www.familyconnect.org

Learning to travel independently and safely is a skill we expect all students to acquire. It is a greater challenge for a student who is blind and who lives in a remote village. For people who are blind we call learning travel skills “orientation and mobility” (O&M). Jeremiah Ticket is a talented, 10-year old blind student from Buckland, AK. Jeremiah, family and school staff has received training in O&M in the village of Buckland. Jeremiah is ready to learn different O&M skills needed to travel in the small town of Kotzebue. Northwest Artic School District brought Jeremiah, his mother, sister, and two school staff into Kotzebue to meet and work with SESA’s O&M specialist for 3 days of O&M instruction.

Photos: Jeremiah Ticket has independently completed a walk around a block in Kotzebue. This is a high point in the travel skills for anyone who is blind. For Jeremiah it was even more challenging because there are no sidewalks around the block he traveled.

Via: The Official Google Blog
Tuesday, December 26, 2006
Speech-friendly textual directions from Google Maps
By T.V. Raman, Research Scientist
12/26/2006 08:31:00 AM

by permission from T.V. Raman

From time to time, our own T.V. Raman shares his tips on how to use Google from his perspective as a technologist who cannot see — tips that sighted people, among others, may also find useful. – Ed.

Google Maps and its associated local search is a quick and easy means of locating businesses and obtaining directions. Most people who use it already seemto enjoy the graphical interface with its extremely reactive GUI. But when using spoken output, this visual richness can get in the way of quickly listening to the results of a maps query.
As an alternative, Google Maps also provides a simple to use a textual interface that serves up directions very efficiently when working with a screenreader or a Braille display. This alternative view into Google Maps is here, at the Textual Maps UI.

LINK:

http://maps.google.com/?output=html

It’s extremely useful for blind and visually impaired users, as well as an effective solution for those times when you’re at a non-graphical display and need to quickly look up a location.

Just type a simple English query of the form start address to end address and quickly get the information you’re looking for. Though we added this option to enhance the accessibility of Google Maps for blind and low-vision users, perhaps others will find this alternative view a useful addition to their maps arsenal.

LINK TO T V Raman

http://emacspeak.sourceforge.net/raman/

(Source URL and permalink below)

http://googleblog.blogspot.com/2006/12/speech-friendly-textual-directions.html

TYPING AND NOTETAKING
Hi guys, This question was on the AER list and one of the replies was so good that I thought you guys might be able to use it. I’m forwarding the question and reply below.
-Andrea

—— Forwarded Message
From: *****
Date: Wed, 13 Dec 2006 20:20:31 -0800 (PST)
Subject: [AERNet] advice for college bound student

I need some advice regarding a student I see. She technically graduated HS last year but I see her 1 period a day to work on keyboarding and a voice dictation program. From there she works at a pre school. She plans on going to a local college in the Fall, only taking 1 or 2 classes a semester, and her mom says the Dean is open to any suggestions on how to accommodate her.

She has ocular albinism, and it takes her a very long time write. In HS she had an aid as a scribe and the mom is asking me for suggestions on how she will be able to take notes in a college class. She will have a laptop but her typing skills are not that quick. Besides audio taping the class, are there suggestions anyone can share on how to accommodate a new college student with a visual impairment?

Read through this. It seems to be very good, experience-based advice for students starting in middle school to take notes.
-Andrea

—— Forwarded Message
From: “Ike Presley”
Date: Thu, 14 Dec 2006 13:16:22 -0700
To: “888″ “AER list”
Subject: Re: [AERNet] advice for college bound student

I totally agree with Alexis that the student needs to get connected with voc rehab and disability services and that she needs to improve her keyboarding skills. From your message I’m assuming she has the basics down, but just needs to work on her accuracy and speed. The Talking Typer program from APH is an excellent tool for the type of drill and practice this student needs. (However, I don’t recommend keyboard tutorials for beginning typists. They need teacher instruction and then use the computer programs for drill & practice.)

Some people find it difficult to type on a laptop as compared to a desktop computer so when she’s doing her keyboarding practice I’d suggest that she do it on the laptop. However, there is one alternative that might be feasible. She could get a full size wireless keyboard to use. This would require connecting the receiver to a USB port on the laptop and that would just be one more thing to carry and deal with. On the other hand she can place it wherever it’s comfortable for her to type, and it has the same feel as a desktop keyboard.

