Methods to enhance the learning of CVI (cerebral/cortical visual impairment) children with multiple disabilities

The following is a translation from the Chinese article: https://lowvisionandcvi.blogspot.com/2019/07/cvi.html
Keywords: teaching strategies, CVI children/students with multiple disabilities

(Note: CVI (cerebral visual impairment, also known as cortical visual impairment or neurological visual impairment) children with other disabilities or multi-handicaps are children whose visual impairment is caused by brain damage and also accompanied by other impairments/disabilities/disorders, such as intellectual disability and physical disabilities, etc.

This article has been written for teachers, but it is also appropriate and useful for parents and other relevant training providers such as therapists and caregivers as a reference and to increase their awareness to the needs of such children/students.)

How to help/improve the learning of CVI (cerebral/cortical visual impairment) children who also have other disabilities or multiple disabilities?

The number of CVI (cerebral/cortical visual impairment) children who also have other disabilities or multiple disabilities has been increasing. As they also have other disabilities, their conditions varied considerably. Moreover, these children cannot fully express themselves. For those who take care of them (besides teachers, there are also therapists, rehabilitation services staff, dormitory staff, etc.; they are collectively referred to as trainers in this article), they should try to have an in-depth understanding of all aspects of the individual child's abilities as soon as possible, in order to provide them with more appropriate services and subsequently to help enhancing the child’s abilities, such as:

-           Medical reports and records;

-           Physical conditions;

-           The best time of mental state and performance during the day;

-           Physical limitations;

-           Language comprehension and expression abilities;

-           Characteristics of social and emotional behavior;

-           Personal likes and dislikes;

-           Mastery of concepts, etc.

In order to foster trainers’ understanding of these children's various abilities, it is especially important for trainers to have more regular exchanges (communications) among themselves.

On the other hand, many people have mistakenly believed that the training of CVI children with other disabilities is only the responsibility of specialist staff who provides vision training (low vision training) and not related to other learning or training. However, if children can make use of their residual vision as much as possible in daily life and during other learning processes, they will be able to improve their learning abilities in other aspects, because the concepts from vision will help them develop more holistic concepts of the things they are exposed to. Therefore, trainers for CVI children should pay attention to the following:

1.   To understand these children

1.1   Trainers should conduct tests or trials in a variety of ways to understand these children's visual functions and to pay attention to non-verbal responses:

Most visually impaired children with intellectual disability cannot tell what they have seen or what are their visual problems. Therefore, it is necessary for trainers to conduct repeated tests and tests in various aspects in order to understand more comprehensively the visual characteristics, problems, and abilities of these children.

For children with severe intellectual disability, the trainer can carefully observe children’s non-verbal responses, e.g. when the trainer presents the visual stimulus, the child becomes nervous, or reaching out, or turning his face to the other side, or breathing unusually, or raising his head, or clenching his fist, or lifting his arms, or sitting straight, or kicking his feet, or smile, etc. These behaviors may indicate that the child could see the visual stimulus.

But we must bear in mind that the images that they can see are different from what we can see. The images that they see may be blurred or partial, or they could see some images but they don't know what the image are.

In any case, the most important task is to stimulate the CVI child's response, so that he can first detect the existence of objects and subsequently enhance their visual discrimination ability.

1.2   Vision test reports sometimes fail to reflect accurately CVI children's visual abilities. This is especially true for CVI children with other disabilities. So parents and trainers should not easily give up their expectations.

1.3   Observe the child's daily performance more often in order to understand the child's visual ability and visual performance. For example, when someone passes by him, is he aware of the person or follow the person’s movement with his eyes. When facing light emitting or reflective objects, will the child blink or avoid, or stare at the objects?

2.   Selection and usage of teaching aids

2.1   Training aids should have novelty:

Although CVI children whose abilities are weak need familiar environments and teaching aids, and also need repeated practices, some children are curious about novelty objects. They may feel bored with repeated practices or familiar training equipment. Therefore, the trainer must understand the characteristics of each child so as to select and use appropriate teaching aids.

2.2   Encourage CVI children with funny sounds or rhythmic music, such as toys that make funny sounds.

2.3   For children with poorer abilities, try and use more of the real objects or toys that they often come across in their daily life as teaching aids, such as bowls, spoons, cups, towels, drums, balls, etc. The toys are especially different from person to person, but must select those with sharp colors and simple designs (not too "fancy", without complex pattern). If the design of the object is not suitable, trainers could try to make simple modifications, such as silver reflective paper put on the drum or wrapped in a fluorescent color cloth.

