variety of different ways. So for example, a person with apperceptive agnosia, their visual brain is really unable to put together that raw data from the retina into a coherent object or image that makes sense.
If you ask the person to draw an image that they're looking at, or an object to copy it and draw it, they wouldn't be able to. And of course, then, they wouldn't be able to name it either. In contrast, a person with associative agnosia, they might have a fully formed precept, in their visual brain, of that object or image. If you ask them to draw it and copy it, they'd be able to, but they wouldn't be able to name it.
So just very interesting about how this can manifest in a variety of different ways. So do my students have agnosia? I think about this a lot. And the way I see it is that, for most of my students, rather than being very localized forms of CVI, of brain-based visual impairment, their impairment is really more global, covering a lot of different areas. And so I think it would be hard to parcel out, is this apperceptive agnosia, or is it associative?
To me, it's much more accurate, as a TVI, to say they have difficulty with complexity of objects. But I think of them as agnosia-ish, as showing agnosia-ish visual behaviors that are part of their global CVI. And the reason why that helps me is because then I can look into the literature on adults that have had visual agnosias.
Read their accounts of what it felt like to go into the grocery store and not be able to recognize the fruits or vegetables, what it felt to pick up the newspaper and not be able to recognize the pictures or the words. And it just helps me better imagine, and be able to put myself in the shoes of my students a little bit, and try to see the world from their perspective.
So difficulty with complexity of object-- going back to my initial misconception, does it resolve? And we know from Christine Roman-Lantzy's work that it rarely does resolve. And I offer up a few examples here from my students in late phase II and in phase III. So I showed my student this picture on the left of a black and white line drawing of a pair of scissors. This is a student in late phase II, and he was reading on grade level.
He was in first grade. And he said that it was a bicycle. And we found out that he was thinking that the handles were the wheels. I showed him the same picture of this kind of clip-art-looking picture of a toothbrush with a pink handle and yellow bristles. And he answered that it was a bus driving down the road. The picture on the right, which is a regular color photograph of a rhinoceros, I showed to one of my students in phase III, who had just written an 18-page paper on rhinoceroses.
She was in fourth grade. So she knew a lot about these animals. But when I showed her a picture of a rhinoceros on Google Images and said, what do you see here? She said that it was an elephant. And when I asked her why she said elephant, she pointed to the front leg and said, because it has a gray trunk. So I think these are all good examples of students who are demonstrating some pretty high visual skills and who cognitively have an understanding of what scissors are, what toothbrush is, what a rhinoceros is.
But visually, are still not-- are still having difficulty with complexity of object. And we know that from reading, too, on Christine Roman-Lantzy CVI Range. In order to be resolved with this characteristic, a student would have to meet the following criteria-- visual fixation and object discrimination. Recognition or identification of the target is commensurate with the age of the individual.
And clearly, that wasn't the case with these students. Therefore, it was not resolved yet. So every now and then, I'm going to pause in his presentation. And just imagine that if we're going on a journey or a kind of a metaphorical road trip in learning more and more about CVI, what are the books that I would try to fit into that suitcase if I had to do it all over again?
And here are a few really interesting ones that specifically have a lot of information on visual agnosia. The first two are by Oliver Sacks. One is called The Man Who Mistook His Wife for a Hat, and the other one is The Mind's Eye. And both of these have pretty amazing examples of adults who acquired visual agnosias later in life and could really eloquently describe how they were seeing things differently.
The third book is more academic but still very interesting and helpful. And that's called A Case Study in Visual Agnosia by Humphreys and Riddoch. And this book follows one man after he had a brain injury later in life, and his descriptions in the studies that they did on how difficult-- how much difficulty he had recognizing both three-dimensional and two-dimensional things in his life.
Let's shift to another ventral stream-related issue-- difficulty with complexity of faces. So we know that many children with CVI have difficulty looking at and/or recognizing faces, and that could also mean facial expressions, being able to tell gender by someone's face, as well. The related term from the literature on cerebral visual impairment is prosopagnosia, which means, simply, lack of knowledge of the face.
And this is another book for the suitcase. This is one of my favorite books, and it's an excellent book on this issue with recognizing faces. It's called Understanding Facial Recognition Difficulties in Children, Prosopagnosia Management Strategies for Parents and Professionals. And it's edited by Nancy Mindick, who is a person with prosopagnosia. And a lot of the book is filled with anecdotes, and stories, and strategies that people with difficulty recognizing faces have developed throughout their lives.