Some people like to try to get the professor to give the student everything they will say in an electronic format. This would be great for information that is being displayed on a chalkboard / whiteboard / overhead / PowerPoint, etc., but I don’t recommend it for general class notes. Besides, most professors will not have everything they are going to say written down anywhere. They usually just have an outline and then pull the details from memory. The other drawback to this approach is that it doesn’t allow the student the opportunity to develop their own note taking skills. The ability to take written/typed/brailled notes is essential to the completion of many educational and employment tasks. Therefore, I think it’s important for the student to have some tool for taking notes.

Here’s what I usually suggest, and this goes for high school as well as college students. Have the student use some tool to take notes: paper & pencil, slate & stylus, braille writer, accessible PDA, computer, etc., and do the best they can at keeping up with the lecture and getting as much information as possible down in their notes. Sooner or later, the presentation will be too fast for the student to keep up and they won’t be able to write all the needed information. Here’s where I like for the student to have a back-up system. I recommend that the back-up system be a recording of the lecture, but not just a straight beginning to end recording. What do I mean? Read on.
There are two types of tools that can be used to record lectures and presentations; a cassette recording, and a digital recording. (There are probably others, but these are the two most readily available.)

To accomplish a cassette recording the student will need a modified tape player/recorder similar to the Handicassette II from APH. There are other models available from other sources, but I like the APH model because it has the following features: 2 track & 4 track recording and playback Tone indexing Variable speed control Variable pitch control Rechargeable battery, AC, and standard battery power options Tactile indicator to determine tape movement (in other words, a way to know if the tape has stopped or run out) An external microphone jack

To make a digital recording of lectures the student has several options. There are digital talking book player/recorders that can be used. Standard digital voice recorders used in many business meeting can also be used if they have the ability to allow the user to insert bookmarks in to the recording and then access the bookmarks in the playback mode.
There are quite a few of these devices on the market so I won’t suggest any one model. The key factors to look for besides the bookmark feature are length of recording, ability to transfer the recording to a computer of some type of memory storage device, availability of additional memory storage options, external microphone jack, battery/power options.

There is one more piece of hardware necessary to make this system work effectively. When recording with the internal microphone of either type of device, the quality of the recording may be poor and background noises may make the presenter’s voice difficult to hear or hard to understand. Therefore, I strongly recommend that the student have a cordless microphone that the instructor can use and the appropriate connections needed to hook it up to the recording device being used. These types of microphone systems are usually available from stores like Radio Shack for under $100.

Now that we have the hardware in place, here’s how it can be used.
1. Have the student take written notes with whichever tool or system they prefer.
2. Have the student record the lecture with one of the systems described above with the recording device within easy reach, and the lecturer using the cordless microphone.
3. . When the student feels that the lecturer is going too fast or they’re missing something have the student reach over and press the tone-indexing button on the tape recorder, or the book-marking button on the digital recorder.
4. If they are writing or brailling notes on paper, suggest that they leave a few blank lines.
5. If they are taking notes with an accessible PDA or a computer, suggest that they insert a unique string of characters such as 3 asterisks (***), or something that would not normally occur in the document.
6. Suggest that they take a deep breath, relax for a second, and then begin their written notes again. They won’t need to worry about what they missed because they will be able to access it again on the recording.
7. Continue this process until the presentation is complete.
8. Once they return to their dorm, library, or study room they can combine the information from their notes and the recording.
9. To do this they will need to open the file or pages containing the notes and search for the unique characters (***), or blank lines. Read the text just before this point to get an idea of what the professor is talking about.
10. If using a digital recording advance to the first bookmark.
11. If using a cassette recording, press the Play button and hold down the Fast Forward button until you hear the first beep tone.
12. Listen to the lecture at the marked position as many times as necessary to absorb the information and then insert it into the written notes.
13. Repeat these steps until finished.

I know this may sound a little complicated, but it works. I have taught it to many students and I have used it myself. I strongly suggest that teachers start teaching students how to use this system and the associated tools in middle school so that by time it’s needed in high school, the process will be “second nature” to most students and they can concentrate on the lecture and not have to worry about the technology and the process. I also suggest that when you start teaching the process that you use recordings on topics of high interest to the student for your lecture material. They will be much more motivated to acquire the skills if they’re getting to learn about something that’s important to them; i.e. sports, fashion, music, etc.

Well, for those of you who’ve stayed with me and made it this far, thanks for reading and I hope these suggestions will be helpful. By the way, if anyone chooses to use this approach, I’d love to hear your feedback (and your students’ feedback) about how it works.