2.4   Pay special attention to the use of strong glare or flashlights:

A considerable number of children with intellectual disability, especially those with severe intellectual disability, suffer from epilepsy   (commonly known as fits or seizures). For such children, trainers should avoid using objects with flashlights to avoid triggering epileptic seizures.

In addition, long-term use of excessively strong lights can also damage the photoreceptor cells in the child's retina, so the luminance of the illuminating objects should be moderate, and should avoid direct exposure to the eyes. (illuminate the table surface, walls, or from the side of the child's face or from the side of his head instead of illuminating his eyes).

2.5   For some CVI children with intellectual disabilities, when they are watching a strong light source, they will not blink their eyes to show discomfort or turn away to avoid glare. They even look at the glare for a longer time than ordinary people, as if they "turn a blind eye" or "do not know how to react". Even worse, they may be mistaken for having an interest in looking at light sources.   (In fact, it may be because the child's response to the light source is very delayed, or the number of times that the child blinks is less than people with normal vision).

Therefore, parents and trainers should pay more attention to avoid children's prolonged light gazing to avoid damages to vision, and when they present visual stimuli, there should be short breaks, so that the children's eyes and brain can take a rest.

3.   Instructions

For children with very weak language comprehension, instructions should be concise, the sentence structure should not be too complicated, and should be used concisely and repetitively, so that the children need not spend too effort or time to understand, for example: "hit" (hit the drum), "hold" (to hold a toy). The sentence could be extended after the child has mastered the instruction.

4.   Consider the child's physical conditions and mental state

Children are easily affected by medications. For those CVI children who need to take anti-epileptic medications, they should be trained during times when they are in a better mental and physical state.

5.   Duration of training

Training should be carried out in short sessions with breaks in between:

Some children with severe intellectual disability have weaker physical strength and shorter concentration. Training duration may be as short as 15 minutes per session, or a break after five to ten minutes of training.

6.   Difficult to use vision and hearing at the same time

Most CVI children with intellectual disabilities use their hearing first, then use touch, and finally use vision. It is difficult for CVI children with physical disabilities to manage training activities that require "listening", "looking" and "doing" at the same time.

Whether "listening before looking" or "looking before listening" depends on what the child listens to and what he looks at. It also depends on the stage of training, the stage of the child's ability, even the learning state of the child on that particular day.

For example, if a child fails to understand the trainer's request, he should "look before listening to the instruction". If the child can understand the trainer's request, he can "listen to the instruction before looking".

If the child has not yet established the habit of looking, and if the trainer wants to get the child's attention, he can shake a musical instrument or press a toy that will create a sound so as to attract the child's attention before the child looks at the musical instrument or toy.

However, if the visual stimuli already have strong visual effects, or if we want to test the child's visual abilities, it is appropriate to "look before listening". The rationale also applies to "look before touching".

In addition, if the child is not in a good state, the trainer may also need to draw the child’s attention to the object by auditory input before presenting the object.

In short, whether to listen first or to look first is not a fixed rule.

7.   Cater for individual needs and abilities of the CVI child

CVI children with intellectual disability could also develop some higher-level concepts. This depends on his intellectual development, the training he receives, his motivation to learn, and his personality, etc.

They can develop picture/object identification, literacy, color/form discrimination, etc. For intellectually disabled CVI children with better fine motor, they may also develop writing skills and apply various visual functions to motor and life skills.

So don't give up the multi-disabled CVI children’s learning opportunities and opportunities for training.

The design of the training should also suit individual needs and abilities, and the difficulty of the training program could be raised step by step.

8.   Foster a favorable learning environment

8.1 Simplistic auditory and visual environment/background could help CVI children with intellectual disability to learn, to make them more attentive. Therefore it is not appropriate for many people to speak to the CVI child at the same time.

8.2   Not all children need to be trained under a simple figure-ground; training need not always be conducted under a simple background. As children's abilities improve, trainers can adjust the training appropriately and increase the complexity of the environment/background.

8.3   A distinct color contrast can highlight the subject/target, helping the CVI children’s “figure-ground discrimination”, such as placing a yellow/orange cup on a black plate/tray.

8.4   Place the child in a sitting position /posture that makes it easier for him to respond. For example, if the wheelchair is tilted slightly backwards, the child can easily lift his head or sit straight. For some children who are unable to lift up their heads in order to see, they need somebody to hold and support their heads. Some children are more nervous when they are in a wheelchair. If they are placed on a soft foam mattress, they will respond better when they feel relaxed. These behaviors vary from child to child.

