Assessing Functional Vision in Children with Visual Impairment and Additional Disabilities

1. Assessing Functional Vision in Children with Visual Impairment and Additional Disabilities Flavia Steiner-Viggiani, M.Ed. COMS. CLVT Michigan AER, 2009

2. Objectives • Understand the difference and implications of visual functioning and functional vision. • Explore some of the connections between the brain and the process of vision. • Discuss some of the most common disabilities associated with visual impairment and their implications in functional vision • Learn strategies and techniques to observe and assess functional vision in children with VI and Multiple Disabilities.

3. What is visual function? “Visual functions depend on ocular, refractive, ocular-motor status and the integrity of the primary visual pathway. Visual functions are clinically evaluated during a low vision examination by a medical Professional”. Luisa Mayer, Ph.D., Anne Fulton, MD “Perspectives on Cortical Visual Impairment, 2005”

4. What is functional vision? Functional Vision represents vision mediated performance of tasks required for daily living. Cooking, reading, walking, choosing between pictures, are all examples of activities that can be visually guided. Luisa Mayer, Ph.D., Anne Fulton, MD “Perspectives on Cortical Visual Impairment, 2005

5. Functional Vision is: • A Holistic view of how a student uses his/her vision. • Is “Vision within a Context”. • It never occurs in isolation. It has a purpose and a motivation. • It is impacted by cognition, emotions, language, physical abilities and educational opportunities.

6. Which is which? • “The student appears to detect objects, both familiar and unfamiliar, when they are presented on the lower, right field on a contrasting surface” • “There is an alternating Esotropia both at distance and at near when looking at a moving target”. What do you think?

7. Clinical or Functional? It is a clinical finding! The student is being diagnosed and evaluated clinically. There is a definitive diagnosis. Measurement of an eye deviation (turn) is part of a comprehensive low vision evaluation performed by a medical professional. • It is a functional observation! • The student is being observed in a learning environment • Statements include observations about the environment, contrast in a variety of situations. • It does NOT include a diagnosis.

8. Educational Implications of Functional Vision • Communication • Expressive language • Receptive language • Learning media • Use of other senses to communicate • Environment conducive to communication

9. Educational Implications of Functional Vision • Cognition • Acquisition of concepts in the classroom • Functional skills • Pre-literacy or literacy skills • Computation or mathematical skills • Access to materials • Combination or learning medias

10. Educational Implications of Functional Vision • Social/Emotional integration • Choice making • Friendships • community involvement • Integration of family in the social process. • Ownership of routines and schedule for the day. “Vision is an emotional sense” (Mary Morse Ph.D.)

11. Educational Implications of Functional Vision • Orientation and Mobility • Spatial awareness and navigation • Depth perception • Orientation • Ability to recognize landmarks and familiar places • Ability to use mobility devices • Use of visual skills to remain oriented and safe

12. Educational Implications of Functional Vision • Motor Development • Fine motor skills • gross motor development • Posture • gait and body balance

13. Many times we find visual Impairment associated with • Physical disabilities (Cerebral Palsy) • Neurological insults or brain abnormalities • Brain trauma or stroke • Chromosomal abnormalities • Genetic conditions • Hearing Impairment • Learning disabilities • Cognitive impairment

14. What is Cerebral Palsy? Cerebral Palsy means “Brain Paralysis”. It occurs when areas of the motor areas don’t develop properly or are damaged due to a neurological insult, complications during pregnancy or delivery or in smaller proportion to trauma.

15. Cerebral Palsy and Vision Functional Vision Decreased Visual Attention Eye-hand coordination Poor visual skills Most common visual challenges in children with Cerebral Palsy Refractive errors Amblyopia Optic Atrophy Visual Field Defects Retinal Abnormalities Oculo-Motor Impairments Strabismus Nystagmus Additional disabilities CVI Developmental delays Sensory integration difficulties

16. Children with Neurological Vision Loss • Children who experienced asphyxia, abnormalities with brain development or maturation, cerebral bleeding, infections either pre birth or at birth. • It includes children with acquired permanent brain damage, such as: shunt failure, asphyxia, injury or trauma or stroke. • Nearly always have additional disabilities. • They can have Cerebral Palsy, but not all children with Neurological vision loss have Cerebral Palsy. • Visual acuity and visual field can be severely damaged but not in all cases. • It can include children with visual acuity loss, visual field impairment and visual perceptual problems (or visual dysfunctions) • Children with normal acuity, normal fields but experiencing perceptual problems. • Dr. Gordon Dutton, Scotland , UK