Ike

P.S. Don’t be fooled into using a peer note taker or I’ll have to write a 10,000 word reply on the evils of that approach. Ike Presley, Immediate Past Chair AER Division 5 – Information and Technology

Ike Presley
National Project Manager
Professional Development Department
American Foundation for the Blind
100 Peachtree St., Suite 620
Atlanta, GA 30303
404-525-2303
presley@afb.net

From the SESA Spring 1999 Newsletter

Building Study Skills for Students with Vision Loss

By Stanley Hirschberg, M.S., and Barbara Cronie, M.A.

Every student must accomplish five tasks to complete academic studies: reading, copying from a visual display, taking notes, writing a paper and taking tests. A student with a visual impairment must also develop adaptive methods, use adaptive devices and draw upon a support system of peers and teachers. As these activities can be time consuming, students with vision loss must be efficient.

While formal low vision assessment should be conducted to determine the best medium, or combination of reading media and adaptive devices and individual student needs, below are some general suggestions that can help visually impaired students develop their own study habits.

Reading

Text is available in three forms: print (standard and large), braille and aural (personal reader or electronic).

Print

Print readers should ask themselves the following diagnostic questions:

• What is my read/rest cycle for standard print? Is the duration affected by the use of large print and/or low vision aids?
• What kind of print (size, font and contrast) will allow me to use vision for the longest period of time?
• How many words can I see within my field of vision?
• Given this optimal print, how quickly can I read a page of text?

Answers will help estimate the time needed to complete assignments.

Braille

For some students, the development of braille skills is a priority. The ability to use Grade I and/or Grade II increases the range of resources and tools available. Grade I Braille restricts the student to using braille as a personal system since textbooks are available only in Grade II. In addition, the transfer from braille to print will be more efficient if Grade II rules for contractions are followed. Some Grade II users may not learn the correct spelling of words that always appear in contracted form in Grade II Braille. However, visually impaired students who use computer equipment with a standard keyboard need to learn standard spelling.

Aural Reading: Tape, Live Reader or Electronic Format

Aural readers should receive instruction in strategies to develop a systematic way of using tapes as study material. They must be active listeners with control over the text, using a systematic way of taking notes, as well, and mentally review the auditory material. Control over taped materials can be, for example, by tone indexing–inserting an aural marker (a beep, or series of beeps) to mark key pages or chapters. These markers allow the person to locate specific information or fast forward through non-relevant material.

The environment must also be taken into consideration. Background noise such as televisions, radios or voices can make listening to the tape energy consuming. Alternatively, if playing the tape would cause others to be disturbed, earphones may help.

Students using live readers should be comfortable asking the reader to repeat specific passages and to pause while the student summarizes or paraphrases the information read. The reader should know in advance what the student needs from the text, and give careful verbal descriptions of diagrams and charts.

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Storage and Retrieval

Copying a Visual Display: Blackboards, Over-head Projections, Films and Slides

Information from these displays can be accessed by photocopying a fellow student’s notes, asking the teacher for a copy of the visual presentation, taping a verbal description and requesting extended time to use adaptive low vision devices.

Taking Notes

Although a student may need to rely on another for copying visual displays, the older student should not depend on other people’s notes–even those supplied by the teacher, highlighting major concepts and key words–as primary source material. Support systems should not foster dependence nor restrict academic progress. “Research shows that students who record and review personal lecture notes score higher on tests than do students who only listen to the lecture or read the text” (Lazarus, 1996). Therefore, it is important that students devise their own systems for taking notes both in the classroom and at home.

Notes based on text should replicate the structure of the text; i.e., headings and subtitles should form the basis of an outline. In contrast, notes based on a lecture require the student to develop the structure and organize the information by writing key words, and using such adaptive devices as a tape recorder or a braille note-taker.

Expression

Writing a Paper: Topic Selection, Research, Outline and Draft Revisions

For a visually impaired student, writing a paper is complicated by the need to produce the final products in regular print, follow the specific formatting guidelines and adhere to page length limitations. Computers with adaptive equipment can help meet format requirements. However, students must first be evaluated to identify the appropriate equipment, and then be afforded the opportunity to acquire the skills needed to use it.

Taking Tests

In order to select the appropriate adaptive methods to take a test, answers to the following questions are required:

• What kind of test will it be?
• What kinds of answers are expected?
• Where will the test be taken?
• How much time is permitted?