And it just gave me so many ideas for working with my students. This is one particular excerpt from the book by a man named Jim Cooke who has prosopagnosia. And he gives us this sentence that we see in blue right here, and asks us to read it, and see if we can make any sense out of it. So it says, "That That is is That That is Not is Not."
So Jim Cooke then writes, "You know what each of these words means, but what does the entire sentence mean?" He basically says it means nothing until you put some punctuation into it. So then with a couple of commas and periods, the sentence now reads, "That that is, is. That that is not, is not." And Jim Cooke says, "Without punctuation, it's just a bunch of words.
When I look at a face, I see the face, and I see the eyes, but it's just a bunch of features that means nothing. So it's almost as though the punctuation is missing when I look at a face." So it's anecdotes like this that have been so powerful in helping me understand what it might be like to be a student with difficulty with complexity of faces and to help their teams and families try to understand this, as well.
So let's shift to another subcategory of visual complexity, and that is difficulty with complexity of the visual array. So of course, we know that many children with CVI have difficulty with complexity of the visual array. That's from the CVI Range by Dr. Christine Roman-Lantzy. And this characteristic, of course, refers to difficulty finding or noticing a visual target in the presence of competing visual information.
It's often referred to-- I think the closest correlate in the cerebral visual impairment literature is simultanagnosia, which is the inability to see multiple things at once. And it specifically involves bilateral damage to the posterior parietal lobes, which are part of the dorsal stream. And they're very involved in visual attention and awareness.
So people with simultanagnosia, or it's part of a larger syndrome called Balint's syndrome sometimes, may look at a visual scene and only see a few objects at once. Some affected individuals have described objects in a scene as fading in and out of visual consciousness kind of randomly so that only one or two are seen at a time. So there's a fantastic video on YouTube, and I provided the link here.
It's about a man with Balint's syndrome, and he's in a laboratory being evaluated by another person. And in this lab test, the man can only see one object at a time. At one point, he sees an equation on the board several feet behind the evaluator instead of the two objects that the evaluator is holding up right in front of him, which is a good example of how many of our students with CVI may have difficulty separating foreground from background.
And so the results indicate that this man has difficulty with complexity of the array, and that he also has difficulty with that foreground-background separation. So let's look at this for our students in-- I showed a few examples here, one from phase I. There's a picture of Clifford on a black APH work tray with some leaves surrounding him. This was from a book box, a literacy kit, about Clifford raking leaves.
And my student in phase I was able to look at Clifford and show some visual attention to him when it was just Clifford in this scene. As soon as we added the leaves, he looked away and didn't look back at all, indicating that the complexity added by the addition of the leaves was just too much for him. In phase II, complexity of array can look different. We see a picture in the middle here of one of my student's place settings at lunch.
Despite the yellow handle and the yellow tape around his cup, he was unable to use his vision to find these things during his meal. And he was mostly looking away and using a tactile approach to find them. As soon as we moved everything else out of the way-- the radio, the speakers, the bins of manipulatives-- then he was able to use his vision to reach out and interact with the spoon and the cup.
For one of my students in phase III who was a senior in high school at the time, she showed me the worksheet that's pictured here on the right. It's not really a worksheet. It's a handout of a Venn diagram for her civics class, and it's got three overlapping circles. And she brought this to me and said, this is just too much for me to see. It doesn't matter how big I blow it up, it's just too complex. So this was too much of a complex array for this student in phase III.
So in order to resolve, we go back to Christine Roman-Lantzy's rating 2 in the CVI Range. And it says that in order to resolve complexity of array, a student would have to meet this criteria. "Targets are located against any background commensurate with the age of the individual." And clearly, neither of these three students were meeting this statement, so still would be unresolved.
And two more books for the suitcase-- these are both terrific books by Martha Farah who is a vision scientist, I believe, at Harvard. The one on the left is called Visual Agnosia, and it has some really, really clearly and interestingly written chapters about specific agnosias, like simultanagnosia, apperceptive agnosia, alexia, which is difficulty being able to read due to ventral stream impairment.
Very, very interesting, and it's helped me understand the visual behaviors of some of my kids in phase III a lot more than I would have otherwise. And then her book The Cognitive Neuroscience of Vision is also very interesting. A little bit more difficult-- there were some sections I found hard to get through, but overall, very, very interesting and informative.
