Collaborative Rehabilitation
and Learning Strategies for
the Visually Impaired Student
Presenter:
Heather Shattuck, PT, MS, PCS
hshattuc@clarkson.edu.com
Objectives:
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Demonstrate an understanding of the etiology and pathology behind visual
disorders as they relate to clinical practice.
Identify appropriate classroom and physical education class modifications for the
visually impaired student with a wide range of strengths and needs.
Adapt testing procedures and protocols in a way that captures the best
performance of the child while maintaining the reliability and validity of the test.
Apply practical strategies for enhancing a child’s gross motor and fine motor
function to help them meet their IEP goals.
Provide the related service providers with information for parents and caregivers
about resources to help them support their child both at school and at home.
Development of Normal Visual Acuity
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Good visual acuity requires proper functioning of both the eye and the neural
pathway.
At birth visual acuity of a full term baby has been approximated to be 20/400 with
acuity rapidly increasing in the first 6 month then more slowly for the next 24
months
Although visual acuity is still developing at age 3 years, often 20/20 vision will
emerge around this age.
The visual system is very plastic and remains highly responsive to changes in visual
stimulation until visual maturity is reached between 10 and 12 years of age when
this plasticity is greatly reduced.
Levels of Severity of Visual Impairments
Best Correctable Snellen
Acuity equivalent
Levels of Severity
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Normal Vision---------------------------------------Near Normal Vision---------------------------------Moderate Low Vision------------------------------Severe Low Vision----------------------------------Profound Low Vision-------------------------------Near Total Blindness-------------------------------Total Blindness---------------------------------------
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20/25 or better
20/30 to 20/60 (newspaper print)
20/70 to 20/160 (children’s books)
20/200-20/400 (small headlines)
20/500-20/1000 (1 inch letters)
Less than 20/1000
No light perception (NLP)
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Only 10% of those who are blind have no light
perception
Levels of Severity of Visual Impairments
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Legal Blindness: visual acuity of 20/200 or less in the better eye after correction
Children whose corrected visual acuity ranges from 20/70 – 20/500 are often able to
perform some visual tasks, although not as efficiently as compared to their sighted
peers.
Children whose best correctable visual acuity ranges from 20/800 to no light
perception will most likely not have enough visual acuity for gross visual tasks.
Children whose visual acuity falls between 20/500 and 20/800 may or may not have
enough functional vision to see and interact with the objects and people around
them, to move around and explore, and to imitate actions.
Causes of Visual Impairment
• Problems with one or more of the following processes:
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Allowing light to pass through the eye
Focusing the light appropriately on the retina
Causing a reaction to occur within the photoreceptors of the retina
Transmitting the information via the optic nerve and visual pathways
Receiving and interpreting the visual information by the brain
Integrating the information and providing appropriate feedback to the eye and extra
ocular-muscles so that fixation can be maintained on target
Impact of Visual Impairment on Development:
Overall Development
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Overall developmental consequences of visual impairment depends both on the
child’s visual function and any co-occurring global developmental delays
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Children with visual acuity of 20/800 or less show lower developmental age scores across
time on the Battelle Developmental Inventory for all developmental domains as compared
to the development of children with better visual acuity.
Some visual mild impairments are not identified until a child is school age and is
unable to do tasks requiring discrimination of fine details.
About 60% of children who have a visual impairment also have been diagnosed
with another developmental disability.
Impact of Visual Impairment on Development:
Motor Development
• This domain is the most likely to be adversely affected by a visual
impairment
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Tend to be delayed in all areas of gross motor development as compared to their
sighted peers.
Early motor development: to be motivated to reach for something and to move, the
child needs to be aware that something is present is present in their environment.
Realizing that something is present in their environment based solely on auditory cues
generally develops later than visually directed motion.
Visual information also provides feedback facilitating continuous correction of
movement.
Motor imitation precedes verbal imitation.
Impact of Visual Impairment on Development:
Cognitive Development
• Early cognitive development is strongly inter-related to motor
development.
• Delays in object permanence and object concept (understanding the
relatedness of objects to other objects, events, persons, and experiences)
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This will also result in delays in understanding other concepts such as spacial
relationships and the relationship between cause and effect.
Impact of Visual Impairment on Development:
Communication and Social/Emotional Development
• Many children with visual impairments acquire language at the same rate as
their sighted peers.