17. The human brain • Common terms in the visual brain • Cerebral Cortex (grey matter) • 2 Hemispheres connected • Corpus Callosum • 4 Ventricles • Cerebrospinal fluid • Brain Stem • Cerebellum • 4 Cerebral Lobes • Frontal • Temporal • Parietal • Occipital • Lateral Geniculate Nucleus • Ventral and Dorsal Stream • Optic radiations

18. The Cerebellum • Coordination of movement • Motor activities • Learning and remembering physical skills

19. The Brain Stem • Main motor and sensory innervations to the face and neck via the cranial nerves. • Guides nerve connections of the motor and sensory systems from the main part of the brain to the rest of the body • “Primitive brain” acts without any input on our part. • Important role in the regulation of cardiac and respiratory function. • Regulates the central nervous system, and is pivotal in maintaining consciousness and regulating the sleep cycle.

20. The Ventricles • 2 Lateral Ventricles • Located in the hemispheres • Communicates with the 3rd. Vent. • Third Ventricle • Located in the middle of the cerebral cavity • Communicates with the lateral ventricles. • Fourth Ventricle • Located in the most inferior portion of the brain • Communicates with the central canal of the brain stem • All ventricles are filled with cerebrospinal fluid which travels throughout the cerebral cavities and the spinal cord.

21. The Cerebral Hemispheres Left Right • Task analysis • Mathematical operations • Logical interpretation of information • Sequence • Symbolic information • Abstraction • Reasoning • Holistic Functioning • Processing multisensory information • Provides us with a more complete picture of the environment • Language processing

22. The Cerebrum Lobes Frontal Parietal Temporal Occipital

23. The Frontal Lobe • Motor Function • Movement: • Motor patterns • Voluntary motion • Motor speech • Problem Solving • Memory and cognition • Language • Judgment • Impulse control • Social and sexual behavior • Ability to concentrate and attend to a task

24. The Parietal Lobe Processing and discrimination of sensory input. Spatial Processing Tactile recognition Localizes objects around us and directs movement in space Visually guided movements Body orientation Involved in processing pain and touch

25. The Temporal Lobe Auditory receptive area Expressed behavior Receptive speech Perception of melodies Reading facial expressions Visual object recognition and categorization. Image library Processing details or individual units Processing auditory input Long term storage of sensory input

26. From the eyes to the brain

27. Ventral and Dorsal Streams: Integrating vision within the brain Where? What?

28. Grab a slice!

29. Where are you?

30. Functions of the Dorsal and Ventral Streams

31. Educational Implications of dorsal stream disorders • Difficulties with seeing details in a complex visual scene. (crowding, visually overwhelmed) • Difficulties engaging visually while doing other tasks • (sensory overwhelmed) • Impaired visual attention (challenges with fixation) • Impaired visually guided movements of the upper or lower limbs, or both (difficulties with depth perception, stairs, curbs, eye-hand coordination tasks) • Difficulties placing objects or people in relation to self or among them (visual skills, scanning, tracking, mapping, remembering lay outs) • Reading, finding a place on the page. (slower reading fluency, organization, processing written information) • Organization of space and spatial layouts (inability to identify and remember landmarks, lack of orientation, bumping and tripping, difficulties with writing) Dr. Gordon Dutton, “CVI Summit, 2005

32. Educational Implications of Ventral Stream Disorders Impaired • Object, shapes or face recognition • Ability to recognize facial expressions • Animal recognition • Route finding or reversals • Word recognition (alexia) • Color naming (color anomia) • Letter and word recognition Dr. Gordon Dutton, “CVI Summit, 2005”

33. A Meaningful FLVA is: 80 % Observation 20% evaluation, testing and structured activities A process that helps us grow as teachers and makes us look at students as completely unique individuals

34. Considerations for a fruitful observation • Be quiet • Be still • Be patient. • Be 100% present in that moment. • Be open to discoveries instead of assumptions. Michigan AER Conference, 2009

35. Pay attention to: • Environment: • Complexity, contrast, glare, lighting • Processing of sensory information • Use of other senses, sensory selectiveness • or defensiveness, ability to integrate sensory • input. Can vision be combined? • Levels of assistance • degrees of independence and motivation • Communication: • concrete symbols, • pictures, verbal, multi sensory. • Intentional and unintentional • Emotional behavior • Frustration levels, stamina, advocacy • Community traveling skills

36. How does the process look like? What do I know about the student? • Preparation and Observation What do I need to find out? • Thinking, wondering and evaluating How do I use the information gathered? • Communicating and Moving Forward

37. Preparation and Observation What do I know about the student? Concerns or questions: • From teachers, specialists and parents. Records: • Ocular and Medical reports (if available) Observation: • Near Tasks: Lunch, table work, snack, reading, art, science. • Intermediate Tasks: Recognizing people, reading close signs, social interactions • Distance Tasks: Traveling, reading signs, recognizing people without sound input, looking at traffic signals, being visually attentive at a distance greater than 3 feet. .

