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Cortical Visual Impairment is the leading cause of visual impairment in children in the United States (Blind Babies Foundation, 1997), yet many doctors and professionals in the field of visual impairment still do not know much about it. It can be difficult to diagnose because many children with CVI have other neurological factors that may interfere with testing such as cerebral palsy, seizure disorder, or a pre-existing ocular condition. CVI is somewhat of a “hot topic“ in this day and age. Some professionals believe that children with multiple disabilities should not be described as having Cortical Visual Impairment because they are “untestable“ (13). Dr. Luisa Mayer and Dr. Anne Fulton from Children’s Hospital in Boston spoke of this phenomenon in an article they presented at the CVI Summit in San Francisco last year (2005) entitled Perspective on Cerebral Visual Impairment.
I have been interested in CVI since I started teaching in my classroom in 2002. I had never heard of CVI until I started teaching where I then found I had a greater number of students with CVI than students with an ocular condition alone. Out of the 5 children in my classroom with visual impairments 3 had a diagnosis of cortical visual impairment. The Vision Teacher that I used to work closely with at my school taught me that these children have a very fragile visual state. She stated that their vision could literally turn on and off, change minute-to-minute, day-to-day. She also taught me about the importance of having shiny, reflective materials that simulated movement (children with CVI are more visually responsive to items that move). She also told me about the importance that color plays, especially red.
In early 2003 the Vision Teacher at my school relocated and we did not have a replacement until earlier this year. Therefore I knew that I had to do the research on my own. I learned more about CVI and how to best educate my students by taking a variety of classes on visual impairments and neurological damage. I also attended classes on prematurity to understand how that can affect visual outcomes for students.
I feel it is important to take a multi-disciplinary approach to educating my students, integrating therapeutic services so students are learning generalization of skills rather than learning how to perform tasks in certain environments only. Pullout “vision stimulation“ times don’t make sense for teaching children how to use their vision functionally- what makes more sense is to utilize environmental modifications across environments to teach children to see while at the same time making vision functional. In the Spring 2006 edition of Deaf-Blind Perspectives Susan Edelman et al. wrote, “Improved vision naturally increases opportunities for incidental learning, resulting in greater personal control and independence for a child“ (2). The research question that I posed examined to what degree environmental modifications benefited 3 children with a diagnosis of CVI in my classroom. This research question also helped me to determine which modifications proved most beneficial to students at various ends of the spectrum of CVI. If I, as the teacher and leader of the educational team, know the proper environmental modifications to make for an individual student, then I can share that information with fellow team members such as occupational therapists, physical therapists, speech and language pathologists, and parents so students may excel in other educational, and home settings, as well as within the classroom.
Overall my research was led by the beliefs that all children can learn and all children have a right to services that help them learn. Children can make educational progress when given appropriate instruction, and the improvement of the visual performance of a young child can have a profound effect on their development and, subsequently, their overall quality of life.
I chose to investigate this question for a number of reasons. For one, as I previously stated, I want to be able to provide my students with the best education possible. I teach at a Collaborative school in a rural town in North Central Massachusetts. I am the teacher in the early childhood classroom that services students ages 3-7 with significant multiple disabilities, including sensory impairments and medical issues. The focus of our school is to maximize physical, cognitive, creative, social, and communication abilities in order to improve independence at school, home and in the community. A team of experienced professionals carefully studies each child’s unique personality, strengths, and needs. These teams, along with parents, create individualized programs. In each class, students have compatible skills, learning needs and styles, and behavior.
The three students who are involved in this research study are considered to be multiply disabled and sensory impaired. Some educators who are not familiar with current research on Cortical Visual Impairment may see their diagnosis of “legally blind“ and assume that there is nothing that can be done to help improve their vision. According to the American Printing House for the Blind (2005),
Vision is not a single sense but a combination of complex senses which have evolved over millions of years. Almost the entire brain is involved in the process of seeing. In different locations there are specialized areas for distance vision, recognition of faces, objects, colors, contrast, and movement. There are also areas of the brain that coordinate visually directed movements, and process visual information to achieve perceptions of directionality and depth. (www.aph.org/cvi/define.html, 2).