And even though these two books are on the older side-- I think they were published in the early 2000s-- they're still really, I think, kind of foundational and fundamental to our understanding of these topics today. OK. Let's take a look at another pair of related topics from the cortical and cerebral visual impairment literature. So we have the characteristic, the CVI Range characteristic of movement.
And then we have the cerebral visual impairment characteristic of blindsight. So let's turn first to cortical. So most children with CVI alert to visual movement and tend to be attracted to objects that move over those that are stationary. Often, our children seem to see moving targets better than stationary targets. And Dr. Roman-Lantzy's work has done so much to help us in our understanding of how we can use movement to help our kids with CVI see better.
Now, from the literature on cerebral visual impairment-- "Due to a separate visual pathway that travels from the midbrain to the parietal region of the dorsal stream, even a person with significant damage to their primary visual cortex, or the occipital lobe, or V1 may still be able to notice moving targets." And there's an amazing video on YouTube which I included the link here. It's done by NPR, and it's called the "Blind Woman Who Saw Rain."
And it's about a woman who sustains an injury later in life to her occipital lobe and has almost really no conscious vision at all, but then starts to realize that she can see moving objects due to this spared pathway that is written about here. It's very interesting. So from the literature on cerebral visual impairment, the preservation of the ability to see movement in spite of damage to the primary visual cortex is often referred to as blindsight.
And people with blindsight alert better to moving targets and also may be able to see when they are moving through an environment. Dr. Dutton sometimes refers to this as travel vision. And I have certainly had many students who, when they're sitting at their desk looking at some stationary materials, seem to-- those materials don't even seem to be there sometimes. But yet, those students can move through the hallway using that dorsal stream vision, and are avoiding obstacles, and doing very well.
I think of these examples of blindsight, as being very closely related to that. So I think of my students' behavior usually as blindsight-ish when they're able to do those things, meaning that I wouldn't say that they're cortically blind. They have more usable vision than that. However, seeing movement is a relative strength compared to their ability to process the static visual world.
So it was really helping me to see all this overlap between the cortical visual impairment literature and the cerebral when it came to movement. However, then I came to something that confused me. I was encountering the term akinetopsia quite a bit in the cerebral visual impairment literature. And that means when a person is unable to process vision-- I mean, I'm sorry, unable to process visual movement.
But what I found was that this is actually something different than blindsight. This condition is an impairment in the higher level conscious perception of moving objects-- so seeing a fast moving car or a ball coming toward you. And this can occur to varying degrees in kids with CVI. But Dutton and Lueck write that it is possible to have degrees of this condition while still maintaining the lower level ability to alert to a moving object in the periphery, as in blindsight.
So what first seemed to me like a contradiction actually wasn't at all. It was describing two different conditions. And this is another amazing book for the suitcase. This is one of my favorite books about vision and the brain. It's called Sight Unseen, by Milner and Goodale. They were two of the earliest pioneers, really, in the ventral-dorsal stream theory.
And this book, it has a lot of great information about both dorsal and ventral stream processing, specifically some really fascinating discussion of blindsight and that whole idea that we can see things subconsciously, even if we don't have a conscious perception of what we're seeing. In just reading through their examples and their discussion of this, I felt like I had a lot better understanding of my students and how movement might help them in their daily lives.
Let's turn to the visual motor characteristic. So we know that children with CVI often have difficulty using their vision to guide motor actions, such as reaching. In the cerebral visual impairment literature, they write that the dorsal stream, or the sometimes called vision-for-action stream, plays a major role in integrating our visual map of space with proprioceptive input from our limbs so that we can use vision to guide reaching, stepping, and other motor tasks.
Optic ataxia is a condition in which this system is disrupted, and the person has difficulty using their vision to guide to reach, or to guide steps, or to perform other motor actions accurately. And the region of our brain called the parietal reach region, which is part of the dorsal stream, is often discussed as one of the main areas of impairment when a student has difficulty with visually-guided reach.
So in my experience, too, when we think about, are the characteristics resolving-- well, most of my students in phase III can use a visually-guided reach pretty consistently most of the time, if not all the time. But when it comes to more fine motor, visually-guided fine motor actions like maybe using their vision to guide their fingers as they try to button their jacket, or their zipper, or hanging up their backpack, then I see that looking away behavior a little bit more.
