vermont sensory access project susan edelman, ed. d.,pt emma nelson, ms ed
TRANSCRIPT
Vermont Sensory Access Project Susan Edelman, Ed. D.,PT Emma Nelson, MS Ed
Introduction to Deafblindness
Deaf-blindness & CVISession Outcomes
• Understand how a combined vision and hearing loss impacts attachment and family bonding as well as all domains of development
• Understand Cortical Visual Impairment (CVI) and the use of effective strategies designed for infants and toddlers with CVI
• Increase knowledge of effective intervention or instructional strategies for children with deafblindness and/or CVI
Conversation (under simulation)
• Prepare:• Read and think about how you will convey
your message • NO SPEECH, SIGN, OR WRITING
• Put on goggles and put in ear plugs• You will be moved and placed with a partner• Introduce yourself and then give your
message (from the paper handed to you)• A tap on the shoulder will signal to remove
your blindfold• Reflection and discussion
What is Deaf-Blindness?
Deaf-Blindness represents
the combinatio
n of varying
degrees of hearing
and vision loss.
Drag picture to placeholder or click icon to add
What is Deafblindness?
• A combined vision and hearing loss
• Also known as dual sensory impairment
• Very few children identified as deafblind are totally deaf and totally blind
• There is a wide range of of cognitive and developmental ability among children who have dual sensory impairments
Did you know…
• Vision and Hearing are both distance senses• 95% of all learning is through
distance senses• 80% of learning is through vision • 90% of learning is incidental
Critical Factors
Four critical factors which affect the severity of deafblindness on the child and his development are:
•Age of onset
•Degree and type of vision and hearing loss
•Stability of each sensory loss
•Educational intervention provided
Tremendous Variability
National Deafblind Child Count Summary• 10,471 (2012)
Losses range from mild to completely blind or deaf
Combination of losses is the significant factor Additional disabilities
• 55% have physical impairments• 62% have cognitive impairments• 47% have complex health care needs• 68% have speech language impairments• 26% have Cortical Visual Impairment
How Many Are Deafblind?
• Nationally• Children (ages birth – 21 years) 10,471 (National
Child Count Data 2012)• Collected via state deafblind projects
• Birth-2 (2012): 555
• Vermont• 2012: 3• Now: 0
Combinations of Hearing & Vision Loss
Blind & Deaf
Minimal Vision & Deaf
Low Vision & Deaf
91 + dBProfound
Blind & Very Limited Hearing
Minimal Vision & Very Limited
Hearing
Low Vision & Very Limited Hearing
71 – 90 dBSevere
Blind & Hard-of-Hearing
Minimal Vision & Hard-of-Hearing
Low Vision & Hard-of-Hearing
50 – 70 dBModerately Severe
41 – 55 dBModerate
Blind & Func
Hearing
Minimal Vision & Functional
Hearing
Low Vision & Functional Hearing
26 – 40 dBMild
0 – 25 dBNormal
Totally Blind
Light Percepti
on
Visual Acuity
20/400 – 20/1000
Peripheral Field
<20 degrees
Visual Acuity
20/200 – 20/400
Visual Acuity 20/70 – 20/200
Normal 20/20
Created by Susanne Morgan Morrow, MA, CI, CT - NYDBC
-Common experience of children with
combined hearing & vision loss
-Some degree of functional vision &
hearing
Etiologies of Deafblindness
Syndromes• Down• Usher• Trisomy 13
Multiple congenital anomalies• CHARGE• Hydrocephaly• Fetal alcohol• Microcephaly• Maternal drug
abuse
Etiologies of Deafblindness
Prematurity Congenital
prenatal dysfunction• AIDS• Herpes• Rubella• Syphilis• Toxoplasmosis
Post – natal causes• Asphyxia• Head
injury/trauma• Stroke • Encephalitis• Meningitis
Assessment Issues
Clinical data important but insufficient
Functional assessment of vision & hearing in natural settings essential
Beyond function of eye and ear, into functional use of sensory input
Assessment Issues continued
• Traditional clinical evaluation and many other assessments tend to be communication dependent