Another reason why I have chosen this research question is because I am intrigued by the differing opinions in the field of CVI in regards to what the intended visual outcome is for students. Some researchers feel that children with CVI have unreliable visual abilities due to the damage in the brain, while others feel that it is the environment and our expectations of these children that are unreliable.
Finally, the last reason why I have chosen to investigate this question is because it is beneficial to many students, not just in my class but also in the rest of my school. I am hoping that this information will also be helpful to our TVI, who works at our school once a week. If I know the proper educational modifications and accommodations to be making for my students with this particular neurological impairment then I can maximize their learning. I can then share this knowledge with other teachers of children with CVI. Teachers of students with severe special needs have seen numerous students with Cortical Visual Impairment and, as the research suggests, this is not going to change anytime soon. CVI is now found to be as prevalent as “72 per 100,000 children“ (Cohen-Maitre “ Haerich, 2005, 1). This finding reflects “better methods for identifying visual impairment due to Central Nervous System injury and also advances in perinatal care, which have increased the survival rate of children with neurological morbidity“ (Good, Jan, Burden, Skoczenski, “ Candy, 2001, 56). To learn more about CVI I have also become involved in a research study and a New England-wide initiative to set up a network of CVI Advisors. There has been an identified need for training of professionals who provide services to students with Cortical Visual Impairment, especially those children who also have significant multiple disabilities. Dr. Christine Roman-Lantzy, who is the Cortical Visual Impairment Project Leader at APH (American Printing House for the Blind), has developed the CVI Range Rating Scale to determine the level of environmental modifications a student will need to gain visual information and build visual pathways. Dr. Roman-Lantzy believes that with proper environmental modifications some of the characteristics children with CVI exhibit may resolve over time.
We, the New England CVI Advisors have committed to a four-year collaborative multi-state training initiative. The purpose of this project is to consolidate resources and to provide training and mentorship experiences to professionals working with children with CVI in our respective states. By the final year of the project the goal is that we will be prepared to train, mentor, and advocate for service development related to CVI as needed within each state.
"In Cortical Visual Impairment… lesions of the posterior visual pathways result in impaired visual functioning in children. Visual functioning varies from child to child and affects such factors as visual acuity, visual field, sensitivity to light, visual attention, figure-ground discrimination, and recognition of faces“ (Lueck, Dornbusch, “ Hart, 1999, 778). CVI is caused by some type of damage or trauma to the brain usually resulting from asphyxia (lack of oxygen to the brain), brain maldevelopment in utero, head injury, or infection (www.aph.org/cvi/define.html, 2005, 2). Table 1 lists the unique visual/ behavioral characteristics of children with CVI.(www.aph.org/cvi/define.html, 2).
American Printing House for the Blind has established it’s own definition of CVI for educational purposes. APH states that CVI is “a neurological disorder, which results in unique visual responses to people, educational materials, and to the environment“ (Edelman et al, 2006, 1).
Cortical Visual impairment does not remain static; it will get better or it may become worse. Visual prognosis in babies and young children depends on 2 critical factors: the neurological stability of the child’s brain (seizure disorders affect progress negatively), and the environmental supports that the child receives. According to Dr. Christine Roman-Lantzy “The greatest window for change occurs in the first 3 years of life- this time provides the best opportunity for permanent change in visual behavior“ (2005, 2). At a young age the brain has much plasticity and visual pathways can be rewired and rerouted.
As previously stated in my Rationale part of my intrigue with this question is in the body of research that surrounds it. When I ask the question: “What happens to the visual behaviors of my students with Cortical Visual Impairment when I implement environmental modifications?“ I am wondering if whether or not environmental modifications would improve the visual behaviors of my 3 students diagnosed with CVI. Some of the research suggests that modifications will improve visual behaviors and therefore student learning, while other research appears to state that these children have such a fragile visual state that environmental modifications may not affect visual functioning or outcomes.
Amanda Hall Lueck, Helen Dornbusch, and Jeri Hart did an exploratory study that investigated the effects of the components of environmental management, visual skills training, and visually dependent task training on the performance of visual behaviors of a young child with cortical visual impairment. This study can be found in December 1999’s Journal of Visual Impairment “ Blindness. They found that instructional intervention methods for students with CVI have been recommended in the literature and are being quickly integrated into common practice (Lueck, Dornbusch, “ Hart 1999). These modifications include reduction of competing stimuli, use of certain colors, and reduction of complicated figure-ground displays (Groenveld, Jan, “ Leader, 1990).