• Communication is more than just speaking and listening:
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Non-verbal cues are primarily visual
Social interaction scores on the Battelle Developmental Inventory are lower for those
children with severely impaired visual function as compared to their sighted peers.
Visual acuity of 20/500-20/800 appears to be the amount of vision needed to establish
eye contact, recognize facial features, and perceive gestures and facial features.
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Lacking this will influence a child's attachment and play.
Impact of Visual Impairment on Development:
Communication and Social/Emotional Development
• Children with visual impairment:
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Need more verbal information and descriptions for objects
May not easily attach verbal labels to tactile and auditory experiences
May stay in the echolatic stage longer than sighted peers
May take longer to develop an understanding of pronouns, comparison words, and
words that deal with spacial relationships and activities
Impact of Visual Impairment on Development:
Adaptive/Self-Help Skills Development
• Skills such as eating, dressing / managing clothing, and personal hygiene
skills are often delayed in the visually impaired population as compared to
their sighted peers on the Battelle Developmental Inventory.
Clinical Clues of Possible Vision Impairment in Young
Children
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Photophobia (avoidance of bright light/squints in
bright light/ preference for dim light
Stares at bright lights
Non-directed or “roving” eye motions
Does not seem to respond to parents face
Does not seem to imitate parent’s facial
expressions
Does not seem to follow movement of objects or
people
Does not reach for bottle when presented quietly.
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Does not seem to show interest in toys/objects
within reach
Does not seem to show visual interest in
watching television
Does not seem to show an interest in books
Seems to have limited interest in different kinds
of toys
Does not seem to recognize colors or shapes
Bumps into objects
Visual self-stimulatory behaviors (eye rubbing,
pressing, or poking)
Cortical Visual Impairment (CVI)
• Defined as a “temporary or permanent visual impairment caused by the
disturbance of the posterior visual pathways and/or the occipital lobes of
the brain.”
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Can range from severe visual impairment to complete blindness
Degree of neurological damage and resulting visual impairment is dependent on
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Age of the child at onset
Location of the insult
Intensity of the insult
• This is not an indicator of the child’s cognitive ability- rather an inability of
the brain to consistently understand or interpret what the eyes see.
Cortical Visual Impairment (CVI)
• Causes:
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Asphyxia
Perinatal hypoxia ischemia
Developmental brain defects
Head injury
Hydrocephalus
Central nervous system infection (meningitis ad encephalitis)
Characteristics of CVI
• Initially children appear blind but vision can improve
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Can co-exist with ocular visual loss
• Can be difficult to diagnose
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Children who have poor or no visual response but normal pupillary reactions and a
normal eye structures.
Eye movements are typically normal
Typically an MRI is needed to confirm diagnosis
Common Characteristics of Visual Function in
Children with CVI
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Vision is often variable: changing rapidly (minute by minute / day by day).
Peripheral vision may be spared as compared to central vision.
Some children are compulsive light gazers while others are photophobic.
Color vision is generally better preserved as color is represented bilaterally in the
brain and therefore less susceptible to complete elimination.
A child’s ability to reach for a target may be hampered by poor depth perception.
Often children are better able to see a moving target than a stationary one.
CVI has been described as looking through a piece of Swiss cheese.
Behaviors of Children with CVI Reflecting
Adaptive Responses
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Crowding phenomenon: difficulty differentiating between background and
foreground information when looking at a picture.
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To magnify the object or to reduce crowing, they often will view items at a close distance.
Rapid horizontal head shaking is uncommon (shaking head no).
Overstimulation often results in short visual attention spans.
“Blindsight” a brain stem function allowing some children to navigate through
crowded environments without bumping into anything.
Many children see better when told what to look for ahead of time.
Children will often use their peripheral visual field when asked to look at something
thus appearing to look away from the target.
When reaching for a target children may look at the object and then turn away as
they begin their reach.
General Recommendations for Testing Children with
Visual Impairment
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Present objects so they touch the body
Adjust the lighting for the comfort of the child
Present objects in the most acute visual field of the child
Reduce background clutter
Increase contrast between the background and test objects
Present the objects at different distances
When possible, use objects with features that interest the child
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Sound, texture, taste, smell, size, colored lights
When possible, position the child with appropriate support to facilitate motor
activity
Common Problems
Gross Motor
• Poor Muscle tone and Posture
• Lack of or delayed transitional
movements
• Delayed crawling, walking,
running, skipping
• Immature gait patterns
Fine Motor
• Delayed reaching due to lack of
visual information about where
objects are in relation to self
• Delayed grasp and release of
objects due to low muscle tone and
inability to imitate
• Delayed wrist rotation due to low
muscle tone and poor posture
Teaching Strategies:
Specific to CVI
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A child with CVI uses a significant amount of energy to process visual information
and will often tire easily when asked to perform this task. Frequent breaks are
needed to help ensure maximal performance.