• Symptoms of loss (especially hearing loss) similar to other diagnoses (lack of language development, speech, attention, behavioral challenges, atypical reactions to sensory input or difficulty regulating input)
• Interaction skills of the communication partner during observation or assessment make all the difference in how successfully the child can demonstrate skills
Effects of Hearing Loss on
Development of Communication Loss of adequate
language models Inhibited social
interactions on the part of others
Concept development may be limited
Partners may be limited
May sharpen other senses
Effects of Vision Loss onDevelopment of Communication
Relationship with others- especially infant bonding
Relationship with material world
Concept development Mobility, curiosity,
exploration May sharpen other
senses Compensate for missing
stimulation (“blindisms”) People distance
themselves
Effects of Hearing and Vision Loss
on Development of Communication
• More difficult to compensate for missing input
• Environment is narrowed- without physical contact or close physical presence- ALONE
• Difficult to communicate with more than one person at a time
• May be accompanied by other disabilities• Lack of shared modes of communication• Lack of partner skill to communicate• Intelligence may be underestimated or
overestimated
Tips for Instructional Practice
• Best Practices in Deaf-Blindness:• Developing rapport• Active Learning• Appropriate hand use &
respectful touch• Identifying appropriate
communication modalities• Shared experiences• Interveners
Developing Rapport
Every introduction with a deaf-blind child
requires a ‘greeting ceremony’.”
~Dr. Jan van Dijk
Developing Rapport
• Approach the child from the side, first point of contact should be at the shoulder or leg so as to not startle
• Tap lightly and use your voice to announce yourself, when appropriate
• Wait for acknowledgement and allow the individual to reach or look for communication
Developing Rapport
• Make your hands available; do not manipulate the child’s hands- remember, children who cannot see use their hands as their eyes
• Move slowly, and listen to the child with your whole body. Provide wait time so that the child can process information and move at his/her own pace
• Observe the child closely for communication attempts in the form of movements, muscle tension, change in posture, eye gaze, vocalizations, and gestures and then respond through turn taking
Video Example: Rapport
Barbara Miles Video• Conversations
Chapter 3
Developing Rapport
• The child builds relationships and feels secure
• With this sense of security, the child begins to explore and reach out to learn about the environment
Active Learning
• Active Learning:
• Emphasizes toys with sound and touch
• The Learner is the active one
• Everyone can learn
• Equipment to support active learning: The Little Room/Resonance Boardwww.lilliworks.org/
Appropriate Hand Use
Appropriate Hand Use
What is it?Tactile learning depends on the use of touch to access
information for learning.
•Tactile learning is part of the somatosensory system along with proprioceptive and kinesthetic components of perception.
•People who are deaf-blind depend on their sense of touch for learning, communication and social relationships.
Video Example: Joel
Appropriate and Respectful Touch
Hand UNDER Hand: Placing your hands under the child’s hands allows the child to engage in the activity at his or her own pace. This does not force the child into activities but provides a safe and respectful platform for interacting with the environment.
Hand Under Hand
Shared Modes of Communication
Communication Modalities
Pre-symbolic (concrete) modes• Touch cues, name cues and name signs• Object cues, some tangible cues• Photographs, line drawings (some)
Symbolic (abstract) modes• Tangible symbols• Line drawings (some)• Sign Language• Spoken (Voice Output) Language
Deaf-blind individuals, regardless of etiology or
additional challenges, are, by nature, multi-
modal communicators.