The young child in the study “appears to have benefited from visual environmental management training, visual skills training, and visually dependent task training and did so despite great gaps in training that were due to illness and hospitalizations“ (Lueck, Dornbusch, “ Hart 1999, 791). The mention of illness and hospitalizations in this article is a very true statement for this population of students. As previously mentioned a vast majority of students with CVI have co-existing medical conditions such as Cerebral Palsy, brain malformations, and/ or seizure disorders. While reviewing my data I will keep this knowledge at the forefront knowing that other medical conditions may affect the outcome of my results.
In the article entitled: “Recent Advances in Cortical Visual Impairment“ written for Developmental Medicine “ Child Neurology authors Good, Jan, Burden, Skoczenski, “ Candy found that the goal of visual rehabilitation is to maximize the use of functional residual vision. They stress that early and proper assessment of CVI is critical. “Younger patients, who have not reached developmental maturity will require special learning environments that promote maximum stimulation of residual vision“ (2001, 58). The authors even go so far as to say that “such environmental stimulation may help to prevent developmental delays“ (58).
A simplified visual environment is more beneficial to children with CVI because it forces them to focus attention on a particular visual stimulus. This is contrary to what is seen in most traditional educational settings that strive to provide stimulation and diversity to encourage students’ developmental growth. Color, high contrast, and the use of motion may facilitate visual recognition of an object for these students (Good et al., 2001).
Carefully designed instruction and environmental adaptation help a child progress toward the resolution of CVI in 3 phases according to Dr. Christine Roman-Lantzy. During Phase 1, the focus is on building visual behaviors. Phase 2 involves integrating vision into daily routines and activities. During Phase 3, a child begins to develop more typical visual functioning (Roman, in press). During each phase the emphasis is not on vision stimulation activities but rather on carefully selected modifications and adaptations of environmental characteristics that support the student’s best visual functioning at the time. This “environmental engineering“ can enable a child to use his or her vision more effectively and influence a child’s capacity to make progress and benefit from structured and incidental learning opportunities (Roman, in press). Other researchers in the field such as J. Greeley state “CVI improves with developmental input and visual modifications and adaptations in the learning environment and learning approach“ (www.aph.org/cvi/articles/greeley_1.html, 2004, 1).
Most patients with CVI will not regain normal vision, however, improvement is usually seen over time (Good, Jan, Burden, Skoczenski, “ Candy, 2001). “In general children with CVI and extensive neurological damage have the least favorable prognosis for recovery of vision. The finding of PVL (Peri-Ventricular Leukomalaysia) confers a particularly poor prognosis, compared to damage to the visual cortex only“ (57). Involvement of the basal ganglia indicates a poor developmental and visual diagnosis states Good et al. Their article goes on to suggest, “Epilepsy is also associated with a poor prognosis. CVI is very common in infants with infantile spasms. Abnormal visual function can result from loss of visual acuity and impaired perception“ (57). This will be an important factor to consider because 2 of the 3 students in my study have a confirmed diagnosis of a seizure disorder and I highly suspect the other student has seizures as well.
Jan, Groenveld, Sykanda, “ Hoyt write that tiredness, a noisy environment, preoccupation with other activities, medication, illness, or seizures can cause major fluctuations in visual function in their study of the behavioral characteristics of children with CVI as published in Developmental Medicine “ Child Neurology (1987).
As previously stated in my Rationale there is research that states that these children cannot form consistent visual responses. The Spring 2004 edition of DVI Quarterly states “Vision in children with CVI is variable and can change minute by minute or day by day“ (1). Carolyn Palmer, who is the Associate Dean at the School of Special Education and Disability Studies at Flinders University, writes in her article Children with Cortical Visual Impairment: Implications for Education that these children have “fluctuating visual abilities/ variable visual performance, inconsistent or lack of motivation or attention“ (4). Even the Pediatric Visual Diagnosis Fact Sheet published in 1997 by the Blind Babies Foundation states “Vision appear to be variable: sometimes on, sometimes off; changing minute-by-minute, day-by-day“ (2).