When focusing on visual tasks, ensure that the child is properly positioned to
comfort and energy conservation.
More highly involved children will need head support in order to prevent shifting of
the visual field – even if they present with functional head control.
Many positions will need to be explored prior to finding the one in which the child
feels most secure and performs the best. This position will allow them to utilize
their adaptive behaviors (use of peripheral vision etc.)
If the child requires a lot of energy to work on fine motor activities, separate visual
tasks from fine motor tasks until the two can be integrated effectively.
Teaching Strategies:
Specific to CVI (cont.)
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In order to enhance a child with CVI’s ability to handle visual information, use
simple, consistent, and predictable visual information. The child’s physical
environment should be uncluttered. Use instructional materials with one simple
picture on a contrasting simple background.
Simplicity and familiarity is very important – use real items whenever possible.
Present these items one at a time to prevent confusion of the visual field.
Repeated use of these familiar items will increase the child’s sense of security and
increase the child’s response.
As colored vision is often intact, use contrast and bright fluorescent colors. Some
TVI’s have had really good responses from colored mylar tissue.
Look for things that stimulate the child – different toys, activities, and colors.
Introduce new items and toys slowly using touch and auditory description.
Teaching Strategies:
Specific to CVI
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Items that stimulate more than one sensory system at a time may be used as
effective teaching materials.
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Vision is often best stimulated when paired with another sensory system.
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Most commonly paired with auditory or tactile information but do not forget the senses of
smell and taste.
Different lighting situations (including the position of the source) will need to be
explored to determine what works best for the child for optimal vision.
Move the target you want the child to see. Use different visual fields to determine
where the child is able to see the material the best.
Increased time will need to be allowed in order for the child to see, process, and
respond to what is being presented.
Responses to visual stimuli may be very subtle: changes in breathing pattern, shifts
in gaze, changes in body position.
Questions to ask when selecting an
intervention
• What do we want to accomplish from this intervention, and is this
intervention likely to achieve that?
• Are their any potentially harmful consequences or side effects associated
with the intervention?
• Has the intervention been validated scientifically with children with visual
impairment?
• Can this intervention be integrated into the child’s current program?
• What is the time commitment? Is it realistic?
• What strategies of motor learning are going to be most effective for this
intervention?
Orientation and Mobility
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Mobility is difficult to teach in isolation: the Orientation and Mobility Specialist
must consult with other team members to determine what skills would benefit the
child.
In general, multiple impairments and cognitive ability are not justification for
preventing a child for being considered for adaptive instruction.
It is recommended that a cane be introduced when the child moves from cruising
to walking.
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http://www.youtube.com/watch?v=Mf04ECPFuZA
For children who use a wheelchair for their primary means of mobility
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Bumpers made out of hula-hoops, or some other flexible material, can assist in the
detection of obstacles and trailing parallel surfaces.
Trays for children with some residual vision
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Clear so they can see their feet for positioning
Solid colored surface to minimize visual distraction
Characteristics of Play Items:
Play is learning to learn
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Textured features
High contrast colors: separated
primary colors
Shiny, mirrored, reflective surfaces
Sounds that help the child recognize
the toy
Sounds related to separate functions
Immediate sound response
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Imitative sounds responses
Touch or sound activated
Vibrating toys
Three dimensional toys with defined
boundaries
Differently shaped dials and switches
Structured play environment (puzzles
with raised frames)
Myth:
Those with usable sight should use sight; by using
alternative methods we are making them blind.
• Competence and achievement are impacted by methods; methods can not
change physical characteristics.
• Those with severe low vision will lose more vision beginning as teens and
will need to know alternative methods.