And so even in phase III, this visual motor sort of disconnect is still very common. But I find that it's with more fine motor tasks in my children with phase III. This is an article for the metaphorical suitcase. This article is called "Disturbances of Visual Orientation" by Gordon Holmes. And it just came out in September, but actually 100 years ago, in 1918.
And this is a foundational article in the literature on brain-based visual impairment, and it's still so useful today. In the article, Gordon Holmes describes-- I think it's six World War I veterans that returned from the war with shrapnel wounds through their dorsal streams, through their occipital parietal regions. And one of the many difficulties they have is difficulty with visually-guided motor actions.
And just some fascinating discussion and anecdotes in there about what those men went through and what that experience was like for them. So in the next two slides, I put together a couple of tables with the CVI Range characteristics on the left, and then when I felt to be the most closely correlated cerebral visual impairment literature findings on the right.
So for difficulty with complexity of objects, we talked about how visual agnosias can be pretty closely related in some ways. When it comes to complexity of faces, I've learned a lot from the literature on prosopagnosia. When it comes to complexity of the visual array, I think of simultanagnosia and Balint's syndrome from the cerebral literature. And when it comes to sensory complexity, there's really no term that I've found in the literature on cerebral visual impairment.
But there's a lot of discussion on difficulty combining vision and hearing, and it's often attributed to dorsal stream issues. And then if we turn to some of the other characteristics like color, there's-- we know that, from the CVI Range, that color tends to be a strength, and color perception is usually preserved. And those findings are substantiated in the cerebral visual impairment literature, as well.
Sometimes the term achromatopsia is used, meaning color blindness due to damage to the brain, but that's very rare. And then that movement is related to blindsight. We talked about that. Difficulty with distance viewing is a characteristic on the CVI Range. And in the cerebral visual impairment literature, this difficulty is often treated, as well. And it's described usually as a result of visual complexity or of difficulty sort of zooming in and out to a broader and more narrow visual scene.
And then, of course, too, in the cerebral visual impairment literature, it's often attributed to a poor acuity, as well. And then finally, the visual motor characteristic, I find, is highly correlated to information on optic ataxia from the literature on cerebral visual impairment.
So when I was talking to Mary Zatta from Perkins about doing this presentation, I mentioned to her that when I'm walking around in the schools working with my students and their teams, I really kind of carry this Venn diagram in my head of just what are the differences and similarities between the literature I'm reading on cortical visual impairment and that on cerebral visual impairment.
And I just mentioned how there's, in my mind, there's way more overlap than there are differences. And Mary said, well, can you put that down in concrete form for the presentation? And so I did, and I did my best. I tried, and I think this is a pretty accurate representation of how I've come to see the differences and the overlap between the two schools of thought.
I want to save time for questions, so I won't go in depth into each of these here. Most of them were already covered just now. But the main theme that I'm hoping everybody will take away is that, at least to me, there's a lot more overlap than there is differences. And I've found that when I inhabit that common ground, that area in the middle there, it really serves me well in my ability to imagine the world from my students' perspective and to serve my students as best I can.
Before we end, a few more great books for the suitcase-- two of Gordon Dutton's books, one that he wrote with Josef Zihl. And then finally, Visual Intelligence, which is a fascinating book that really just talks about how all of us, how all of our visual brains, go about creating, building meaning out of that raw data that they receive from the retina. It's a fascinating book. I highly recommend it.
So let's think about-- and I've talked a lot about books now. I want to quickly mention some of those web resources that have been there on my virtual journey. So Little Bear Sees, I think, is a fantastic resource. I especially love it for families of students who are new to CVI, and those who are in phase I and early phase II. The West Virginia State Department of Education has some terrific webinars of Christine Roman-Lantzy.
There's several hours of webinars of her describing everything from phase I to phase III, social skills, orientation, and mobility. It's really a great resource. CVI Scotland is one of my favorite websites, and it's from Scotland. And it's from the cerebral visual impairment school of thought, but very, very useful website. The Perkins eLearning webinars-- I've watched so many of those over the years, and I've learned so much.
And sometimes I find it overwhelming how much good information is there. And there's still more that I want to explore there. Google Scholar is great for just looking up some foundational articles by James Jan, and Groenveld, and by Gordon Holmes just to see where the schools of thought for cortical visual impairment, cerebral visual impairment-- what seminal articles those were founded on.
