Speech Pathologists and Cortical Visual Impairment

1. Speech Pathologists and Cortical Visual Impairment An overview of the SLP’s role in working with children with CVI Presented by Jenna Friedman, M.S. CCC-SLP

2. Objectives • Identify the role of a Speech Language Pathologist when working with a child with Cortical Visual Impairment, or suspected CVI. • Learn strategies to address and utilize students’ unresolved characteristics of CVI to encourage more appropriate speech, language and feeding assessment and intervention.

3. CVI Experience • Throughout presentation, referencing children who have been evaluated by the The CVI Range • The CVI Range experts; professionals with experience with The CVI Range • TVI, PT, OT, O&M specialists, SLP, teachers, etc. • The CVI Range should be administered for all children who have suspected CVI • Perkins-Roman endorsement ensures reliability • Regardless of your level of familiarity with CVI, you most likely have multiple children on your caseload with CVI

4. POLL: Who is an SLP and has administered The CVI Range?

5. CVI Experience • For those just beginning their CVI education journey • Familiarize yourself with the 3 phases of CVI & the 10 characteristics of CVI • This webinar will cover; • General accommodations and adaptations that can be used in therapy sessions, classrooms, home/natural environments based around the 10 characteristics of CVI • Info for SLPs to consider integrating into practice • Examples to make you think about how you are setting up your speech, language and feeding sessions to ensure accessibility for children with CVI • Best practice is to have child assessed using The CVI Range for specific accommodations

6. CVI Phases • Phase I – Building visual behaviors, getting the child to look • Phase II – Integrating vision with function • Phase III – Resolution of CVI Characteristics • We will see children in all phases of CVI

7. Role of SLP • SLP should always be involved with students who have CVI • “Due to improved medical care, children with severe brain insults have increasingly begun to survive over the last 30 years. The vast majority have tended to have severe multiple disabilities, including a variety of learning difficulties. A minority of them also have permanent visual loss, but normal or minimally abnormal eye examinations.” –Dr. James E. Jan • “…it has become necessary to offer services for those whose visual loss is due to brain damage.” – Dr. James E. Jan

8. Role of SLP • Medical conditions associated with CVI • Periventricular Leukomalacia • Asphyxia/Hypoxic Ischemic Encephalopathy • CVA (stroke) • Intraventricular Hemorrhage • infections • Structural Abnormalities • Trauma (e.g. head injury) • Huge overlap of children who need speech therapy and children with CVI

9. Role of SLP… COMMUNICATION

10. Role of SLP • Breathing is the only prerequisite that is relevant to communication. Breathing equals life, and life equals communication. It is that simple." – Pat Mirenda, 1993 • Whether the children on your caseload are working on oral speech, signs/gestures, AAC (no-tech, low tech, or high tech) or a combination, considerations must be made for the impact CVI has on their learning and engagement

11. CVI Characteristics & Interaction with Speech, Language, & Feeding

12. 1. Light gazing and non-purposeful gaze • Positioning for all children during sessions • Starting at lights; may be difficult to redirect attention • Position lights behind child • Lamps instead of overhead lighting • Use lighted objects in therapy

13. 1. Light gazing and non purposeful light

14. 1. Light gazing and non-purposeful gaze • Great apps for kids with CVI • Tap-N-See Now • EDA play • Infant Zoo • Big Bang Pictures Application: EDA PLAY TOBY Application: Infant Zoo Application: Tap-N-SeeNow

15. 1. Light gazing and non-purposeful gaze • We need to help children engage with their environment to encourage engagement with others • We would never do a speech session with no toys! • If we are doing a speech session with inaccessible items due to functional vision, really no different!