8.5   When presenting the object, the trainer should pay special attention to whether the object is placed within the visual field of that is most suitable for the child.

People usually place objects on the table, but if the wheelchair in which the child is sitting leans backwards and the child could not lower his head, or the child is used to tilting his head backwards, the objects placed on the table cannot be seen at all.

On the other hand, many people are also accustomed to presenting objects at the child's eye level, but if the CVI child is used to drooping their heads or eyelids, they will not be able to see the objects in front of them. Therefore, the positioning of the objects to be displayed should cater individual’s needs.

9.   Eye-hand coordination

Many multi-disabled CVI children have motor limitations, e.g. they could not bow their heads spontaneously, they could not lift their arms up. So it is difficult for them to see the object touched by their hands and so they fail to achieve eye-hand coordination. This particularly affects concept formation. However, we should try to find methods to enable them to see the objects touched by their hands, and also to touch the objects that are seen by their eyes, in order to help them establish a more comprehensive concept of the objects.

For example, we can use some objects with larger areas or larger sizes, so that although the CVI child can only see the upper part of the object, he could at least touch the lower part of the object. Of course, it would be more desirable if the trainer can help the child bow his head or lift his arm to touch what he sees.

In short, when an object is presented to the CVI child, in addition to taking into account the child's best visual field and optimal visual distance, the object should be placed in a position accessible to the child's hand, so as to enhance the child's eye-hand coordination as much as possible.

The optic fibre light is too high, it should be presented
in an accessible position so that the child could touch it,
otherwise, he would soon lose interest.

However, some children with excessive muscle tension may become more nervous if other people touch them or lift their heads or arms. In this case, the trainer should first let the children look at the object and then slowly lift up their heads to look or lift up their hands to touch the object. On the other hand, the trainer should also cooperate with the child’s physical therapist and occupational therapist to strengthen the child's motor ability, thereby reducing the overreaction in CVI children with hypertension in muscles.

In addition, some CVI children who have muscle hypertension seem to overreact, i.e. when they want to lift their arms to touch objects, their heads or eyes may move to the other side. In behaving so, besides a misunderstanding that they can't see, resist, or dislike the object, they also have difficulty in eye-hand coordination. In this case, the trainer or caregiver also needs to strengthen the child’s motor training and practice eye-hand coordination with the child in order to reduce the child's excessive reaction to objects.

10.   Establishing self-confidence and sense of achievement in multi-disabled children with CVI

Although children with multiple disabilities and cerebral visual impairment have a lower level of intellectual function, they also need self-confidence and sense of achievement. Therefore, training must be in line with the child's ability, and there must be a logical causal relationship that enables children to build their self-confidence from successful experiences, which in turn could help keeping their motivation and interest in learning.

Therefore, trainers should particularly avoid over-practicing the same procedures so that children would not misinterpret that they have made mistakes or feel boredom.

11.   Develop a close relationship with multi-disabled CVI children

It is important for trainers to establish close relationships with these children in order to help them master the requirements of the trainers and cooperate with their trainers.

Familiar voices from people are especially helpful for CVI children with multiple disorders so as to develop a sense of security and intimacy to relax and accept changes. In general, trainers and these children take a long time to establish relationships because children's memory is weak and it is difficult for them to distinguish between different people.

12.   Improve CVI children's visual ability

There are three approaches to improve their visual performance:

12.1   Gradually extending the visual distance between the visual stimulus and the eyes of the CVI child. In order to enhance the ability of the child, such as gradually extending the viewing distance from four inches to a foot and also gradually reducing the size of the object, e.g. discriminating a large ball initially, then a small bead.

12.2   Gradually widen the visual field that the CVI child uses, such as initially presenting an object in his best visual field, and then if the child is already familiar with the item, the next time the item is presented on the edge of his visual field.

12.3   Gradually improve CVI children’s ability to deal with complex environments/teaching materials/activities. For example, initially, the child learns to recognize individual pictures. After he has mastered individual pictures, he would learn how to discriminate or identify two pictures, then three or four pictures.

Conclusion

The learning progress in CVI children with multiple disabilities is slower than that of CVI children with normal intellectual function, but almost all of them would progress after appropriate training is provided.

Vision is the main medium of learning. If the trainer can understand the children's ability in all aspects and teach in accordance with their abilities, and appropriate co-ordination is achieved among the environment, teaching materials, activities and procedures provided to the children, they would improve their learning, self-care, communication, emotions, and social ability. Even motor ability will definitely improve and the overall quality of life of these children would also be enhanced.

- The end -

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.