38. Thinking, Wondering and EvaluatingWhat do I need to know? • What areas do I need to evaluate further after observing the • student? • What areas of functional vision do I need to assess better? • How will I structure the environment? • Complexity, lighting, familiar people, brakes • contrasting surfaces, team approach with other professionals • What materials are appropriate for this student? • Age, interests, salient features of objects, size, textures • cognitively meaningful. • How can I maximize the student’s use of vision? • Positioning, instructions and use of language

39. Planning and Evaluating General observation (ocular health) Near and Distance Vision (clinical, functional) Visual Fields Preference /Limitations (gross observation) Color awareness and relevance (matching, preference) Ocular Observations (alignment, motilities) Visual behaviors (visual skills)

40. General observations of ocular health and appearance • Eye appearance: • Appearance of eyelashes and conjunctiva • Cornea (opacity, cloudiness) • Eye rubbing, scratching, watering, inflammation. • ALWAYS refer to the appropriate professional and contact the family.

41. Clinical and Functional Visual Acuities Uses clinically calibrated visual charts to obtain resolution acuity results (object identification) Requires the cognitive ability to identify pictures or letters Usually designed for testing at 10 feet (distance) At near, they are designed to be tested at 40 cm. “Flavia was able to identify a 3.5 inches symbol at 10 feet which represents an acuity of 20/200 using the Patti Pics Chart” “Flavia was able to identify a 4 mm. size letter at 10 inches” (functional notation) ALWAYS make a copy of the actual chart for a concrete representation

42. Functional Visual Acuities Used in very young children or students and adults with intellectual disabilities. Students who present challenges staying visually attentive or motivated. Uses real life motivating objects It is notated using the size of the object FIRST and then viewing distance. It specifies the conditions of the environment. “Flavia is able to identify a 2 in. tall, green cereal bowl from 5 feet when placed on the table on a black mat”

43. Considerations for evaluating Visual Acuity • Sometimes 10 feet is too far away. Move closer. • If you are using concrete, tangible objects, start at 5 feet and move closer until you see a visual response. • Sometimes responses are NOT visual! • Pay attention at the distance where vision is at its maximum potential. (longest amount of fixation and attention time) • Frequently, using more than two symbols or objects is too visually/cognitive overwhelming. Use only two symbols (square and circle) or 2 or 3 cheerios, gold fish, pictures, or objects. • Place objects in different portions of the surface to observe patterns of reaching or awareness. • Present objects in different sections of the visual field.

45. Peripheral Visual Field Assessment • Modified Confrontation with both eyes open • Best performed with two evaluators involved. • Functional and qualitative. Not clinical. • Uses 2 targets: one central and one peripheral. • Target needs to be symmetrical DO NOT RUSH! Children with multiple disabilities need additional time to spot a peripheral target Let’s watch it!

47. How do we communicate the results? • Use observational terms, not clinical diagnostic terms. Flavia was able to identify the presence of the 4 cm multicolor penlight on the right side of the peripheral field without difficulties. However, when the target was presented inferiorly, Flavia spotted the penlight when the object was reaching her nose. When the target was presented from the left side, Flavia had difficulties spotting the object until it reached a distance of 1 or 2 inches from the left side of her face. She did not appear to have challenges identifying the penlight superiorly. It should be noted that the peripheral target was moved very slowly, providing Flavia with enough time to react and show awareness of the peripheral field. The room was dimly lit and numerous brakes were offered to rest”

48. Color discrimination and awareness • Color helps us determine: • Contrasting surfaces • Type of print and color based on background • Challenges identifying objects around the environment • Predominant color for tactile symbols, maps, and objects in the environment (street signs, bus numbers, pedestrian signals, traffic lights) • Preferred colors to use in materials • What materials can we use? • Wheatley Kit with shapes and colors • Color squares (Paint catalogues) • Interactive games that include color (Candyland, Legos) • Color sticks or beads, Lightbox with translucent shapes

49. Ocular Observations Ocular Alignment Esotropia (eye turned in) Exotropia (eye turned out) Hypertropia (eye turned up) Hypotropia (eye turned down) Most infants who are developing normally acquire binocularity or stereopsis between 4 and 6 months of age.