While research in the field varies one thing researchers agree on is that careful consideration of a child’s medical history and neurological diagnosis is critically important. “The field of medicine has provided the constructs and clinical data to define CVI as a condition, and it is now the responsibility of the educators to create meaningful experiences and positive educational outcomes for children“ (Edelman et al., 2006, 3).
For the purpose of this assignment I observed the visual behaviors of 3 students in my classroom who have a diagnosis of Cortical Visual Impairment secondary to a diagnosis of brain malformations. Visual behaviors are defined as my students’ ability to localize, fixate, and track objects/ items presented. Individualized environmental modifications were made following preliminary assessments of each of the students’ visual functioning with the CVI Range Rating Scale created by Christine Roman Ph.D. (revised 2005 edition). Environmental modifications will be defined as modifications made to materials and the child’s immediate environment to promote visual behaviors. The names of the children have been changed for confidentiality purposes.
Student 1- Elsie
Elsie is a 7-year old girl with a primary diagnosis of Pachygyria (abnormal surface of the brain- parts are smooth, some parts have too many folds), microcephaly (small head size), a seizure disorder, and cortical visual impairment. Elsie is considered legally blind due to her diagnosis of CVI. Elsie’s seizures are currently controlled by medication. Elsie also had cataracts removed from each eye in August of 2002 and had intra-ocular lenses implanted. Elsie is a non-verbal communicator who is also non-ambulatory as a result of her disability. Elsie attends school 5 full-days per week.
Student 2- Tucker
Tucker is a 7-year old boy with a primary diagnosis of Lissencephaly (smooth surface of the brain), and cortical visual impairment. Tucker is considered legally blind due to his diagnosis of CVI. He is home schooled due to his fragile medical state. Tucker is a non-verbal communicator who is also non-ambulatory as a result of his disability. Tucker requires supplemental oxygen 24 hours a day. He does not have a diagnosed seizure disorder but I highly suspect he is having seizures. Tucker receives educational services twice a week for an hour and a half.
Student 3- Jack
Jack is a 3-year old boy with a primary diagnosis of Lissencephaly (smooth surface of the brain), a seizure disorder, and cortical visual impairment. Jack is considered legally blind due to his diagnosis of CVI. Jack is currently taking medications for seizures but he is still averaging 5 per day. Jack is a non-verbal communicator who is also non-ambulatory as a result of his disability. Jack attends school for 3 half-days per week.
The intervention began by administering The CVI Range Rating Scale created by Christine Roman Ph.D. (revised 2005 edition- See Appendix A) to each of the children in a quiet environment outside of the classroom setting. By administering the assessment scale I was trying to get baseline data from which to discern my interventions from. Each assessment was videotaped so that I could go back and look to know exact student behavior and responses since I was also the one administering the assessment. The video camera however was not set up on a tripod. Frequently it is difficult to pick up on something as small as eye movements by just leaving a camera in one spot to film. Another teacher at the school held the camera to be able to zoom in and out at appropriate times during the testing.
I also used Dr. Roman-Lantzy’s Answer Guide for Interview Questions (1995- See Appendix B) to interview the parents of the children involved in the study. Parents are a wealth of information and they know their child better than anyone else knows them. Many times parents will know their child’s favorite color or will know that their child doesn’t respond visually in cluttered environments. The interview questions helped me build up a knowledge base of the child’s current level of functioning.
After the preliminary testing was performed the videotapes were examined through the use of the Video Assessment Observation Form I created (see Appendix C). I carefully examined each of the videotapes and used the form to see how the students responded to the various materials presented to them throughout the testing period. I evaluated visual fields, color preferences, attraction to movement, latency, attraction to visual novelty, complexity, visual reflexive responses, visual motor abilities, and whether or not the child exhibited light gazing behaviors. I used the accompanying Scoring Guide (2006 updated edition- See Appendix D) so that I was able to accurately answer the questions provided on the CVI Range. The Scoring Guide analyzes the statements provided in the Range and helps the evaluator to determine how to score the student (-, +, +/-, or R). Following this I used Dr. Roman-Lantzy’s CVI Resolution Chart to analyze just what phase each of the 3 students fell under (See Appendix E). The intention of the Resolution Chart is to help determine areas of need for writing IEP (Individualized Education Plan) goals and objectives. As mentioned previously in my Literature Review Dr. Roman-Lantzy believes that students with CVI fall under 1 of 3 Phases. Knowing what “phase“ of CVI they are in helps one to determine what level of environmental modifications they will need.