The Texas School for the Blind and Visually Impaired has a great CVI site. As it Paths to Literacy has many, many resources on adapting books and literacy activities for children with CVI. And Strategy to See by Diane Sheline has a lot of practical strategies for phase I, II, and III. For blogs and social media-- for whoever doesn't know yet of the CVI Neuroplasticity Research Group headed by Dr. Lotfi Merabet and Corinna Bauer. I highly recommend following them on Facebook.
And maybe for starters, the link is a little hard to see on the presentation here, but if you Google Lotfi Merabet on YouTube, there's a couple of great presentations that come up about the brain imaging that they're doing on children with CVI. On the CVI Scotland website, Nicola McDowell has a blog. She's an individual with CVI. And she just describes, in such elegant terms, how it was in high school for her, as an individual with CVI.
Christine Roman-Lantzy has a new blog on CVI Resources, which is fantastic. One of my favorites, CVI Teacher by Ellen Mazel. Gordon Dutton's blog has a lot of great information. There's some really interesting stuff on there right now about auditory processing issues in kids with CVI. And then finally, Start Seeing CVI is a terrific parent advocacy and CVI awareness blog and Facebook page by a mother of a child with CVI.
And there's just daily, daily updates. A lot of good information there. So finally, if I could only fit two-- if I had to go on this metaphorical journey of learning about CVI all over again, or even starting today, for that matter-- if I could only bring two resources with me, I would bring these two. I would bring Cortical Visual Impairment, an Approach to Assessment and Intervention by Christine Roman-Lantzy and Vision and the Brain by Amanda Lueck and Gordon Dutton.
And yes, these are my two kids, and there's a funny story behind this picture that I won't go into for time's sake. But I recreated it. Well, we restaged the picture for this presentation. But the reason why I like it so much is basically-- well, it's two of my favorite people reading my two favorite CVI books. And I think it's obviously humorous that two kids this age appear to be reading these books.
But the thing that I like best about this is that I find it hard to imagine looking back at my journey of learning about CVI without both of these resources, and without trying my best to inhabit that space in the middle of a Venn diagram, and really take the rich ideas of both sort of schools of thought, and find the common ground, which there's tons of. It's really enriched my journey, and I think it probably has for many of you, as well.
And if you haven't tried that approach yet, I highly recommend it. So on this journey, I hope that I'm at CVI competence right now. I feel like I am. I feel like I can walk into a classroom, and I'm excited when I get a new student with CVI not only because I get to meet the child, but because I can feel I can actually help the child now. But as you can see, the road keeps going.
Never done learning about CVI, learning something new every. Dr. Merabet says that CVI is a public health crisis. So I think the call for us, as a field, to go as far as we can on this journey, too, is more important than ever now. Thank you very much. I hope there's still some time for questions.
Well, thank you, Matt. That was perfect. I think, exactly the right thing to just kick off this whole webinar series of CVI for the TVI. So I'm going to take questions now, if people will write those into the Question and Answer box. We'll see if people have some questions that Matt can answer in the next 10 minutes.
I don't see any questions yet. I'm reading Oliver Sacks's The Man Who Mistook His Wife for a Hat. I'm rereading it again because it's such a good book, when you think about visual processing. But it turns out he also has facial recognition difficulties that he talks about in that book. So he has an interesting perspective, also. OK. We have a question coming in from Anna.
When you mentioned Little Bear Sees app, do you mean the Tap-N-See Now, or My Talking Picture Book, or both?
Oh. Well, both. I was thinking of the website Little Bear Sees. It has a lot of ideas for strategies, and it describes the phases and the CVI Range. And it has some great pictures, too, of items that might be good for a child in phase I or early phase II. But yeah, the app-- I actually haven't used the second one that you mentioned yet, but I'm very familiar with Tap-N-See Zoo.
And for a few of my students, when they were in late phase I emerging into early phase II, Little Bear Sees Tap-N-See, where you have the red animals sort of floating and moving on the screen, was the first thing that they looked at and touched on an iPad. So yeah, I do recommend that. And if anyone has experience with the second app by Little Bear Sees, please let everybody know, too. I haven't tried that one.
Great. We have another question saying, can you turn back the slide to the websites? And I think what I'll say is just, tomorrow this will be released as a PowerPoint on Perkins eLearning website. So if you're interested in seeing those resources, just log in tomorrow, and you'll be able to see the whole presentation again and capture those websites and resources that Matt has mentioned. Some of the books that you mentioned, will they be available in your session on Friday? If not, can I purchase them somewhere in the area?
