Low vision training ( visual training ) strategies for cerebral visual impairment (CVI) children with multiple disabilities

This is an English translation from the Chinese article: 
https://lowvisionandcvi.blogspot.com/2019/07/cvi_15.html

Keywords: multiple disabilities, children, cerebral visual impairment (CVI), low vision training, training methods to enhance visual functioning and performance, training at home, guidelines for teachers, trainers, parents.

(Note: As vision is not only used at school and children use their functional vision more often in daily life, the methods explained in this article are also applicable in the home setting.)

The visual problems of cerebral visual impairment in children with multiple disabilities are not easy to be identified and thus often neglected

The child seems not interested in the tambourine.

If a child with multiple disabilities (abbreviated as ‘he’) also have intellectual disability or physical and motor disabilities, his visual problems are often easily overlooked by the caregiver. For example, if a teacher / trainer / parent (hereinafter collectively referred to as a ‘caregiver’) handed a toy to a child and he does not respond, the caregiver may think that the child is not interested in the toy, or that it is just because he does not know how to respond.

People may misunderstand when a CVI child 
could not locate the position of an object accurately.

If the child reaches his hand out for an object but the position is not accurate, the caregiver may think that it is only because the child is restricted by his fine motor ability. It is very difficult to imagine that the underlying cause is due to problems in spatial relationship perception of the child, or because the child’s vision is relatively weak and can’t see clearly, or because the child's binocular vision is impaired (such as due to strabismus, monocular vision, or great difference between his two eyes' visual acuity). If the visual problem of the child is not obvious and the appearance of his eyes is not significantly different from normal peers, but his intellectual ability, motor ability or communication ability is weak, even his parents may not realize that he has visual problems.

The importance of low vision training

Most people have the misconception that children with multiple disabilities are weak in their learning ability and their progress is slow. However, if they can fully understand various aspects (not just visual aspect) of the individual CVI child and teach him according to his ability, accompanied by systematic and step-by-step training, these children could achieve unexpected progress in visual ability and concept formation.

For example, there was a child who appeared to be ‘blind’ initially and have developed picture and object discrimination in a few years’ time. Another child with only light perception could see objects which are brightly colored in a single color after training.

As vision and concept development complement each other, the visual training received by multiple disabled CVI children could certainly help to improve their overall quality of life. Therefore, caregivers should recognize the significance of the child’s visual problems.

The low vision training (visual training) provided for CVI children with multiple disabilities depends a lot on the stage of concept development of the child. Some children still need training for their visual awareness, while others may have developed the ability to discriminate objects, to choose familiar or favorite objects, or even to identify pictures and words.

Therefore, the trainer should assess individual child's various visual functioning abilities during training, and then, base on the child's developmental  stage, strive to continuously improve the concept development of the child in order to build a good foundation for other learning or training. The most important task for the trainer is to fully understand various aspects of the visual functioning of the CVI child.

Assessment

We need a long period of time to observe and assess students' various visual abilities, such as visual acuity, the best visual field, the best viewing distance and viewing position, binocular vision, eye-hand coordination, muscle control of both eyes, the most suitable light setting, and the most suitable color, etc.

However, because assessments take time and children often lack patience, in order to understand the abilities of new students as quickly as possible, a simple and quick assessment can be designed, for example, to assess individual student's initial responses in the following four aspects:

1. Reaction to light;

2. Reaction to silvery reflective objects;

3. Reaction to yellow objects;

4. Student's reaction when an object is close to the student's eyes.

The author once assessed the performances of twenty students with cerebral visual impairment and found that the order of responses is  (1), (2), (3), (4), i.e. most students responded to item 1 and the least number of students responded to item 4.

As some students with cerebral visual impairment are afraid or do not like to look at light sources, the use of yellow objects will help to test their vision.

Of course, the above tests are carried out on a black background to reduce other visual distractions.

In addition, the design of the baseline assessment should use a uniform set of testing kit when testing each CVI child so that the performances of different children could be compared.

Aims of the baseline assessment:

- How individual CVI child respond to different visual objects;

- Children's requirements for the visual environment (background control, colors of the objects);

- The visual perception concepts that the child have.