I then took this information per student and used it to make recommendations regarding specific environmental modifications that were necessary for the students to make effective progress in, and out of the classroom setting. Once these environmental modifications were made they were shared with classroom staff, therapists, and parents. The modifications were then implemented and data was collected as to whether or not they improved the students’ ability to localize, fixate, and track objects presented. Data was collected by way of a data sheet that I created to look at the relationship between what modification was made and how the students “visual behaviors“ (localize, fixate, and track) were affected, if at all (see Appendix F). At the end of the study Dr. Christine Roman-Lantzy’s CVI Range Rating Scale was administered again to see whether or not the students had made any progress towards “resolving“ any of the aforementioned characteristics.
This research project utilized a mixed method approach to research. The interviews that I did with the parents embodied qualitative research while the data that I kept, and the pre and post assessments that I implemented were quantitative. I find that when working with students with multiple disabilities it is necessary to employ this type of approach. Accurate and consistent data is needed to help teachers and professionals understand if the students are making progress and data helps teachers identify what areas of instruction need to be changed. While qualitative data on the other hand is equally as important because some things cannot easily be displayed by numbers and graphs. This is especially true for parents who are busy enough at home caring for their child with special needs without having to take data on how their child may be reacting to stimuli and settings. This doesn’t mean that a parent’s observations shouldn’t be valued.
Data was taken individually for each student since each of the students involved in the study, while similar in their diagnoses, are all individuals with different learning needs. All 3 of the students required different types of environmental modifications after review of the preliminary assessment. To try to keep interpretation of behavior consistent data was taken by myself or by classroom staff even if the behavior was observed in other environments. Due to the time constraints involved in this study I did not feel there was enough time to train therapists in how to use the data sheets that I had made. I felt I would get the most accurate data if I had people who were familiar with the data sheets, and the visual behaviors, to observe the behaviors. Therefore myself, or a trained staff member from the classroom, accompanied students to therapies, when able.
Results| Elsie | Tucker | Jack | |
|---|---|---|---|
| CVI Range Rating Scale Score- 1 | 1-2 for Part 1" Student functions with minimal visual response" | 3-4 for Part 1 “Student functions with more consistent visual response“ | 1-2 Part 1 “Student functions with minimal visual response“ |
| CVI Range Rating Scale score- 2 | 1.75 for Part 2 | 3.75 for Part 2 | 1.00 for Part 2 |
| Resolution Chart | Phase 1“Building Visual Behavior“ Level 1 Environmental Considerations | Phase 2 “Integrating Vision with Function“ Level 2 Environmental Considerations | Phase 1 “Building Visual Behavior“ Level 1 Environmental Considerations |
Level 1 environmental considerations are those modifications that offer a high degree of environmental support. Level 2 environmental considerations are those modifications that offer more of a moderate degree of support. If a student is in Phase 3, therefore needing Level 3 accomodations, they need a low level of environmental support.
After careful observation of the videotaped pretests and parent interviews the following modifications were recommended and then implemented.
| Modifications | |
|---|---|
| Elsie | 1. Black backgrounds and room dividers (high contrast) 2. Red, shiny Mylar materials 3. Present 4“ in front of her face 4. Present to lower left periphery 5. Add movement to presentation |
| Tucker | 1. Black backgrounds and room dividers (high contrast) 2. Shiny Mylar materials (no specific color) 3. Present to upper right periphery 4. Add movement to presentation 5. Limit overhead lighting |
| Jack | 1. Black backgrounds and room dividers (high contrast) 2. Gold, shiny Mylar materials 3. Present Central to Right periphery 4. Add movement to presentation 5. Limit overhead lighting |
The following are examples of how various materials were made to accommodate the students in the study.