Treatment Techniques:
Gross Motor
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Ball Skills: Use commercial beep balls, balls that light up, balls with a variety of textures,
bean bags with bright primary colors
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Know the visual field and distance the child can see
Start close, work to increase the distance
Use targets with high visual contrast
Hand over hand or hand over foot to assist the child in learning the technique
Slow the action: use a balloon instead of a ball
Balance: Focus should be on enhancing input from other systems to compensate for lack of
visual input
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Balance beam activities: contrasting tape, bare feet, tape on carpeted floors, elevated beam
Vestibular boards: anterior/posterior tilt, medial/lateral tilt, ball skills or other highly familiar task on
the board, directional cues
Trailing – extending the arm at a 45 degree angle in front of and off to the side of the body to follow a
surface with their hand
Treatment Techniques:
Gross Motor
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Locomotion: May require body to body contact to learn high level mobility
techniques
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Child may desire to hold your hand, use of peer modeling
Create a high contrast track for them to follow
Performing on the trampoline for increased proprioceptive input
Climbing a ladder or stairs, wheelbarrow walking, monkey bars all can increase
proprioception
Jumping
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Allow the child to feel vertical surfaces prior to attempting the jump
Use contrasting targets and items to jump over (let them feel them first)
When playing games such as hop scotch, adapt the board with tactile and contrasting lines
Treatment Techniques
Fine Motor / Sensory
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Grasp: early tasks should focus on hand strengthening
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Pushing the keys on a brail machine is HARD
Touching, reaching for, grasping and releasing objects of different sizes and weights
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Bigger is not always better – children with a small visual field will do better with smaller objects
Bilateral manipulation of objects – twisting, turning, exploring – to unilateral manipulation
of objects
http://www.youtube.com/watch?v=9UVriPd21uM
Sensory Interventions
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Provide a child with increased sensory stimulation (vestibular / proprioceptive) will often
increase vocalizations.
Sensory Diet including touch / deep pressure, proprioception, auditory input, smell, and
taste
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Can be used to calm or stimulate the child depending on needs
Treatment Techniques
Sensory
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Touch/Deep Pressure
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Log rolling, water play, glitter glue, climbing under mats, petting an animal, sitting in the
sun or shade
Movement / Proprioception
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Rocking horse, dance, pushing a cart or stroller, rolling down a ramp or hill, playground
slides, commando crawling, using a tunnel (place different items inside the tunnel for
increased sensory experience)
Listening/Auditory
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Humming, whispering, silence, identify and label sounds, explore the stereo volume control
knob
Smell/Taste/Oral Comforts
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Smelling flowers, explore tastes, blowing bubbles, sucking thick liquid through a straw,
smelling game (sighted peers can be blindfolded for inclusion), eating frozen foods, eating
different textured foods
Examples of Visual Stimulation
Moderate Low Vision
Profound Low Vision
Visual Attention
Provide colorful toys, talk to child Use black and white toys, use
face to face
toys that light up and play music
Near Total Blindness
Expose the child to light coming
through the windows, use colors
and patterns on a light box
Tracking
Encourage play with bubbles,
wind toys, balls, and cars
Use flashlights with colored
filters
Talk to the child as you slowly
walk around the room; have the
child run their fingers over a
raised line as you shine a penlight
behind it.
Eye Hand Coordination
Provide solid color table tops
that contrast with fine motor
toys; provide a reading stand to
use for coloring and stacking
Use a desk lamp to focus light on
fine motor toys; provide a
reading stand to use for coloring
and stacking
Provide hand over hand
prompting and lots of practice for
fine motor skills necessary or
interesting for the child
Exercise Throughout the Lifespan
• Children who are visually impaired often do not participate in the same level
of physical activity as their sighted peers.
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Do not get the benefits of exercise:
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Experience an increased chance of dying from heart disease, chance of diabetes, high blood
pressure, dangerous cholesterol levels, high stress levels, poor posture, poor muscle tone,
limited lung capacity, obesity
• Children with disabilities who regularly participate in physical activity show
improved sleep patterns and self esteem as compared to children with
disabilities who do not exercise regularly.
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Decreased self injurious behaviors
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Exercise Throughout the Lifespan
Common physical activities adult with visual impairment participate in
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Tandem Cycling
Beep Baseball
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Goalball
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http://www.youtube.com/watch?v=5c6Z7hieTQU
http://www.youtube.com/watch?v=-MLbC3er2Fc
Pilates
Running
Swimming
Weight Training
Zumba / Dance
Soccer
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http://www.youtube.com/watch?v=gwALivViwPg
References
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www.blinbabies.org
www.aph.org
www.nyhealth.gov/community/infants_children/early_intervention/