TETN # 30910 Visually Impaired Students with Vestibular Issues Presented by

1. Welcome to TSBVI Outreach TETN # 30910 Visually Impaired Students with Vestibular Issues Presented by Kate Hurst and Jim Durkel TSBVI Outreach KateHurst@tsbvi.edu JimDurkel@tsbvi.edu With Special Guest David Brown California Deaf-Blind Services

2. Workshops and Conferences • June 5-7 Appropriate Communication Assessment for Babies with Deafblindness HAS BEEN CANCELED • June 25-26 ECI Conference @ Embassy Suites in San Marcos • June 26-27 5th Annual Statewide Texas Parent to Parent Conference
@ Omni Austin Hotel at Southpark in Austin

3. Roll Call • How many participating? • Remote sites? • Taping or streaming?

4. Visually Impaired Students with Vestibular Issues Presented by Kate Hurst, Statewide Staff Development Coordinator, TSBVI Outreach with Jim Durkel, Audiologist/Speech-Language Pathologist and APH, VI Registry, & Deafblind Census Coordinator, TSBVI Outreach and David Brown, Education Consultant, California Deaf-Blind Services

5. Our Special Guest . . . • David Brown • Formerly of SENSE, UK • Currently with California Deaf-Blind Services • World-traveler • Funny guy

6. How do we achieve balance? Three separate components make up “Equilibrium Triad” • Input from the eyes (vision) • Input form the muscles and joints (proprioception) • Input from the vestibular organs (balance)

7. A Good Place to Start • Pediatric Resource - Vestibular Disorders Association (http://www.vestibular.org/vestibular-disorders/specific-disorders/pediatric-vest.-disorders.php)

8. Causes Pediatric Vestibular Disorders • Head/neck trauma • Chronic ear infections • Maternal drug/alcohol abuse • CMV • Immune-deficiency disorders • Meningitis • Migraine • Metabolic disorders (e.g., diabetes) • Ototoxic drugs

9. Causes Pediatric Vestibular Disorders • Neurological disorders (CP, Hydrocephelus) • Genetic syndromes (e.g., Wallenberg, Usher, CHARGE) • Posterior brain tumor • Family history of hearing loss/vestibular issues • Cochlear implants • Lack of use - movement issues, fear, ill health

10. VI Registry - 84 or 14% CP - .3% CHARGE - 7.7% CMV - 2.7% Hydrocephaly - 1% Meningitis - .5% Shaken Baby - .5% Usher 1 - 1.7% Deafblind Census - 147 or 19.9% CHARGE - 9.7% CMV - 4.8% Hydrocephaly - 1.9% Usher 1 - 1.2% Some data . . .

11. So how does the vestibular system work?

12. Vestibular organs • Located in the bony chambers of the skull in the inner ear • 3 semi-circular canals positioned in different planes for rotational movements • Otoliths (Utricle and Saccule) for linear accelerations

13. Semicircular Canals • Bulge at base of canals - ampulla • Ampulla contain sensory receptors for each canal • Canals filled with endolymphatic fluid and surrounded by perilymphatic fluid • Detect heads rotation • Demonstration on The Physiology of the Senses Transformations for Perception and Action, Tutis Vilis, University of Western Ontario, Canada

14. Otolith Organs • Utricle • Saccule • Demonstration on SenseWeb

15. Vision and Balance

16. Vestibular Occular Reflex • Normal head rotation: eyes move in opposite direction of head to stabilize retinal image (VOR) • Conflicting sensory information from visual and vestibular senses is a problem • The cerebellum repairs “slippage” • Demonstration

17. What Part Does Proprioception Play? • Sensation experienced by muscle and joint receptors • Requires a normal range of muscle tone to work properly • Feeds information to the brain that allows for awareness of where body parts are in space, movement, speed and direction of movement

18. A Redundancy for Balance Brain and Spine Foundation Online When one of the three parts of the Equilibrium Triade do not work or work well, the other two can compensate.