16. 2. Color Preference • What colors alert the child to look? • If not sure – use red & yellow • “Individuals with CVI often have a strong attraction to visual targets of a particular color.” (Roman-Lantzy, 2008) • Use preferred colors throughout your therapy to attract the child’s attention toward specific objects or symbols

17. 2. Color Preference • Example: Red • Feeding – red spoon, red bowl, red Mylar tape around a cup • At school – red tape to highlight cubby space • Reading – red to highlight salient difference between two similar letters, like b and d • Speech therapy – red objects to attract attention

18. 3. Latency • Latency = lag time before child responds to a visual object • Communication partners need to wait quietly and patiently while the child slowly processing the incoming visual information • Wait longer than you might expect • Get to know each child’s individual wait time and respect it • Latency is key when working on • Joint attention • Turn taking

19. 4. Visual novelty • Children with CVI prefer familiar objects over novel objects • Ask parents during evaluation specifically which toys their child likes (rather than categories of toys) • Important to understand how to select new objects, based on the critical elements of the preferred object

20. 4. Visual Novelty

21. 5. Visual Reflexes • We do not work on this characteristic

22. 6. Need for movement • This is important, as we are often basing our sessions at a table, or on the floor sitting in one spot • SLPs are typically the therapists in offices, rather than out on the gym floor with OTs and PTs • Movement may be needed to initiate and/or sustain visual attention • Movement alerts the brain • Even if it’s not something you can sustain for whole session, movement activities are a great warmup • Way to jumpstart the visual system

23. 6. Need for movement • Shiny objects are interpreted as movement due to the light’s reflection • Use objects with properties of movement in sessions • Objects with shiny, reflective surfaces such as Mylar pom-poms, balloons, papers • Use Mylar tape to create borders for work spaces, bring attention to important items, etc.

24. 6. Need for Movement • “Some students with CVI will increase their ability to function visually by using movement…[moving] their head or body in order to provide themselves with visual stimulation.” (Roman-Lantzy, 2008)

25. 7. Visual Field Preferences • Visual field preferences are present in almost all students who have CVI • As SLPs, we are often ’centering’ target objects, toys, devices • Sit on the child’s preferred side • Follow their gaze, and place target objects in the areas they are looking • Try moving your toys and tools, rather than repositioning the child

26. 7. Visual field preferences • Example: Setting up eyegaze device • Inclusive Eyegaze: Your Essential Guide to Eyegaze in the Classroom • http://www.inclusive.co.uk/Lib/Doc/catalogues/eye-gaze-booklet-2015-usa-v2.pdf

27. 8. Decreased visual complexity • Auditory complexity • Complexity of sensory environment • Speech Pathologists TALK! Auditory background distractions draw children’s attention away from seeing • Difficulty fixating in a noisy environment • Complexity of patterns • Many children with CVI do better with simple patterns or colors on their surfaces • Complexity of visual array • Objects placed on visually complex backgrounds and objects placed too close together can be difficult to see

28. 8. Decreased visual complexity • What can we do about this in our sessions? • Auditory/Sensory • Limit noise/talking when looking for a response • Limit touching, hand over hand • Patterns • Carpet, black plain surface • Visual Array • For AAC – how many symbols per page? • How many objects on table? • How many words in a sentence?

29. 9. Absence of visually guided reach • Children with CVI often look, look away, and then reach • Often localize or fixate on a target, turn away, and then reach in the direction of the target • Looking and reaching can occur as two separate, rather than simultaneous events.

30. 9. Absence of visually guided reach

31. 9. Absence of visually guided reach What this means for SLPs • Think about when you are requesting a choice (looking or reaching) • Make sure you are honoring a child’s look or reach as accurate • Get to know each child’s look and reach pattern • We are often requiring eye contact with target objects, but that is not always possible at the same time as touching an object

32. 10. Distance • We are typically set up well for this specific characteristic, as we normally work very close to the child, whether sitting on the floor, or at a table • Think about language acquisition and incidental learning • Make sure to bring items within child’s functional visual range to show them what you are talking about • Your speech sessions may be set up very well, however… • Think about functional situations and the child’s life

33. 10. Distance • Classroom • Where is the child sitting, and what can they see? What needs to be brought closer? • Home • EI/home based care- Is the family communicating with the child within their visual range of functional vision? • Community • What is happening in the community? What can you bring closer? • Example: Having 3D animals with child while they are at the zoo if they can’t get too close to animals

34. Summary • There is so much variable in speech and language, especially when children are developing skills • Might hear great sounds/words/sentences at one time of day • We know children with CVI’s vision does not fluctuate, it is the environment that fluctuates • Think about how you can alter the environment (positioning, objects, distance, lighting, etc.) so the child can interact with more ease • Most likely will lead to increased communication!