Oh.
Would you say there's a--
The books. Yeah, I can-- you know, yeah, I'll bring them up. I can bring them up there and kind of leave them on the table to look at, just my personal copies. But they're all available on Amazon.
OK. That will be a great thing, so people can get a closer look to decide whether or not they want to buy. What's your number one advice for teaching reading to grade level student-- elementary students in phase II?
That's a good question. You know, I'm trying to think of my students. Each one is at slightly different of a level. Number one advice for teaching reading. I mean, I would say-- OK, so I would say first, the number one thing-- if I could pick any one thing, it would have to be, make it interesting. I mean, there's so many different types of approaches for different students, depending on where they're at.
Are they at an object level right now as far as interpretation-- real photographs, cartoon drawings, words, and things like that? But I think the first and foremost is make it interesting. I mean, I have so many times when I've tried-- when either a team, or me and a team, have tried to use materials that weren't highly individualized and motivating for a student. It's just sort of like, I think, a battle, both for the team and for the student.
I mean, like some of the-- I have had a few students who do like some of the early readers, the leveled books, and everything, but I think that they're usually the exception. The most success that I've had with literacy-- whether it's literacy with objects, whether it's literacy using pictures, or whether it's literacy using words-- has been when it's highly customized. So I had a student who was really into Corvettes.
His neighbor had a Corvette. His grandfather had a Corvette. So he really wanted to talk about Corvettes most of the time. He loved it. But so what we did was we started with books about Corvettes. We used Matchbox cars of Corvettes. We had photographs of Corvettes. We have the word Corvette. And then he would pick like-- you know, we had the word for his-- we had his name.
We had his mom's name. We had one of his peer's names, one of his teacher's names. So he would pick which-- he would pick the word to correspond with who you wanted to drive the Corvette in the story. And so just things like that. Another avenue that worked for him and for another student in going from objects to pictures-- and we're now working on pictures to words-- was his daily calendar system, because it made sense to him.
We set it up with color-coding so that he could follow it really well from left to right in really sequential order. And we started with objects on there, so he would have an object that he would use for each-- an object of reference for each activity in his day. And in the morning, he would pick out the objects from a box and put them up in the right order. Well, then we eventually paired a photograph of those objects with the object and used those together for a while.
And then after about a year, we went right to photographs. And now you can put six photographs up on a wall with same-color distractors, and he can pick all the right ones off there and set up his schedule. So now we're pairing those photographs with words to try to get that. So now I think the question may have said on grade level for reading, too, if I remember correctly.
So that wouldn't be an example of on grade level. For on grade level for reading, you know, I think-- I think it's even with the-- I'm thinking of one of my students in particular. Even when they're able to read the words, I've found that it can be a lot more interesting for them if there's photographs that they can interpret to go with the words, even if they're not part of the story.
Like choosing-- let's say the story has words, but then it has kind of abstract, cartoonish photographs. Well, taking real photographs of those things from Google Images and substituting those things, and then also having a literacy kit for the story-- having the book box that goes with it, so finding objects from the story to pair with those photographs, to pair with those words.
And if possible, even having the child answer questions based on the-- using the objects, using the photographs, and maybe act out part of the story after they read it. Things like that, I've found very helpful. I do have a student who-- two students, actually, who learned using the bubble outline method developed by Christine Roman-Lantzy. That worked really well for them, and they both got to the point where-- they used to have to have every word always highlighted all the time, even in connected text, to be able to read it.
But now they're at the point where, as long as there's extra spacing between words and sentences, they don't need the bubble outlining for familiar words, but they just use the bubble outlining for new, unmastered sight words. So those are just a little bit of some of my recommendations for reading. And I think it gets so specific based on the student.
That's great. The next question, Matt, is about-- can you talk a little bit more about the role of the dorsal stream in vision?
Yeah. So from how I understand it, so the dorsal stream has-- that I kind of have a few major parts of the visual functioning that it's involved in. So one of the things is simultaneous awareness of multiple-- I should say, awareness of simultaneous pieces of visual information.
So the ability to walk into a room and simultaneously be visually conscious of everything that's in that room, all the different-- the furniture, the people-- and maintaining a visual awareness of all those things at once, and then to be able to manage visual attention across all of those things. So in some of Gordon Dutton's articles, and I think in maybe one of the first couple of chapters in Vision and the Brain, he gives these really nice examples of like-- let's say you're in a crowd of people.