The following are some test items selected for children with intellectual disabilities (sequence according to the degree of difficulty):

Search and track a red toy car on the floor.

Search for a red spoon on the table and pick it up.

Search for a black bead on the white table.
(Be cautious that the child would not put it into his mouth.)

Search for a peanut on the white table.

Search for the white bead on the white table.
(Be cautious that the child would not put it into his mouth.)

Search for the white towel on the white table.

Discriminate two shapes in the same color.
 (Give the one named by the evaluator.)

Match similar pictures,
with objects common in the child's daily life.

However, if the student does not respond, the trainer should carefully analyze the possible reasons and try to verify them. What could the reason be? Since these CVI students have other disabilities, his failure to respond may not be due to vision constraints. The child might have been affected by the following factors:

-         Physiological and mental state (feeling tired, hungry, dozing, after seizures);

-         Emotional state;

-         Sound interference (noisy environment, more than one person talking at the same time);

-         Tactile interference. For example, the trainer touches the child's wheelchair and he is over-reactive to this; the wind from fan(s)/air conditioner(s);

-         Motor constraints - the child can't raise his hand, the object is too far away and unreachable, one hand can't move over the mid-line of his body to the other side, the child can't lift his head spontaneously to look, the child can't use his fingers for touching or grasping the object, etc.) ;

The child could lift up her hand
and touch the yellow tactile ball.

The child did not touch the bell, 
maybe it's because the bell is too small 
and she is not aware of it, 
or because she is tired of too much testing. 
(There could be many reasons behind the child's lack of response.)

- Can't understand the instructions, don't know what is the response expected by the trainer;
- Too much testing, fed up;

- The object/activity is not attractive, have no interest in the object/activity;

- The child wants to leave (Near the end of the lesson/school day);

- Unfamiliar with the trainer;

- The object is too small to be noticed.

If the student is not affected by the above factors, the trainer needs to explore whether it is due to the following visual reasons:

- Can't see clearly (objects are too small, too far away, colors of the objects are not suitable);

- Objects are outside the best / preferred visual field;

- Difficulties in muscle control and coordination of both eyes.

In other words, the trainer needs to interpret the possible factors behind the various responses of the students. It requires careful assumptions, inferences, and repeated testing on different days to prevent the lack of response as the child may feel fed up.

Curriculum design

The content of visual training is based on the low vision training program designed for students with intellectual disabilities. It is roughly divided into two areas: visual functions training and perceptual functions training. However, trainers must adapt training aids, procedures and methods for CVI students.

What can intellectually disabled students learn? According to the degree of students' intellectual ability, after long-term training, they could achieve the following (the list is only a suggestion and not inclusive): 

Severe intellectual disability

- Visual awareness (aware of people, objects, and the environment)

Aware of lights

- Gaze:

Gaze at the red light
from a penlight with a red cap.

- Extend the time of visual attention, extend the visual distance of the target, and expand the visual field that he is able to use;

- Search (find a target within an area);

Searching magnets on a whiteboard.

- Visual tracking of moving objects;

- Peripheral vision training (mainly for walking and movement, such as not bumping into anything during walking);

- Discriminate familiar objects, such as finding a specific one between two or among three or more  objects;

- Identify familiar objects, such as naming them or use them in appropriate ways;

- The CVI child chooses the object that he likes, expresses his likes and dislikes;

- Eye-hand coordination (touch the object that he is looking at):

- Enhance contrast sensitivity and the ability to handle complex environments:

Moderate intellectual disability

-               Real objects, models, pictures with concepts;

-               Matching/sorting, e.g. real objects and pictures, photos, line drawings, colors, simple shapes;
-               Discrimination (select or point at) / identification (naming), e.g. objects, models of objects, line drawings, photos, colors, simple shapes:

Discrimination, 
point at the right picture.

Puzzle matching.

Photos of similar objects,
discriminate by forms.

Objects of same color,
discriminate by forms.

Daily utensils,
discriminate by forms.

Mild intellectual disability

- Identify abstract line images, shop logos, common signs, and matching of pictures (according to the functions of objects)

- Word recognition, writing

How to choose training aids

Selection of the appropriate training aids is mainly based on the students' visual ability and intellectual functioning level, besides, the training aids should also match with the fine motor (hand motor) and interest of the individual student. 