35. Specific Roles for SLPs • There are so many! • Touch upon three large areas that we work in, and point to resources if this covers much of your caseload • AAC • Feeding • Literacy

36. POLL: What setting do you work in?

37. Augmentative and Alternative Communication (AAC) • Think differently than a ‘typical’ progression of AAC • Picture Exchange Communication System (PECS) could be super frustrating for kids with CVI • Symbol-based communication often uses cards • Many colors, fonts, items on one page

38. Augmentative and Alternative Communication (AAC) • When feature matching for an AAC device, always think about 10 characteristics and how that affects what the child can access • Light increases attention  backlit devices • Example: YES NO cards are very different than YES NO on an iPad

39. Augmentative and Alternative Communication (AAC) • Get the child to “buy into it” and understand the value of AAC • Do not lose hope when children are not showing interest in low-tech, no tech AAC! Trial iPad based communication apps, and even eyegaze! • Can always introduce no-tech & low-tech later on (novelty is tough; by then the system will be familiar!) • Eyegaze – an amazing tool for assessing where kids are looking on a screen • Start with screen engagement • Do not rule out eyegaze because of vision difficulties

40. Augmentative and Alternative Communication (AAC)– more resources • Start with Dr. Roman’s webinar • ”Cortical Visual Impairment: The Everyday Impact on People Who Use AAC” • Direct link: https://www.youtube.com/watch?v=GE23MGY87PQ&feature=youtu.be

41. Feeding • Personal note: Feeding is my specialty! • I got into working with children with Cortical Visual Impairment because so many children on my feeding caseload had CVI

42. Feeding • Make sure you know what colors are seen best (for feeding materials) • Help set up feeding environment to screen for complexity • Tray, area surrounding them, shirt you are wearing • If you notice a child’s visual attention is wavering, check out environment and tools you are using • Sensory aversions • So common (for many different reasons) in children with feeding difficulties • Sensory...vision! • Example: Child wouldn’t eat sitting up in high chair, but reclined in mother’s lap works. • Could see what was coming at their face! Ceiling was a less-complex background

43. Literacy • Reading and writing often falls under the scope of SLPs • We are specialists in phonological awareness and phonological processing • School settings especially! • Children in Phase III of CVI continue to need accommodations

44. Literacy • Print motivation – one of the most important pre-reading skills • Make sure books can be seen • Make books predictable (e.g. Brown Bear Brown Bear) • Pay attention to color and complexity • Teaching directionality; left to right • Motor skills needed for reading  interested in with page turning, drop of glue from a hot glue gun or plastic bumpers to help turn pages • Print awareness • Print on a page represents words that are spoken • One word per page, discuss salient features of letters and shape of word

45. Literacy • Blocking materials • Block out excess detail on page • Letters • Use sharpie pens & markers to draw visual attention to key features of letters • Large print • Backlit technology

46. Literacy • My goal: Bring awareness that there are strategies we can employ as SLPs to help children with CVI learn how to read and write • So many wonderful, specific resources out there! • Additional Resources: • Diane Sheline, “Literacy for Children with CVI: Overview and Implications for Different Phases” • http://www.pathstoliteracy.org/literacy-children-cvi-overview-and-implications-different-phases

47. Where to start... Tomorrow! • We already have so many children with CVI on our caseload • Keep going back to the 10 characteristics, and think about how you can employ what you know about the characteristics, to the goals you have for your child • Four box advice:

48. Where to start... Tomorrow! • Environment • Complexity, distance, lighting • Objects • Color, novelty • Cuing • Hand over hand, verbal models  wait time, placement • Variation in behavior during session • Keep track when behavior varies; what is happening?

49. Thank you! Jenna Friedman jennafriedmanslp@gmail.com