Every student with impaired vision should know what test-taking adaptations are allowed by law. The guideline is: “reasonable accommodation.” It is our opinion that any adaptation must meet two standards to be considered reasonable accommodation: Does the adaptation permit the person to demonstrate level of skill rather than visual limitation? And does the adaptation preserve the integrity of the test? For example, if a math test is primarily a test of problem solving, a talking calculator is a permissible accommodation; however, if it is a test of mental computation, it is not. Adaptive methods used in the classroom include:

• variable of special lighting
• modified print size or font
• alternative method (e.g., test on tape)
• live reader
• optical devices to read standard print text
• adjusted time limits

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Conclusion

Parents and professionals must focus on helping students with impaired vision develop the skills to accomplish the tasks outlined in this article. Emphasis should be placed on managing time efficiently, technology training and establishing a support network that does not foster dependence.

Reprinted from Lighthouse International, EnVision, fall 1998, Vol.4 Nbr. 4
111 East 59th Street
New York, NY 10022-1202
212-821-9200
800-829-0500
212-821-9705 fax
www.lighthouse.org

By Sarah J. Blake

This article presents a compilation of tips for finding and working with readers when material is not available in alternative formats. Most of these suggestions reflect my own personal experience; however, a few are suggestions which have come from other individuals.

This article has been published in The Student Advocate, the quarterly newsletter of the national Alliance of Blind Students. If you would like more information about NABS, please call the national office of the American Council of the Blind, the organization with which NABS is affiliated, at 1-800-424-8666 between the hours of 2:30 and 5:30 PM EST. The author maintains the right to reuse this article in additional publications and to distribute reprints. You may make copies of this article and distribute them as long as they are not sold or altered in any form.

Recruiting

Put signs in the Disabled Student Service office. If the university has a DSS office, it can be a valuable resource, but it should not be the sole source of assistance.

• Put ads on bulletin boards in widely traveled areas around the university.
  1. Near the cafeteria
  2. Near the post office
  3. Library
  4. Dormitory lobbies
  5. Community bulletin boards
• Register with the office of student employment.
• Register with the employment commission in your community.
• Put an ad in the paper.
• Put an announcement in a church bulletin.
• Use word-of-mouth.

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Interviewing

Ask about applicants’ areas of interest and ability. Some types of reading might be best handled by someone with some knowledge in the subject area. Examples include foreign language, mathematics, science, and courses with medical terminology.

Ask about applicants’ schedules. Are they available during class hours to read tests? Are they available at other times to assist you with library research? I tend not to hire people who have busy social lives because they are less available.

Have applicants read materials similar to those they will be required to read.

1. Do they read too fast or too slow? How do they respond when you ask them to speed up or slow down?
2. How do they handle unfamiliar words?
3. Do they interrupt the reading to make comments or summarize?
4. How clearly do they describe pictures, diagrams, graphs, etc.?

Managing readers

The reader needs to know how often he/she will be paid. Some state agencies which pay for reader service require the client to send in a form before they will send the money. In this case, it is best to pay the reader out of your pocket and reimburse yourself when the check comes from the state agency. Readers came to you because they need money, and they generally cannot afford to wait several weeks to get paid. Also inform the reader of the pay rate. I keep a log of hours, and so do my readers. This way there are no discrepancies regarding the amount of money I owe a reader.

When I have material read on cassette without my supervision, I pay by the amount of cassette time, not by the amount of time the reader spends correcting errors. I once had a reader bill me for 14 hours of time when I received four hours of cassette. I could only afford to pay for 45 hours of reading per month, and I felt that she must have been extremely perfectionistic about her reading. This is a good quality in a reader, but there is a limit to the amount I am willing to pay for this kind of reading. We came to a mutual agreement that I would no longer be able to employ her, and I found another reader who was able to read fluently without making many corrections on the cassette.

Set up a schedule so that you know the reader will be available. Make sure the reader understands that he may be needed for extra time on some days and not needed at all on other days.

Even if the reader is reading on tape, have the reader read while you are present. This will allow you to monitor what is being read. If you do allow a reader to record material without supervision, monitor progress by giving reasonable deadlines and insisting that they be met. You hired them so that you would have timely access to information.

Let the reader know if he/she is reading too fast or too slow. A good reader should be sensitive to your needs.

If a reader is reading a test:

1. Make sure he/she reads all the test items and answer choices.
2. Do not accept hints from the reader.
3. The reader should transcribe your answers exactly as you dictate them.
4. Go over the answers after you finish taking the test.