For example, students with better hand control can use rattles etc. if they can hold objects. If the child cannot hold an object, we can use drums for the child to beat with his palm.

      

In addition, most students like toys that can create sounds or music. Using these toys will increase students' interest. Other students may like special sensations, such as a small fan with color lights rotating, and the fan blowing on the face will be attractive.

When presenting visual training aids to students, remember that students are not passively receiving the visual stimuli. Trainers should provide visual stimuli again according to the responses of the students. This is the interaction between the trainer and the student, as well as the interaction between the student and the visual stimulus. Whether the student is interested in the object or not, or even the object that he resists can also be used for training.

For intellectual disabled children with better intellectual development, visual training could help them develop higher level concepts such as discrimination, identification, classification, matching, naming, etc. Visual training should be integrated with other concepts.

A child is discriminating objects in a low color contrast setting - yellow M&M on a yellow plate:

One plate has an M&M, the other has none,

so the child is to discriminate which plate has an M&M
(which is something that the child likes).

Types of training aids

1. Illuminated objects:

 Appropriate illuminated aids should be selected according to the child's degree of light perception. 

For example, if lighting is used, the light emitted should be soft and a cover to avoid glare:

2. Reflective objects:

3. Objects with a pattern of black and white strips, or black objects in a white background:

To search for a black magnet on a whiteboard

4. Bright colors such as fluorescent colors, yellow, red, orange, and pink:

5. With the functions of sound creation or music playback:

6. With a special texture or in strange shapes/forms:

Some of the teaching aids suitable for CVI children are specially designed. For example, bubble columns, fiber optics, and luminescent balls that are common in multi-sensory training rooms and require special ordering.

However, in fact, many daily necessities could also be used for vision training, language development, concept formation, motor training, and self-care training, as long as their colors are bright, the outlines/forms are clear and simple, and that they are presented in a daily life setting.

When parents go for shopping and buying daily necessities, parents can find objects appropriate for visual training if they try to take notice of them, such as sequined clothing, T-shirt with black and white strips / in bright colors, mirrors, brightly colored cups. Furthermore, some training aids are used after modifications. For example, a tambourine covered in silver paper, a bell fixed to a fishing line, etc.

Here are some examples:
1. A doll with big eyes in clear outlines, simple design, no patterns, and in orange and yellow color:

2. Colored windmills that can be blown or move by hands, since moving objects can attract the attention of CVI children:

3. A candy can that could be used to put coins inside. One of Dr. Lea Hyvarinen's CVI assessment tools is a box with such a design so as to test whether a CVI child can put a coin into the jar according to the direction of the hole. For this can, the top of the can is in yellow, which sharply contrast with the black hole, so it is suitable for CVI children. When the child puts a coin into the can, the sound created can attract the child to continue the exercise:

4. Two umbrellas of contrasting colors can test children's ability to discriminate colors:

5. When shopping for clothes, parents can choose clothes with the cartoon characters that their CVI child likes. However, because the child is difficult to see their own clothes clearly, these clothes can also be worn by their siblings so that the CVI child can be more aware of his siblings.

If the skirt, trousers, or socks have strips patterns (a strip pattern is more attractive to CVI children), the child can also look at his/her skirt, trousers, or socks when he/she is sitting:  

     Children with higher abilities can discriminate different colors and choose their preferred colors or designs:

6. Toys with big eyes, clear outlines lines, and fluorescent colors are more easily detectable by CVI children:

7. After simple modification, e.g. self-adhesive color paper purchased in stationery stores could be pasted onto the object:

tambourine

stick

8. Decorations: reflective, different textures, with odd sounds...

9. Stick black lines on the whiteboard to form a line of squares for writing or prewriting skills, such as placing magnets in each square, drawing lines in each square (Chinese characters are written in squares for young children.)...

       

However, the aids selected should be compatible with the training environment. Because although many CVI children with multiple disabilities may suffer from severe intellectual disability, and that they seem to have no sensations about the outside world, they are in fact also very susceptible to environmental influences, such as sounds, light sources, tactile sensation (such as wind), and even smell could disturb them. If a room were specially designed for their visual training, training would be more effective.

