Assessment and Instruction in the Schools for
Children with Cerebral Visual Impairment
Amanda Hall Lueck, Ph.D. San Francisco State University
AER International 2014
San Francisco State University
AER International 2014
Goal: To Look at Big Picture
 Brief background information about CVI
 Discuss a model for assessment
 How this model for assessment can guide the development of
interventions
 Present a model for intervention
 Who are the Children with CVI?
 Profound visual impairment (the vision of some of these children
can improve over time)
 Functionally useful vision and cognitive challenges
 Functionally useful vision who work at or near expected academic
level for age (many of these children have normal/near normal
visual acuity and minimal loss of visual field)
 Cerebral Visual Impairment
Another Way of Seeing
Can include impairment in
processing and analyzing information.
 Visual perceptual impairments can exist with the typical
ophthalmological dysfunctions related to acuity, field, and
oculomotor issues, or
 They can be the main clinical expression of CVI in children with
normal or near normal visual acuity.
 Fazzi E, Bova S, Giovenzan A, Signorini S, Uggetti C, Bianchi P.
Cognitive visual dysfunctions in preterm children with periventricular
leukomalacia. Dev Med Child Neurol. 2009; 51: 974-81
 Good WV, Jan JE, Burden SK. Skoczenski A Candy R. Recent advances
in cortical visual impairment. Dev Med Child Neurol 2001; 43: 56-60.
 Goal
 Propose a system to conceptualize and implement multidisciplinary
assessments and interventions for children with CVI
 Information will be found in Lueck, A.H., & Dutton, G.N. (Eds.) (in
press). Vision and the Brain: Understanding Cerebral Visual
Impairment in Children. New York: AFB Press.
Model for Understanding
Dorsal Stream
Ventral Stream
This is very simplified but can be very helpful in understanding functional
consequences of CVI
Dorsal Stream Disorders
Dorsal Stream processes the whole visual scene and works with the frontal
lobes to give attention to areas of interest and plan motor action
Ventral Stream Disorders
Dorsal Stream:
Immediate, unconscious automatic system used to appraise and move
through the visual world
 more common in children than ventral stream issues
 functions are unconscious
 more amenable to change via intervention than ventral stream
dysfunctions
 ranges in character and severity.
 range of visual acuity and visual field
 varying degrees of CP
 common in children with periventricular white matter damage
(PWMI), preterm births, Williams syndrome
 Dutton, G.D. (2009). Dorsal stream dysfunction and dorsal stream
dysfunction plus: A potential classification for perceptual visual
impairment in the context of cerebral visual impairment.
Developmental Medicine & Child Neurology ,51(3) p170-172
Ventral Stream:
Conscious recognition and orientation system which we are aware of and
which processes more slowly
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damaged less frequently than the dorsal stream in children
usually associated with some dorsal stream dysfunction
difficulty with recognition (due to visual memory issues
Faces
Facial expressions
Shapes and objects and their alignment
Navigating inside and outside (don’t know what you are looking at to
orient)
 Visual memory tasks e.g, copying; learning new information
 varies in degree and severity
Dutton, G.D. (2009). Dorsal stream dysfunction and dorsal stream
dysfunction plus: A potential classification for perceptual visual
impairment in the context of cerebral visual impairment. Developmental
Medicine & Child Neurology ,51(3) p170-172.
 System to work with these children birth to 21 that takes into
account comprehensive assessment and intervention needs
 The system is multidisciplinary with TVI and O&M specialist playing
their part along with other professionals
 Importance of Collaboration
 CVI is multidimensional
 Develop collaborative diagnostic guidelines for assessment and
instruction of children who have CVI
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Collaborative Assessment of
Children with CVI
ophthalmologists
optometrists
pediatric neurologists
neuro-radiologists
teachers
orientation mobility specialists
pediatricians
occupational therapists
physical therapists
psychologists
speech-language pathologists
caregivers
others
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First Tier of Assessment
Part 1:Vision Functions and Functional Vision
Refraction & eyeglass provision
Accommodation
Visual acuity
Visual field
Contrast sensitivity
Oculomotor
 Part 2: Hearing and Auditory Processing Screening
 Part 3: Vision Perception Screening
 History taking
 Quick visual perception screening battery
 Part 4: Behavioral Adaptations
EVA Evaluation of Visuo-Attentional Abilities
Children 4 to 6 years
 Gaze fixation (maintain fixation)
 Visual field test (confrontation test at 30-40 cm)
 Visual extinction (see 2 objects at same time)
 Binocular visual pursuit (follow target)
 Visual memory (find shape among 6 othrs
 Teddy bear cancellation test (x out bears)
 “A” cancellation test (x out A’s)
 Embedded Figures test (Identify overlapping figures)
 Matching test (match drawing found among 6 others
 Require full vision and neurological exam for
o Children 4-5 years who fail 3/9 & suspect CVI
o Children 5-6 year fail who 2/9 & suspect CVI
 recherchesantedeveloppement@gmail.com
Cavézian C., Vilayphonh M., De Agostini, M., Vasseur, V., Watier, L.,
Kazandjian S., Laloum, L., Chokron, S. (2010), Assessment of visuoattentional abilities in young children with or without visual disorder:
Toward a systematic screening in the general population. Research In
Developmental Disabilities, 31, 1102–1108.