If you are working on a homework assignment which involves answering review questions:

1. Write the questions down first for your own reference.
2. Ask the reader to describe the layout of the assignment to be read. It may be helpful to write down some notes so that you can direct the reader.
   1. Is there a chapter outline?
   2. Are there headings and subheadings? What pages do they begin on?
   3. Are there boxes with information in them that may be unnecessary to read?
   4. Are there charts that summarize text? If they can be described easily, these may be helpful in gaining information quickly.
3. Read the questions and direct the reader to read from sections where you think you may find the answers. Ask him/her to point out to you if certain terms or ideas are emphasized (e.g. italicized, in bold, or in a different color).

Firing Readers

Firing readers is unpleasant, but it is sometimes necessary. Do not allow other relationships to influence your working relationship. If a reader is not working out and the problem cannot be resolved, then it is necessary to fire him/her. The best way to do this is to be honest and tell the person that you feel that your working relationship is not working out and that you feel it would be best if you found another reader.

By Andrea Story, education specialist, SESA

The Child

Ramona is two and a half years old. It is not clear what she hears or sees, although neither sense serves her well, according to family and doctor observations. She has a syndrome that includes severe orthopedic limitations, a seizure disorder, and hydrocephalus. She requires special positioning, and she is fed with a G-tube. She is not motivated to move much, and her response time is very delayed. Her parents, various therapists, and other home visitors are frustrated that Ramona tends to shut down often– closing her eyes and sometimes going to sleep.

The Opportunity

What will get her attention and encourage her to try to look, reach, make sounds, and share with others in communicating? One way that was successful with Ramona was to give her access to emerging literacy activities, such as listening to a story or a song, and then participating in taking turns with the storytelling and singing. Storytelling and singing are both ancient human endeavors that happen to be the basic structure that literacy is built upon and can be found happening in homes, day care centers, and schools everywhere. However, they are often not considered useful for children like Ramona. Sometimes books are not provided to children, because it is reported they don’t use them properly, or because they won’t understand the story. Here is one example of how the tradition of reading a story or singing a song can be adjusted for a young child or student who is “differently abled.”

When Ramona was shown the children’s book “Are You My Mommy?” with it’s moving pop-up faces and simple backgrounds, her expression changed from a blank stare to an alert expression. She smiled and she worked to fixate on the images. (A surprise to everyone in the room.) On almost every page of this children’s book there is the line, “Are you my mommy?” After hearing the story, Ramona was given the chance to make this line, “Are you my mommy?” play from a tape recorder set up with a big button switch. On accident, Ramona’s hand hit the switch and the voice said, “Are you my mommy?” Later, she gently pushed down on the switch that was held near her to make the line play the next time the page was turned. During the next visit, the physical therapist was anxious to show a new book that Ramona also liked and responded to. Each of the cardboard pages slid out to show a different picture. Ramona shifted her eyes from left to right in anticipation of the next picture. Her eyes moved to the exact spot where the new picture would be opened up (her response time was in perfect synch with the turning pages!).

A short children’s song was introduced to Ramona. The song was often sung to her, until she was familiar with it. Then the switch was again used to help her participate. The home visitor sang: “All around the cobblers bench the monkey chased the weasel, the monkey thought it all in fun…” Then Ramona hit the switch and the recorded voice sang “Pop goes the weasel”–her movements becoming more and more purposeful.

The Question

Will Ramona ever read the book or sing the song by herself? Ramona’s learning is at a very slow pace. But even the slowest of learners has the capacity to keep learning no matter the pace, no matter the ultimate achievement. Learning to take “your turn” and becoming purposeful in your movements–these are important skills for any human. Limits are placed on the opportunities for children like Ramona and doors are closed. Reasons such as “the child learns too slowly,” or “the child will not handle the book properly” are given. These children need more opportunities, not less. They challenge us all to find ways to keep them learning.

Predictable Books

These books contain a lot of repetition and still maintain high interest.

Are You My Mommy?
Baby-O
Brown Bear, Brown Bear
Chicka Chicka Boom Boom
Coconut Mon
How About a Hug?
I Know an Old Lady
I Went Walking
Is Your Mama a Llama?
Polar Bear, Polar Bear
Sheep in a Jeep
Ten in the Bed
The Three Billy Goats Gruff
The Very Busy Spider
Wheels on the Bus
Wicker’s Wishes

From the Spring 2007 Newsletter–Reference Shelf

by Julie Smith, education specialist, SESA

Please note that the pictures provided are for illustrative purposes only — typically only one or two items at a time would be used for a child with CVI.