The sequence of training aids

Usually, the aids depend on the student's visual ability. For example, if the student's light perception is weak, aids with stronger light or reflective aids could be used. If students vision are better, illuminating or reflective aids are not necessary. Instead, single-color aids such as in red, yellow, and fluorescent colors could be used, and then utensils with multi-colors. For the sequence of training aids, please refer to the "Sequence of teaching aids used according to the visual ability of the CVI child" at the end of this article.

Initially, teaching aids can be selected from objects that children can come across and use in daily life, so that children can increase their opportunities to practise, such as discriminating cups, bowls, spoons, chopsticks, etc. in the same color by their appearance/forms. 

The trainer should also try out bigger aids initially and then gradually switch to the same kind of objects that is in smaller sizes, e.g. in the following sequence:

- Silver reflective paper (A3 size),

- Silver reflective paper (A4 size),

- Drum (5cm diameter) pasted with silver reflective paper,

- Silver stick (3 cm diameter),

- Silver rope (5mm)

Of course, the choice of training aid should be building-up approach and children's reactions are tested repeatedly.

Ideal time for training

CVI children with multiple disabilities, especially those with poorer physical motor abilities, are usually more likely to feel tired. For example, they need a longer rest or a short break after a gross motor activity, so it is not appropriate to conduct visual training immediately after the gross motor activity. Secondly, children with poorer physical state may not be very attentive after a nap, so again, it is not appropriate to conduct visual training immediately after the nap.

Learning to respond to eye examinations

Many CVI children who have multiple disabilities cannot understand the procedures of eye examinations or visual assessments during ophthalmological check-ups, or they may not cooperate and fail to respond to the requirements of optometrists or ophthalmologists.

Therefore, low vision training plays an important role in teaching students in advance to respond appropriately, so that children can understand and cooperate with the examination or assessment procedures so that their real visual ability can be accurately assessed and also that parents and teachers, therapists and other caregivers can know their abilities in order to provide more suitable help or training.

Conclusion

Cerebral Visual Impairment children with multiple disabilities have other disabilities, and these disabilities affect each other. Moreover, these children often do not know how to express themselves. Therefore, trainers should carefully observe, analyze and infer, test repeatedly, and verify from different sources in order to build up a comprehensive understanding of the students' visual conditions and problems, so as to meet the individual needs of each child, to create a suitable learning environment, select appropriate training equipment, provide systematic and step-by-step training.

To improve children's visual functioning, it is not possible to rely on individual training within a short period of time. Teachers and parents should communicate more, exchange experiences and compliment with other therapists and professionals (such as optometrists).

In addition, due to the limited training time and limited practice during one-on-one individual training sessions, other caregivers who also take care of the child also need trainers (who provide low vision training to the child) to share their experiences in order to understand the visual functions of the child, so as to enhance the child’s opportunities to apply their residual vision in learning, dormitory life and at home. In such case, the child can make better progress and training can be effective.

Remarks:

Sequence of teaching aids used according to the visual ability of the CVI child:

Illuminated object (with a black background and turn off the room light);

Illuminated object (with a black background, the room light is on);

Torch with red light;

Penlight with red light;

Small fan with color lights;

Portable fiber optic lights;

Reflective object: Mirror (with a black background);

Gold / silver reflective object (with a black background);

Reflective objects in other colors (with a black background);

Orange/yellow/red (with a black background);

Object with black and white strips pattern (with black/white background);

Red/orange/yellow/black objects (with a white background);

Red/orange/yellow (with other color backgrounds);

White object (with a black background);

Black object (with a white background);

Objects in red and white strips pattern (such as clothing);

Objects in strips of other colors (such as blue and white strips);

Objects in other colors (with a black background);

Objects in other colors (with a white background);

Present fluorescent colored objects in a complex background;

Present black and white objects in a complex background;

Present red / orange / yellow objects in a complex background…

P.B.

This article has been uploaded to this blog under the original author’s consent. May I take this opportunity to thank the parents for their consent to upload their children's photos to this blog.