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Second Tier Assessment:
Children with Functional Vision
Dorsal Stream Evaluation
Ventral Stream Evaluation
Auditory Processing Evaluation
Additional Neuropsychological Evaluations
 Second Tier Assessment:
Profound Visual Impairment
Evaluate salient/preferred
Stimuli
Responses
Environments
Blindsight evaluation
 Auditory Processing Evaluation
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Third Tier Assessment
Within Functional Tasks or Situations
Reading/Literacy
Math
Orientation & Mobility Skills
Daily Living Skills
Social Skills
Physical Education and Sports
Other Subjects
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Understanding of CVI
Environmental Analysis
Social Consequences
CVI can affect, not only learning but
 personal safety
 self-concept
 communication
 movement,
 social relationships
 Behaviors Have Social Consequences
 Not seeing faces, gestures, facial expressions
 Missing subtle vocal cues
 Clumsiness
 Inability to follow fast paced activities
 Problems functioning in crowded areas
 Inability to read print easily
 Problems copying/drawing
 Problems with crowded workbooks/ assignments
 Behaviors Have Social Consequences
 Getting lost
 Not knowing way around
 Unsafe mobility
 Unable to perform functional tasks safely and efficiently (cooking,
cleaning, home repair, toileting, etc.)
Additional Assessment Components
 Psychoeducational performance measures including cognitive and
motor evaluations
 Effects of additional disabilities
Example: Briana
Assessment
Tier 1
 Gathering more information about ocular vision needs related to
refractive error, accommodation, visual acuity, visual field, eye
movement
Tier 2
 Gathered information about salient/preferred stimuli primarily
from interview, observation, earlier reports
Tier 3
 Gathered information about functional tasks and environment from
interview and observation
Linking Assessment and Intervention:
Diagnostic Teaching
Combines assessment and instruction such that information from each
process informs and ensures the validity of the other (Koenig & Holbrook,
1993
Assessment
Instruction
This is a particularly important technique to employ for children who have
CVI
How Diagnostic Teaching Operates
 Assessments lead to hypotheses about how to improve a child’s
functioning in home, school, and community
 Once interventions begin, diagnostic teaching is used to:
 Continue to learn more about how the child functions so
that intervention informs assessment
 Modify intervention as learn more about child
o Modify intervention as child progresses or does not
progress
Additional Considerations for Intervention
 Intervention needs to be multidimensional as determined by the
assessment results
 Infuse instruction into Curricular Areas or Daily Routines
Intervention Plan
 Developed hypotheses about what methods might promote
Briana’s attention to task and increased task performance
 Decided Upon Critical Task with Family:
 Provide an activity for Briana that promotes vision use that will
potentially generalize to other tasks in the home --LightAide
Many Types of Interventions
 Promote visual skills and use
 Use and integrate information from all sensory systems
 Select and use visual adaptations
 Select and use sensory substitutions for vision or supplements to
vision
 Apply assistive technologies to maximize vision use
 Modify the environment
 Promote social well-being and self-determination
Intervention Hypotheses
(Phase 1)
Tactile Kinesthic Interventions
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“Sensory diet” prior to session with LightAide (massage, movement,
brushing)
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Neck pillow and massage ball for pressure to promote visual
attention and reduce vocalization that appears to be a selfstimulation rather than one with a communicative intent
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Tight blanket to swaddle to promote visual attention
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Tactually interesting coverlet over toggle switch
Communication Interventions
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Have consistent language to encourage use of toggle switch for cause
and effect learning (e.g., Briana’s turn) and the use of a simultaneous
touch cues.
