DRAFT — July 1, 2019 by Deanna K. Wagner, MS/CCC-SLP
I have been studying recommendations from many resources to begin the process of summarizing some information and hopefully providing some framework for team-based discussions for emergent literacy supports when students have been identified as having cortical visual impairments, or are suspected of having visual processing deficits in addition to other complex physical and cognitive impairments. According to Roman-Lantzy, (2018), there are 10 characteristics of CVI that are measured by the CVI Range, Rating II. The CVI Characteristics provide information about visual functioning and overall degree of impact in the following areas: color preference, need for movement, visual latency, visual field preferences, difficulty with visual complexity, light gazing, difficulty with distance viewing, atypical visual reflexes, difficulty with visual novelty, absence of visually guided reach. We can use this information to consider how a student’s vision impacts his/her ability to choose a book and interact with the book for an extended period of time at his/her own pace. In order to completely address each of these characteristics, we need to be mindful of the adaptations we make considering the individual’s physical capabilities. When an individual is at the emergent literacy stage (i.e., does not know all letters/sounds and can not independently access meaning from written materials), we need to find daily opportunities for shared reading and self-directed reading (Erickson, 2017). During self-directed reading time, understanding the content of the book is not a pre-requisite. Spending time during shared reading is crucial to building joint attention and shared knowledge in order to build concepts and social-linguistic skills (Lueck & Dutton, 2015).
CVI Characteristics Progress Monitoring for Self-Directed Reading
Scoring guide according to Roman-Lantzy (2018), CVI Range Score II:
0: Full effect of the characteristic is present
.25: Behavior on this characteristic has begun to change or improve
.5: The characteristic is affecting visual functioning approximately half the time
.75: Occasional effect of the characteristic; response is nearly like that of individuals the same age
1: Resolving, approaching typical, or response is the same as others of the same age
A lower score indicates the student attends best to a single, preferred color and may not be able to visually engage with more complex materials.
Ratings in the middle indicate the student can attend to more than one color (though bright fluorescent colors may be most engaging) and may benefit from highlighting visual features of both 2D and 3D items in a preferred color. NOTE from DEANNA: These students may benefit from Experience Books with Tactile Enhancements using preferred color.
Ratings at the highest level indicate that a specific color is not required for visual engagement with a book.
Need for movement
Lower scores indicate the student attends primarily to movement (including being distracted by a ceiling fan).
Middle scores indicate that vision may be distracted by movements 8-10 feet away, but we can also use movement to bring their attention to a particular area where they can focus on a specific item (i.e., elements on the page of a book).
Highest scores indicate we don’t need movement to elicit visual engagement, but we should be aware of movements in the distance that could be distracting while trying to look at the pages of a book.
Lower scores indicate that the student takes a long time to look at an item, every time it is presented.
Middle scores indicate that the time can be reduced with familiarity, but shows up again when the person is fatigued or over-stimulated. Expecting visual attention to a book following a seizure may not be realistic.
Higher scores indicate latency is not a factor very often, and they can look at a target when presented.
Visual field preferences
Lower scores indicate that the person struggles with lateral visual fields, affecting where we might position a book.
Middle range scores indicate visual fixations in more fields, though lower visual field function may remain atypical.
Higher scores indicate the student can visually fixate in all visual fields. Students with CP almost never achieve a perfect score on this indicator due to challenges with lower visual field processing.
Difficulties with visual complexities
Visual complexity is evaluated as it relates to objects, array, sensory environment, and faces. Lower scores indicate visual attention can be focused on a single-colored near object when there are no competing sensory inputs (including overhead lights).
Middle range scores indicate the ability to attend to more details or more items at once is improving, though competing sensory input is still visually distracting. Using backlighting can engage vision.
Scores at the highest level indicate that the student can attend to complex visual arrays even in environments with competing sensory input.
Need for light
Lowest scores indicate that the student attends to sources of light to the point of visual fixation and has trouble looking away from bright lights.
Middle range scores indicate that light can be used as a tool to engage/direct vision (such as through use of a light box or back-lit tablet).
Higher scores may indicate that visual recognition or discrimination may be enhanced by backlighting and there may not be as many difficulties with visual fixations unless the person is tired, hungry, or immediately following a seizure.
Difficulty with distance viewing
Lower scores on this indicator would indicate best viewing is at a distance of less than 18 inches.
Middle range scores indicate ability to visually attend to items as far away as 10 feet, especially if they are moving (such as recognizing a person who is moving in the distance).
Higher scores indicate that distance is not a problem for this individual, and is rare for students with CVI. We should assume that reading books should take place using near vision when possible and without distractions of objects that are moving in the distance.
Difficulty with visual novelty
Low scores indicate the student prefers to look at items that are familiar and is not curious about new things.
Middle scores indicate visual curiosity is growing. Building visual curiosity can be an important target for bookreading. Visual curiosity is built from experiences with objects, and does not occur spontaneously with 2D images.
Higher scores indicate a student is able to use vision to learn about new things.
Absence of visually guided reach
A student scores lowest on this characteristic if he looks, looks away, and then reaches for an item (separate rather than integrated actions).
Scores in the middle indicate more integrated function of looking and reaching, sometimes facilitated by use of bright or shiny/moving objects.
This indicator is scored at the highest level for students with motor impairments if their attempts to target an item include visual attention on the item as they are reaching. Problems with visually guided reach may be minimized when we use eye gaze selection on a tablet or computer.
Atypical visual reflexes
Lowest score means the student doesn’t blink in response to a quick poke at the area just between the eyes at the bridge of the nose (or other visual threat).
Middle scores indicate the blink response to visual threat is inconsistent.
Most students with CVI have an abnormal blink reflex. It is not something we target for educational interventions.
Erickson, K. (2017). Comprehensive Literacy Instruction, Interprofessional Collaborative Practice, and Students With Severe Disabilities. American Journal of Speech-Language Pathology, Vol. 26, pp 193–205, May 2017. Downloadable from: https://pubs.asha.org
Lueck & Dutton, Eds. (2015). Vision and the Brain: Understanding Cerebral Visual Impairment in Children. AFB Press.
Roman-Lantzy, C. (2018). Cortical Visual Impairment: An Approach to Assessment & Intervention. AFB Press, 2nd Edition. ISBN-10: 0891286888; ISBN-13: 978-0891286882