It can be difficult to create environments and find toys that facilitate visual attention for children who experience CVI. Following are some of the favorite things of Teachers of the Visually Impaired (TVIs) throughout Alaska, as well as some ideas from the CVI listserv:

The Invisiboard:

The all-black background reduces visual distractions and draws the student’s attention to single objects. Items can be attached to the Invisiboard with sticky-back Velcro. It can also be fashioned into a triangular pup-tent form that works well when children are engaging in “tummy time.” Invisiboards are available from the American Printing House for the Blind (APH). In the absence of an Invisiboard, try a tri-fold display board covered with black or dark navy material, or a dark colored shower curtain or sheet.

Shows high contrast toys in front of the black felt surface of an invisiboard.

The Light Box/Mini Light Box

The light boxes have a lighted translucent white work surface providing a high contrast background and source of illumination for colored transparent and opaque items. There are two sizes available, both have dimming control and a tilting stand. In a dim environment, the light box helps draw the child’s visual attention and a variety of materials can be presented on the surface. Some favorites are the CVI swirly mat set (available through APH), hair gel in a Ziploc bag with food coloring, wrapping the light box with plastic wrap and putting pudding or Jell-O on top, Gel Gems (plastic gel shapes that are translucent like stained glass and are reusable), and asking peers to make designs on acetate overhead sheets in the child’s favorite color(s). The light boxes and swirly mats are available from APH, Gel Gems are available at various gift, book and novelty stores (www.gelgems.com).

Shows the surface of a lightbox (translucent plastic over a light source) with gel gems on the surface.

GloE Light Changing Bear

This is one of my personal favorites. The white bear lights up with red, blue, green and purple. It changes color slowly and will continue for about 30 minutes once activated. Available at various retailers such as Wal-Mart, Target, and Toys R Us, or on-line through www.lightupbears.com.

Slinkys

Plastic Slinkys come in a variety of bright colors – yellow, orange, green, and purple. These are great for the Invisiboard because they are high contrast, stretchy, and easily graspable.

Shiny Materials

Anything shiny and reflective can give the appearance of movement (which is one way children with CVI cue into their vision). Pinwheels, crinkle paper, beads (Mardi Gras, garlands for Christmas trees), and bright pom-poms are good to try. Seasonal garland is also a great choice — you can find red hearts in February, green clovers in March, etc. One mother on the CVI Listserv posted that her son loves tummy time on a large emergency blanket; the shiny, reflective kind. The sound and reflective properties are very motivating for him.

Shows shiny items (a yellow slinky, a cluster of silver metallic beads, a round shiny metallic object, and a red metallic garland) against the black felt background of an invisiboard.

Light-Up Toys

Any type of light-up wand or flashlight that changes color slowly works well for many children. Popular places to find these items are theme parks, the state fair, and novelty/specialty stores. There is also a great light-up urchin ball: Its soft tentacles protrude from the flashing, light-up center and it comes in various colors. Seasonal lights are also worth trying; such as small Christmas tree lights, snowman lights, hearts, Easter eggs, etc. All these items show up great against the Invisiboard.

Electrical/Duct Tape

Once the child indicates a color preference, that color can be integrated into daily routines through the use of colored electrical or duct tape. Use the tape on cups, eating utensils, brushes/combs, and toothbrushes.

Creativity and not limiting yourself to traditional toys is key. It may take a number of trials to find out what works best for your student but in the end it will be well worth your effort!

IMPORTANT NOTE: Many of the items children with CVI respond to are not traditional toys. Close supervision is required for all activities especially if the child is a mouther or biter. Light-up items that strobe or change quickly should not be used with any child with a seizure disorder or history of seizures.

From the Spring 2007 Newsletter–Reference Shelf

by Mary T. Morse

Originally appeared in RE:view, Spring 1999

In the last decade, children who are cortically visually impaired (CVI) have received increased attention and concern from the medical, educational, and rehabilitative communities. The Association for Education and Rehabilitation of the Blind and Visually Impaired has increased the number of sessions on CVI at its bi-annual conferences. The Journal of Visual Impairment & Blindness and RE:view have published many articles on varying facets of this often confusing condition.

Several recent teleseminars were devoted to children with CVI. All of these efforts have increased our understanding of CVI and given many of us confidence to work with children who are cortically visually impaired. Because we should not become overly confident about our knowledge, I offer the following words of caution.