Modes of Communication
Individuals who are deaf-blind will utilize multiple modes of communication, either simultaneously or at different times for different purposes
The child may: Shift modes throughout the course of a day based
on lighting needs, fatigue, or ease of access, Use multiple modes within the same setting, or Use different modes with different communication
partners
Shared Modes of Communication
• The mode of communication you use must be accessible to the child
• Model communication using shared modes
• Provide for incidental learning through access: allow the child to observe conversations in his/her shared mode
Conversations
Shared Experiences
Shared Experiences
• Proximity- having access to people and things for exploration within close proximity
• Wait time: give child time to process information
• Doing WITH, not FOR – sharing an experience not giving an experience
Video Example
• Video of N drinking water with Mamma
BREAK
Vermont Sensory Access Project
Introduction to
Cortical Visual
Impairment
Cortical Visual Impairment
• Information Based on:• Cortical visual impairment: An approach
to assessment and intervention, 2007, AFB Press by Christine Roman-Lantzy
• Selected slide content provided bySandra Newcomb, PhDConnections Beyond Sight and SoundUniversity of Maryland
What is Cortical Visual Impairment?
• Vision loss due to damage or malformation in the brain that interferes with the child’s ability to understand visual information coming from the eyes
• CVI is the leading cause of visual impairment in young children living in the Western Hemisphere
CVI is suspected when:
• Medical eye exam cannot explain level of visual impairment
• History of brain injury or malformation
• Presence of unique visual characteristics
Medical history significant for CVI
• Asphyxia/Hypoxic-ischemic encephalopathy (HIE)
• CVA/stroke• Intraventricular hemorrhage (IVH)• Periventricular leukomalacia (PVL)• Infection• Structural anomalies• Trauma• Prematurity• Metabolic disorders
CVI Characteristics
CVI Characteristics
Unique visual characteristics
1. Color preference2. Need for movement3. Visual latency4. Visual field preferences5. Difficulties with complexity6. Light-gazing and nonpurposeful gaze7. Difficulty with distance viewing8. Atypical visual reflexes9. Difficulty with visual novelty10.Absence of visually guided reach
Color preference
• Color vision is usually preserved in children with CVI
• Children often have a favorite color or will only look at certain colors
• Children with typical vision or ocular problems will look at any color
Need for movement
• Movement attracts visual attention
• Children with CVI may only look at something that moves or has movement quality (shiny)
• Way to “jump start” the visual system
• Often helps children with CVI with mobility
Visual latency
• Latency is the length of time between when a visual stimulus is presented and when a child looks at or orients towards the stimulus
Visual Field Preferences
• Children often have field losses or field preferences with a strong preference for looking at objects when presented in specific positions of peripheral and/or central viewing fields
COMPLEXITY
Complexity of array
Complexity of sensory environment
Complexity of target/object
Complexity of Target/Object
Complexity of Array
Complexity of Sensory Environment
Light Gazing and Non-purposeful Gaze
• 60 % of children with CVI often compulsively gaze at lights
• Most have periods of non-purposeful gaze when they are not looking at anything in particular
Difficulty with Distance Viewing
• Children with CVI can often only look at things close to them
• Distance is a function of complexity
Distance Viewing
Atypical Visual Reflexes
• Reflexes often absent, latent, or inconsistent
• Blink to touch between eye brows
• Blink to threat
Difficulty with Visual Novelty
• Children with CVI often look at familiar things better than novel items
• Novel environments can be challenging
• Familiarity is easier because CVI is about learning. The child has learned to look at what is familiar.