Step-by-Step switch with glitter red button
Calendar symbol for Elsie before accommodations
Calendar symbol for Elsie after accommodations
Calendar symbol for Tucker after accommodations
Data was collected over a period of 12 weeks on the visual responses of the test group. These test results are displayed on the following 2 graphs depicting the students’ ability to fix and focus on an item presented given the aforementioned accommodations, and also the students’ ability to follow an object presented after the initial focus. All 3 of the students improved their ability to fix, focus, and follow a moving target when environmental accommodations were made. However this improvement has not shown to be consistent yet. The graphs were made by averaging the length of time per day, and then per week, that the students engaged in looking behaviors.
Data was taken when all 5 of the environmental modifications were being implemented together during morning circle, 1:1 work, arts and crafts, story group, independent play time, and during therapies such as Occupational, Physical, and Speech and Language. Morning Circle was the environment that remained the most consistent for both Elsie and Tucker. Morning circle is an activity that happens everyday and its components are consistent. Everyday we do attendance, discuss the calendar, talk about the weather, and read poetry or sing songs. Because children with CVI do better with repetition and familiarity this would account for better looking behavior seen at circle time. Jack, due to the fact that he only comes to school for 3 half-days and spends much of his time in therapy, did not show better "looking behavior" at circle time. In fact Jack seemed to exhibit the most consistent looking behaviors during his occupational/ physical therapy sessions when the room was also quiet and the aforementioned modifications were used.
The modification that proved most successful involved capitalizing on the students’ color preferences. Shiny Mylar materials were used because they exhibit the qualities of movement and color even when they are held still. All 3 of the students best responded to the shiny Mylar materials when they were used with a black background/ divider. Mylar and glitter materials were used as visual cues on switches (voice output devices, switches for toys/ computer), name cards, and on calendars during group and 1:1 activities.
Elsie’s visual latency also decreased with periods of consistent viewing given environmental modifications. Towards the end of the study (mid-November) she was beginning to look at moving red items presented in her lower left periphery without always needing a black background. She was beginning to be able to sort out some of the excess visual clutter. The same can be said for Tucker. Tucker however still remains dependent on overhead lights being turned off when he is expected to use his vision. Tucker did respond to a variety of colors (green, blue, red, gold) as long as they were of Mylar material and or exhibited movement. Tucker used a head switch with a green glitter button similar to Elsie’s (pictured on page 18). Jack’s ability to localize, fixate, and track was highly dependent on his level of seizure activity for the day. Jack’s neurologist and his family are experimenting with different seizure medications and dosages and this affected his alertness states throughout the study. This however was especially true for the last 2 weeks when Jack was coming in and sleeping for the majority of his morning at school. The following is a picture of Elsie looking at her shiny red name card without a black background at Morning Circle. Movement is being used to direct her gaze towards the name card.
The results of the post-test concluded that all 3 of the children demonstrated improvement in their ability to localize, fixate, and track a target given environmental modifications based upon what phase of CVI they currently exhibited the most characteristics in. Tucker’s progress was not significant enough to move him into another phase or change his score on the Rating Scale. The post-test was administered in late November/ early December.
| Elsie | Tucker | Jack | |
|---|---|---|---|
| CVI Range Rating Scale score- 1 | 3-4 for Part 1 “Student functions with more consistent visual response“ | 3-4 for Part 1 “Student functions with more consistent visual response“ | 1-2 Part 1 “Student functions with minimal visual response“ |
| CVI Range Rating Scale score- 2 | 3.25 for Part 2 | 3.75 for Part 2 | 1.25 for Part 2 |
| Resolution Chart | Phase 1 going into Phase 2 “Building Visual Behavior/ Integrating Vision with Function“ Level 1-Level 2 Environmental Considerations | Phase 2 “Integrating Vision with Function“ Level 2 Environmental Considerations | Phase 1 “Building Visual Behavior“ Level 1 Environmental Considerations |
There were several limitations that could have influenced the validity and the reliability of this study. First, while all of the students had similar diagnosis’ they were all slightly different. As current research suggests seizures have a significant impact on a student with CVI’s ability to consistently perform visual tasks. This could account for Jack’s inconsistent visual behaviors because, as stated previously, he is averaging 2 seizures per morning at school. This may also be true for Tucker. Tucker does not have a diagnosed seizure disorder. He is not regularly seen by a neurologist and in my opinion does appear to have seizures. Seizures are common in children with a diagnosis of Lissencephaly (Tucker and Jack) and Pachygyria (Elsie). Elsie’s seizures are controlled through medication.