CVI is a Complex Condition

We need to be cautious not to oversimplify a complex condition. Despite its label, the term cortical visual impairment refers not to an eye condition but to a brain condition. About 80% of the brain, working as functional systems, is required to efficiently process and understand a visual message. We the workers, there, need knowledge of how the brain functions if we are to understand the implications of brain dysfunction (Dutton et al., 1996; Morse, 1990; Morse, 19992; Padula, 19996; Sacks, 1985).

Vision is also a psychological process; as a result, disruptions in visual function cannot be considered in isolation from other functions. Visual attention does not automatically mean cognitive understanding. We the workers should understand the implications of motor, cognitive, and communication problems when we plan habilitative visual services (Dutton et al., 1996; Morse, 1990; Morse, 1992; Nielson, 1991; Padula, 1996: Padula & Shapiro, 1993; Sacks, 1985; van der Kolk, 1994).

A final factor to consider is that vision is an emotional process. All people with complete or partial sight have patterns of visual use and nonuse. People tend to use the visual system more when they feel confident about what they are expected to do, when they are listening to something that interests them, or when they want to related to others. They tend not to use their vision when their senses are overwhelmed, when they are planning or thinking how to do something that is difficult (i.e., giving someone some bad news or when performing a difficult motor act); or when they are bored, tired, stressed, or feel submissive. We the workers should always consider what the child finds motivating and find ways to give the child a sense of self-efficacy in the activity (Morse, 1991).

All Children with CVI Do Not Exhibit Similar Behaviors

We should be cautious not to assume that all children with CVI exhibit the same behaviors. The diagnosis means different things for different children; the effects depend on factors such as how extensive and severe were the insults to the brain, the developmental period during which the insult occurred, the child’s previous experience, the presence or absence of additional disabilities, medications being taken, and the child’s motivation. Some individuals with CVI have no observable visual responses: others have occasional responses to stimuli, whereas still others have a significant amount of usable vision. Some children have field restricts and others do not. Even some of those who have significant peripheral field losses may be able to detect movement, perhaps through the secondary visual system. Over time and with or without intervention, many children show significant improvement in their general use of vision. That improvement may be the result of being more able neurologically to handle complex stimuli (Burke, 1991). Thus, we might see that as children understand their daily experiences more and as they anticipate routines, their functional visual behaviors also improve.

Even when visual behaviors improve to the point of appearing normal, many of the children may have significant difficulty with specific types of visual stimuli. For example, some individuals may be able to see a human face, know it as a face, but be unable to identify to whom the face belongs solely on the basis of the experience of visual information. That difficulty in visual identification may be similar to the experience of those of us who can discriminate cars from trucks but cannot identify the make or year of the car on the basis of our visual discrimination abilities. Faces are often confusing to individuals with CVI. The face changes with every expression and with every physical movement of different parts of the body. The face also presents a kaleidoscope of sensory information – visual, auditory, and olfactory. Moreover, a specific face may change depending on the hair style, on whether the individual alternates between wearing glasses or contact lenses or is using makeup or not. Identifying faces requires complex visual analysis. Other individuals with cortical visual impairment may be able to identify people and concrete objects as well as photographs of them but be unable to understand visual symbolic information in forms such as line drawings or print.

Some children with CVI may have difficulties with depth perception that go far beyond a situation such as mono-ocularity. Others may have significant difficulty in moving through even a very familiar environment. Dutton el al. (1996) described several children who can identify objects when they are moving very slowly but not when they are stationary or moving quickly. Padula and Shapiro (1993) discussed later-in-life trauma and see many patients who have associated strabismus, oculamotor dysfunction, convergence and accommodative abnormalities, diplopia, and balance and movement difficulties. Those patients described a world of distortions that did not match their previous visual memories. Those reports raise interesting questions about the individuals who attribute their CVI to congenital causes or early postnatal insult. The point here is that a major insult may have been localized to one or more specific areas but other parts of the cerebral cortex may or may not come into play and support the functions lost to the insult.

On casual observation, vision use in some children may appear normal. During the school years, however, some of these children may be described as being preoccupied, distractible, and inattentive when, in reality, some of their behaviors result from CVI. The observable school behaviors may be a result of fatigue from trying to interpret difficult visual stimuli. The visual components of a task frequently become even more difficult when combined with the demands of listening, maintaining position in space, and simultaneously performing complex motor actions (Dutton et al., 1996).
A Single Approach Does Not Work for All Children

We should be cautious not to think that a single approach works for all children. As Sacks (1985) pointed out, a diagnosis of seizures is an insufficient label for prescribing a treatment regimen, and so too is a diagnosis of CVI.