19. Moving Platform Posturography

20. From Jean Ayers Sensory Integration and the Child “The vestibular system is the unifying system. It forms the basic relationship of a person to gravity and the physical world. All other types of sensation are processed in reference to this basic vestibular information.”

21. From Jane AyersSensory Integration and the Child “The activity in the vestibular system provides a “framework” for the other aspects of our experience. Vestibular input seems to “prime” the entire nervous system.”

22. From Jane AyersSensory Integration and the Child “When the vestibular system does not function in a consistent and accurate way, the interpretation of other sensations will be inconsistent and inaccurate, and the nervous system will have trouble ‘getting started.’”

23. From Carol Stock KranowitzThe Out-of-Sync Child “Gravitational insecurity is manifested by abnormal distress and anxiety in reaction to falling or the possibility of falling. It is a primal fear.”

24. From Carol Stock KranowitzThe Out-of-Sync Child “Indeed, our need to know where we are in relation to the earth is more compelling than our need for food, for tactile comfort, or even for a mother-child bond.”

25. References on Vestibular Issues David Brown, California Deaf-Blind Services • “The Vestibular Sense”, DbI Review, June, 2007 • “Educational and Behavioral Implications of Missing Balance Sense in CHARGE Sydrome”, reSources, Spring 2003.

26. Organization of ALL sensory information Postural security/muscle tone Use of residual vision Perception/processing sound Remembering auditory sequencing Memory development Speech/Language development Behavioral challenges Bilateral coordination Breathing, feeding, digestion, nutrition Sociability Effects of vestibular problems

27. A S S E S S Vestibular Dysfunction Checklist in Out-of-Sync Child Sensory Learning Kit Vestibular assessment by Audiologist OT/PT Evaluation Sensory Integration Evaluation What do we do?

28. Various testing deviceshttp://www.tchain.com/otoneurology/testing/engrot.html

29. T E A M With OT knowledgeable about SI to develop menu of interventions To plan flexible schedule related to fatigue and need for breaks To select / train staff to respect individual differences in behavior, performance, pacing With family to gain insight to home challenges, child preferences and for support What do we do?

30. M O D I F Y Seating to address postural concerns Positioning for visual and auditory tasks Materials and learning environment (isolate lines of text, reduce distractions) Activities to incorporate SI approaches Pacing Schedule (general / day-to-day) Staffing patterns What do we do?

31. R E S P E C T Student challenges in learning Family struggle to address challenges / knowledge of the child Staff challenges to adapt programming and the expertise each has to offer What do we do?

32. To Learn More . . . • Brown, David, 2007. “The Vestibular Sense”, pp. 17-22. Dbl Review, January-June 2007, Deaf-Blind International. • Brown, David, 2003. “Educational and Behavioral Implications of Missing Balance Sense in CHARGE Syndrome”, pp. 1-4. re:Sources, Spring, 2003. California Deaf-Blind Services, San Francisco, CA. http://www.sfsu.edu/~cadbs/Spring03.pdf

33. To Learn More . . . • Brown, David, 2008. “The Sensory Integration Perspective and What It Offers Us in the Field of Deafblindness”, pp. 22-26. DbI Review, July-December, 2008. Deaf-Blind International. • Brown, David, 2008. “The Forgotten Sense - Proprioception”, pp. 20-24. DbI Review, July-December, 2006. Deaf-Blind International.

34. To Learn More . . . • Kranowitz, Carol Stock, 1998. The Out-of-Sync Child. The Berkley Publishing Group, 375 Hudson Street, New York, NY 10014. • Kranowitz, Carol Stock, 2003. The Out-of-Sync Child Has Fun. The Berkley Publishing Group, 375 Hudson Street, New York, NY 10014.

35. To Learn More . . . • Vestibular Disorders Association www.vestibular.org • Brain and Spine Foundation - Dizziness and balance problems http://www.brainandspine.org.uk/information/publications/brain_and_spine_booklets/dizziness_and_balance_problems/how_does_the.html • Tutis Vilis - SenseWeb http://www.physpharm.fmd.uwo.ca/undergrad/sensesweb/L10Balance/L10Balance.swf