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Reduce distracting sounds in the environment
Vision-Specific Interventions
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Use a visual stimulus that is more discrete to reduce visual crowding
effects
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Vision goal to increase visual attention, visual following, shift of gaze
Intervention Hypotheses
Phase 2
Continue with Interventions
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Tactile Kinesthetic (sensory diet, swaddling, tactile coverlet on toggle
switch)
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Communication (language, environmental sound)
Continue with general LightAide activities for leisure time
Vision-Specific Interventions
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Begin to experiment with apps on iPad (smaller presentation area,
smaller stimuli; touch screen) to engage Briana’s attention and
encourage cause and effect learning
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Add very specific activities within daily routine
Activity Goals
 To attend to various visual stimuli in pleasurable activities within daily
routines
 To follow an object visually from Briana’s left to right
 To encourage Briana to initiate a pleasurable activity
 To learn the touch cue to begin a pleasurable activity
 To enjoy the activity as a natural consequence of participation
 To participate in turn-taking
 To use toggle switch with LightAide to reinforce cause and effect within
visual following activity
Specific Activities
 Eating Activity at Snack Time or Dinner
 Toothbrushing Activity (hairbrushing was in an earlier hypothesis but
Bramble was not really interested in this activity
 LightAide Activity
Data Collection Example for Briana
Case 2: Juan
6 year old boy with
 hearing impairment, right ear
 orthopedic impairment (leg braces, able to walk independently)
 20/40 VA in each eye
 Premature with PVL
 CVI and ONH
 behind in school
 doing well in a very well-organized and quiet classroom environment
Case 2: Juan
Behavioral Observations
 Skips letters when reading if there is not a pointer of some kind
 No problem identifying isolated letters or familiar people in a familiar
room
 Cautious when navigating surface elevation changes
 Cautious in play structures-using hand to navigate through when there
is an overhead structure
 Easily overwhelmed in noisy environments
 Easily distracted
 Poor eye-hand skills
 Difficulty talking and walking at the same time
 Identified only 1 traffic light on pole when there were 3 lights
 Unable to match solid walk-man sign with a matching shape made up
of several dots that would connect to make that shape
Case 2: Juan
Tier 1 – Baseline information in the following areas
 FVA
 Auditory processing screening
 Visual perceptual screening (e.g., quick visual perceptual screening
battery e.g., EVA Battery, Cavezian et al, 2010)
 History taking that addresses CVI issues (Dutton, 2010) (e.g., Can
parents be found in a crowd?)
Cavézian C., Vilayphonh M., De Agostini, M., Vasseur, V., Watier, L.,
Kazandjian S., Laloum, L., Chokron, S. (2010), Assessment of visuoattentional abilities in young children with or without visual disorder:
Toward a systematic screening in the general population. Research In
Developmental Disabilities, 31, 1102–1108.
Dutton, GN. (2003) Cognitive vision, its disorders and differential diagnosis
in adults and children: knowing where and what things areEye, 289-304
Case 2: Juan
Tier 2: Dorsal Stream assessment (gather more observational and
interview information), auditory search information
 Lower field impairment: e.g., When supported. how far does a foot
have to be elevated before it is seen (more than 20 degrees?)
 Can fingers be counted on a rapidly moving hand? (Is there
dyskinetopsia – i.e., objects disappear at lower speed of movement
threshold)
 Additional neuropsychological and audiological testing as needed
Case 2: Juan
Tier 3: Assessment in Functional Tasks or Situations
Observe and Evaluate Juan in the Following Areas
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Reading (have some information here)
Math
Orientation & Mobility Skills (have some information here)
Daily Living Skills
 Social Skills
 Understanding of CVI
 Environmental Analysis (have some information here)
Case 2: Juan
Move on Diagnostic Teaching Hypothesis and Interventions Next
Here are some ideas to be considered in one area for Juan
Difficulty finding a wanted item (e.g., in a desk) if there is too much visual
information
 Keep number of items to a minimum
 Choose items to be of different bright colors, to aid finding them
 Store items horizontally or vertically in specific places so that search is in
one direction
 Design storage system and train in keeping items in specific locations
 Train in putting everything back in correct locations
 Teach salient methods of visual searching, supplemented by touch when
needed
 Give verbal directions when necessary
From Cockburn and Dutton (in press) Parent recommended strategies t assist children with CVI. A. Lueck
and G.Dutton Vision and the Brain: Understanding Cerebral Visual Impairment in Children. New York:
AFB Press.
What is the role of the
TVI and O&M specialist?
Concluding Remarks
 Connect assessment and interventions through Diagnostic Teaching
 A collaborative effort is most often needed and the TVI may not
necessarily be the case manager
 Modifications to environments are key
 Use various approaches including analysis of daily tasks/critical
activities
 Address social-emotional concerns
 Consider the whole child in designing effective interventions
Thank you