A second limitation of this study is that the student’s all receive different amounts of schooling/ educational services. Since Elsie attends school for 5 full days per week it would make sense that she would have made the most progress in this study. She had the most time devoted to the study and the environmental modifications. Tucker only received educational services 2 times per week for a total of 3 hours. Jack only attends school for 3 half days per week and as I mentioned before much of Jack’s time at school lately has been spent sleeping or in therapy (OT, PT, Speech).
A third limitation of the study was the environments in which data was collected. The classroom setting is an environment that is easier to control being the teacher. I can change the structure of the classroom by altering lighting, clutter, and the noise level. When I was implementing these modifications in Tucker’s home it was a different story. When you have a student who is home-schooled you, as the teacher, do not have the same control over the environment. Frequently Tucker’s house would be noisy (brothers and sisters home from school), the lighting would not be ideal (shades and blinds that were left open and out of my reach), and because his bedroom doubles as the living room, clutter was always an issue. Ideally I would have liked to work with Tucker in a quiet room with much less light and visual clutter. But this is what teachers face when they home-school children.
If each of the students attended a controlled setting (such as classroom) for the same length of time per day, and if they all had seizure disorders that were controlled through either medication or by some other means, then I think I would have a much more accurate portrayal of how the environmental modifications affected their visual behaviors. Children with this degree of visual impairment have to work very hard to use their vision and can become very tired. It has been described as being as difficult as a typically developing person learning to knit while walking a tightrope. I think that all the students did exceptionally well given the obstacles they all had to overcome and the effort that was required of them throughout the course of this research.
Cortical Visual Impairment is not a static condition. It either gets better or it can become worse. As all teacher’s of children with special needs can tell you the earlier we begin to work with children the better the outcome. The same can be said for building visual pathways in the brain. As more and more babies are born early due to pre-term labor, and with advances in technology to save these babies, we will need to, as teachers, be prepared to educate these students in the classroom setting.
Modifications and accommodations are something that every special needs teacher is familiar with doing for each of their students in their classrooms. They must be done to help our students achieve their greatest potential by having a classroom environment that is conducive to learning. We modify lessons by breaking down components of the whole into small parts. What teachers may not think enough about is how do we modify the environment so that the student is able to use their vision to then participate in activities. Over the years in settings for children with special needs emphasis has been on vision stimulation activities that were usually done in a separate environment and may have involved tracking a flashlight or a bright object. Why not have the student work on attaining visual skills within the classroom setting during functional tasks and activities? For example during my Morning Circle lesson when we are talking about the weather I have a large flashlight that has been made to look like a sun. For those children involved in the study they were learning to track the sun flashlight, given environmental modifications, while we sang music about the sun. Elsie and Tucker also enjoyed turning on the flashlight through the use of an adapted switch. They are involved in a functional activity that involves aspects of Math and Science access skills.
As the classroom teacher, and leader of the Educational Team, I meet with my students’ specialists on a regular basis to discuss progress and carryover of skills. All members of the team need to be on the same page when it comes to working with our students. By understanding what modifications need to be made to help my students succeed in an educational setting, it enables me to share the information with specialists and family members. By collaborating with other members of my team we will be teaching the students to not just focus on separate skills in isolation but how to approach a task holistically. For example, while in OT my student can be learning how to pair vision with movement by looking at a target while reaching her hand out towards it to touch it. This activity is far more meaningful than just reaching out and touching a toy. For the student to be able to gain visual information while touching an object is an experience that would build meaning and intrigue in many of our students. If we build visual skills in children we are giving them another way to process and interpret information. All children have individual learning styles, but our children can tend to be more reliant on what there strengths are as a result of their disability. If a child who is profoundly deaf and has CVI could learn to use his vision functionally it would greatly improve his quality of life. He would have another way to communicate, explore his environment, and gain independence.
So much of the skills that we teach children with special needs are taught in isolation due to the need for teaching every step in a sequence, that when we can capitalize on teaching the “whole“ we should embrace the concept! When we utilize collaboration between disciplines we are helping the students to link information together and build schemes. And isn’t that what teaching is all about?