And you're trying to find your one friend or your one relative that's in that crowd. And with your dorsal stream, you'd have to be simultaneously aware of everything there, and then manage your visual attention across that crowd in sort of a systematic way to find the person. And then the ventral stream, of course, kicks in in order to recognize the salient features of that person.
So the dorsal stream and ventral stream, when it comes to searching a crowded array, work together hand in hand. You really can't have one without the other if you're going to locate a person in a crowd, or locate a math problem on a worksheet, or read through a line of text. So dorsal stream, really, simultaneous visual attention, and management and guidance of visual attention in a productive way.
Dorsal stream also has a significant impact on the ability to integrate vision with other sensory input, like to integrate vision with proprioceptive input, so you can combine reach and touch, or reach and step-- I mean vision or in step, or vision with other fine motor tasks. And then I've also read, in the cerebral visual impairment literature, that the dorsal stream is involved in basically integrating sound and vision, as well, so being able to listen and look at the same time as a ventral stream function.
So those are some-- like the main categories of functions that I think about. It's also, I think, helpful to know that when a student has an impairment of the occipital parietal area that's part of the dorsal stream, they often have lower visual field loss or impairment, too, because that's around the area where the lower visual field is represented.
That's great. [INAUDIBLE].
I should mention, [INAUDIBLE]. I'm sorry, yeah. Students with dorsal stream issues often have difficulty with math, as well, because math is so spatial in nature-- anything from counting to doing more complex math.
OK. Thank you. I think we have one more comment and question. A comment about sensory complexity rings strongly with me as I'm wondering about my patient with autism who I strongly suspect has CVI cerebral concerns. Any ideas that address my hunch?
Oh, as far as further evaluation? Yeah. So usually when-- usually when there's uncertainty and the student isn't diagnosed with CVI, but you're-- you know, if I'm feeling that hunch that they might have CVI, usually that means that the CVI is more subtle, that they might be in or near phase III. Not always. There's been a couple of exceptions, but usually it means that no one's caught it because the characteristics are maybe presenting themselves a little bit more subtly.
So in that case, what I try to do is think of those higher level dorsal stream and ventral stream functions, and see if I can tease those out a little bit in assessment. So one thing I might do is show what I call the 2D image assessment. I have one that I use, but you can just pull images from Google and make up your own.
And that would be like taking maybe 10 different items, and finding real photographs of those, and then finding kind of like abstract clip art versions of those that are in color, and then maybe abstract black and white line drawings of those things that have no color. And maybe show the person the abstract black and white ones first, totally out of context, and just ask, what do you see here?
And see if the child is able to say what those things are, or if they're saying something that's close but not exactly. And sometimes when they're incorrect, their approximations can tell you a lot. So I'm not an expert on autism at all-- not CVI either, for that matter. But especially-- I mean, I do have students with autism. But I would guess that if a student had autism without CVI that they would probably be able to identify-- whoops-- lost my computer there.
They would probably be able to identify most of those images that you would show them-- maybe, probably all of those images. And if you started to see a pattern of being able to interpret black and white line drawings or more abstract drawings, that could be an indication, to me at least, that we'd want to explore CVI further, that I might want to refer them to an eye doctor who is very knowledgeable about CVI to follow up.
I would also try visual complexity. My guess is that people with autism may have some issues with visual complexity, as well. I'm just saying that as an educated guess. But you know, I would try the APH complexity cards by Christine Roman-Lantzy and see how far the child can get through those.
As we know from her work, if a child can get all the way through the complexity cards but maybe they get stuck on the last one, they're probably not higher than a 7 or a 7 and 1/2 on the CVI Range. So trying that-- I often try those as sort of a baseline for students who I'm suspecting might have CVI.
Oh, that's great, Matt. And I'm sorry, I think we have to wrap it up, Matt. I thank you so much. This is really-- sharing your knowledge on this topic has really been fantastic. Thank you to all our participants for joining us today. We hope you found the webinar to be informative, and we hope that you'll join us to future webinars and love to have any of your ideas.
Our next webinar will be on Tuesday, October 30. And I'll be doing that, Ellen Mazel. We're going to be discussing expanding the understanding of the visual behaviors of CVI. And that will be at 4 o'clock to 5 o'clock on that day. So we hope to see you then, and thanks everybody. Thank you, Matt.
You're welcome. And thanks, everybody, for your time today.