Absence of Visually Guided Reach
• Children with CVI often have trouble using eyes and hands together
• Often look, look away and reach
• Some children cannot look at what they are holding
• Some children need to touch something to look at it
Assessment: CVI Range
Parent Interview
Observation
Direct Evaluation/Interaction with Child
CVI Range
• Number ranges (0-10 scale used in assessment) describe specific levels of functioning
• Phases (I, II & III) describe broad functioning levels and guide intervention strategy to support best visual functioning
Phases of CVI
CVI Phases
Severity of CVI
• Severity of CVI is described in three phases• Phase 1 (Severe)• Phase 2 (Moderate)• Phase 3 (Mild)
• CVI phase is determined by assessment using the CVI Range
• Intervention guided by phase and characteristic
Severe CVI - Phase I
• Limited use of vision and cannot do anything else when they are “looking”
• Most CVI characteristics interfere with visual functioning
• The major goal of Phase I is to build stable visual functioning
• We want to give the student practice “looking”
Moderate CVI - Phase II
• Major goal is to begin to integrate vision and function
• We want to give the child practice using vision in the context of daily routines and activities
Mild CVI - Phase III
• Major goal of Phase III is to use vision for learning
• Children demonstrate visual curiosity
• Children can look at pictures and other 2-dimensional material
• Children can use their vision to learn about their environment
Vermont Sensory Access Project
Intervention for children with CVI
Progression of Resolution
• Early Resolution• Light gazing, blink reflex
• Mid Resolution• color, latency, novelty, visual threat,
movement
• Later Resolution• Field, visual motor, complexity, distance
viewing
General intervention principles
Intervention must be intentional
Intervention must be precise
Expect change
Always be aware of the environment
General intervention strategies
Intervention needs to occur in the context of every day life of the child
Children often perform better at home
Provide input at the child’s level, NOT above
CVI intervention is an approach not a therapy
Interventions “Environmental engineering”
• Careful selection of targets• Background • Sequencing of increasing complexity
Diagnostic teaching • Exposure• Recognition• Discrimination• Teaching child to use vision
Fade supports as visual function shows “resolution” of CVI characteristics
Phases
Intervention by CVI Phase
Build Stable Vision
• High level of environmental control
• Plan times of the day when the child can practice vision without other demands
• For each position that child spends time, place something (from “vision” toys) to look at
Phase One Intervention
Phase One Intervention
Use “down” time for vision activities, e.g. tube feeding
Use single colored objects/favorite toys
Move object slightly/use reflective materials
Use light to initiate looking at an object/target
• Use characteristics of familiar objects to introduce new objects
• Bring items closer and place them on plain black background
• Allow child to focus visually without auditory distraction
• Present objects in the child’s preferred visual field
Phase One Intervention
Phase One Intervention Ideas
Phase One Intervention Ideas
Phase Two Intervention
• Integrate vision into all routines
• Intervention is overlay in all activities
• Plan the vision component of the beginning, middle, and end of all routines
• Use objects from Phase 1 with expectation that child will act on materials
Phase Two Intervention
• Limit number of objects presented simultaneously
• Use lightbox to direct visual attention
• Move highly motivating objects further away
• Touch may initiate looking
• Use familiar objects in daily routines
• Use new objects that share characteristics of familiar objects
Phase Two Intervention Ideas
Demonstrate visual curiosity, visual learning
• Spontaneous use of vision
• May look at self in mirror
• May look at pictures
Phase Three Intervention
Still may have problems in new environments
Remember prior preferences in color, movement, light, etc when introducing novel materials
Literacy: Highlight words with color, limit complexity, teach shapes of words
Phase Three Intervention
Phase Three Intervention Ideas
Phase Three Intervention
Preview environments, teach landmarks
Tell the student what to look for in a visual display or environment
If child does not look at something, review complexity
Use movement for distance viewing
Point out/teach salient features in pictures
Phase Three Intervention Ideas
Activity
• You will be placed in groups around your table
• You will be given a profile of a child with CVI
• Work together as a team to develop interventions that could be implemented in the home across daily routines and activities• Consider: how would you involve the
family, what items would you use, how will these items change as the child moves through the phases
Questions
Questions?
Vermont Sensory Access Project
Susan Edelman, Ed.D., PTProject Director, Vermont Sensory Access
Project (VSAP)[email protected]
Emma Nelson, M.Ed.Project Coordinator, Vermont Sensory Access
Project (VSAP) [email protected]
Thank you for participating. For more information please
contact us at the number or email below.
University of VermontMann Hall208 Colchester Ave, 3rd FloorBurlington, VT 05405http://www.uvm.edu/~cdci/