Some children increase their visual awareness by such means as the use of lighted toys in a darkened room, the light box, distinctive geometric patterns, the use of bright colors, and sound toys (Baker-Nobles & Rutherford, 1995; Jan & Groenveld, 1993). Other children, however, tend to use their vision more efficiently and more frequently when they understand and feel comfortable with the tactile-kinesthetic-motor demands of the task. Farrenkopf, McGregor, Nes, and Koenig (1997) stated, “[T]ypical visual enrichment strategies do not work with children who have CVI because the visual sense is overwhelmed by the visual information” (p. 484). For example, a common lament among educators and therapists is that many children who are diagnosed with CVI tend to turn their head away as they reach for an object. One hypothesis is that the children are using their peripheral vision when they turn their heads away. That may be true for some. I have followed a significant number of children with CVI for over a decade (many on video tape) and believe that many of the children avert their gaze until they understand what their hands are doing. For these children, intervention might be referred to as vision through the back door, through the hands. That approach considers the complexities of the task’s motor demands and the saliency of the tactual experiences so the brain becomes aware of what the hands are doing. It is the hand first; then the vision. When the hands explore real objects, they feed the abstract visual and cognitive systems (Affolter, 1991; Dutton et al., 1996: Hyvarinen, 1994; Morse, 1992; Nielson, 1995: Padula & Shapiro, 1993; Sack, 1985).

Shows a child positioned on a wedge looking at a slinky below eye level.

Many of these same children are extraordinarily attentive to environmental sounds. We need to be cautious that we do not assume that an interest in sounds automatically means an understanding of those sounds. Many, but not all, children with cortical visual impairment display varying degrees of difficulty with language. Indeed, processing auditory information may actually interfere not only with the use of vision but also with motor exploration. Much energy may go into trying to interpret the meaning of the sounds or the sounds themselves may provide a recreational diversion. According to studies by Farrenkopf et al. (1997) and Lane (1996), verbal prompts are not as effective as physical prompts. These children come to understand their visual world better when the language used around them does not interfere with attending to what the hands are doing. Interestingly, language is promoted more effectively when the words used conform to what the hands are experiencing (Affolter, 1991; Hodgdon, 1997; Koenig & Farrenkopf, 1997; Lane, 1996; Morse, 1992).
Treatment Is A Dynamic Process

We should be cautious not to view treatment as a linear and isolated training process. We need to recognize that simplification of the visual environment is not enough. Infants with no disabilities come to recognize those objects and people that have the most meaning to them (parents, bottle, favorite toy) through physical interaction in their everyday activities. For many children with CVI, reaching out and actively participating is a frightening experience. To them, the world may seem chaotic and unfriendly. Our interventions should examine the environments in which these children function, the activities in which they engage, the sensory-motor demands of tasks, time pressures, and interfering variables. We need to relate those factors to the individual child’s ability to modulate his or her states of arousal, ability to determine which aspects of the task are the important ones to attend to, and memory. For many of the children we need to reduce the number of words we use while they are involved in highly demanding tasks. We should be more consistent in what we call objects and people. We also need to learn when not to talk. (Hynd & Willis, 1988; Morse, 1990; van der Kolk, 1994).

We need to be cautious about allowing our own egos and desire for student progress to interfere with our objective professional evaluation of the child’s progress. Many of these students also have severe multiple disabilities that may prevent them from making obvious quantitative changes. Rather, many make qualitative changes. One of the most objective ways to measure change is to video tape a child 3 or 4 times during a school year. Determine ahead of time which behaviors are to be taped during which activities and develop an accompanying data sheet. Subsequently, have staff independently watch the tape and fill in their own data sheet from their professional perspective. The findings then constitute one measure of change. Subsequently, the composite data and the video tape may become part of the child’s permanent record.

Those of us who work on behalf of children who have visual handicaps need to applaud our efforts to secure quality information to use on behalf of children with CVI. However, we should be forever diligent what we do not fool ourselves into thinking that there is a step-by-step single or simple method of enticing these children into their visual world and of assisting them in comprehending what they see.

References

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RE:VIEW, Cortical Visual Impairment: Some Words of Caution, Morse, Mary T., vol. 31, #1, pp. 21-26, Spring 1999. Reprinted with permission from the Helen Dwight Reid Educational Foundation. Published by Heldref Publications, 1319 18th Street, NW, Washington, DC 20036-1802. http://www.heldref.org Copyright © 1999