CVI: Access to People

Written by: Rachel Bennett

At Perkins, we are a gathering place of ideas. The CVI visual behaviors synthesize current research and build on the work of leading theorists in the field. CVI is a lifelong disability and we want to ensure that all individuals with CVI are fully understood. The CVI visual behaviors are an ongoing need, they can change and they can improve for some, but the need never goes away. No one area is separated from the other—the CVI visual behaviors are highly connected and all can impact the individual with CVI at any time.

What is Access to People?

Some people with CVI may have difficulty or inability to:

look at faces and make eye contact.
recognize faces.
interpret facial expressions or understand facial cues.
understand body language, mood, visual cues (e.g. slumped shoulders), and gestures (e.g. high-fives, handshake).
identify familiar people in photographs.
understand the speed, distance, and direction that someone is coming toward them.
follow fast movement—including being able to follow people walking towards them, as well as communication signs and gestures.
respond appropriately within social situations

The difficulty with access to people can cause social anxiety, reduced self-image, and self-esteem.

I missed social cues, I misinterpreted people’s reactions and I couldn’t always recognise the person that was talking to me… I often found it difficult to process what people were saying, especially if I was in a visually cluttered environment, or if there were too many people involved in the conversation.
Nicola McDowell, “CVI and mental health”

What are some compensatory strategies related to Access to People?

Many with CVI build incredible strategies to recognize others when they can’t recognize faces or recognize emotions, or when they can’t interpret facial expressions. Some of these strategies include:

Use of nonvisual cues to recognize people including voice, smell, or sound of footsteps.
Use of non-facial visual attributes such as hair (color or style), clothing, shoes, height, posture, or gate.
Use of specific attributes on the face such as glasses or beard.
Context and memory of the place where they usually find a person.
Tactile cues such as tactile name tag or personal identifier.

I can see everything about [people], except their faces. When I’m at a party, I’ll see people but I won’t see their faces so it’s very hard for me to see who they are.
Young adult with CVI

What are some look fors/questions when observing your child with CVI?

To what extent does your child establish and sustain eye contact? Does it appear they are looking toward you but not directly at you?
To what extent does your child look at faces? Does your child only look at faces of familiar people?
Does your child tend to look at certain features of a person such as hairline, mouth/teeth, clothing, or glasses?
Does your child look away from a person’s face or body when that person is speaking? (Relates to difficulty with access to people and sensory integration).
Does your child look at themselves in the mirror? If so, what do they do? Make eye-contact with themselves? Look at while they move parts of their body such as waving arms or moving the head/body from side to side? Do they use the mirror for self-grooming tasks?
Does your child recognize familiar people without hearing them speak? Does your child recognize a family member outside of their usual context (without voice prompts)?
Does your child mistake others for a family member? For example someone with similar hair or height?
How does your child recognize people around them? Hair color/shape, height, gate, clothing, shoes, glasses, voice?
To what extent does your child recognize gestures such as a wave, high five, or handshake?
Does your child mimic some of your facial expressions, such as a smile or surprised face?
Does your child have difficulty joining groups and/or recognizing familiar people when they are in a group?
Does your child often use strategies to get other people to speak?

I can’t see pedestrians moving. I’m quite likely to bump into them. Or suddenly there’s a person in my face and I’m still walking and I have no idea what to do to avoid them, so it can be very stressful to even just walk along a sidewalk.
Student with CVI

What are some examples of adaptations and accommodations?

All accommodations must be based on individual assessments. The following are meant to inspire and provide a general idea. Accommodations and instructional approaches must be student-specific. Access is individual.

Examples from a guide to common CVI IEP accommodations:

Your child may need a voice cue or verbal confirmation to identify others.
Your child may need educators to wear a name tag or have a personal identifier to support recognition.
When first approached in a busy environment, your child may need a verbal cue to know who is coming near them and be addressed by name. For example, “Hi Harry, it’s Mr. Sean, I’m walking toward you on your right side (accessible visual field).”
Your child may need to receive a consistent alert to show that an educator wants to speak with them. For example, “Hi Mark, it’s Ms. Edwards. I would like to talk to you about ____.”
When your child is interacting with a not-so-familiar adult or peer, the person should introduce themselves and say how they are connected. For example, “Hi Henry, it’s Ms. Amanda, I walked you to your bus yesterday.”
Visible features may need to be pointed out to your child (for example, glasses, hair color, and shape). For example, “Today ___ is wearing a red shirt.” The visual attributes of others, including peers, should be pointed out, too. For example, “Carmen, join Zoe, who’s wearing a bright pink shirt today.”
Your child should be informed who’s in the room with them (especially if others are at a distance) and what they are doing.
Your child should be provided with verbal information during social situations. For example, “Your friend is waiting outside the classroom in her green coat.”
If your child is able to look at photographs of people, the educator might:
- pair photographs of people presented on a plain background with a tactile symbol or written name to support recognition.
- use photographs of faces to support emotion identification and expressions.

Prosopagnosia is not only the inability to recognize faces, it can also involve experiencing faces as twisted and contorted… trying to look at people made it impossible for me to pay attention to what they were saying. If I really wanted to hear them, I had to tune out visually.
Nai, “On Social Anxiety and Cultural Norms”

Following the science

Connecting current research on the brain, our visual system, and CVI to better understand the CVI visual behaviors.

Research shows that facial recognition occurs in several places in the brain: Fusiform Face Area (FFA), located in the inferior temporal cortex, supports recognition and identification of faces, Occipital Face Area (OFA) supports the structural processing of faces, and the Superior Temporal Sulcus (STS) supports the processing of changeable aspects of faces (such as facial expressions, the direction of eye gaze, expression, lip movements, or lip-reading). Both brain hemispheres are activated, but more significantly on the right. (Lange et al, 2009; Nagy et.al., 2012)
Beyond these facial recognition areas, the brain processes complex information about a person such as mood, level of interest, attractivity, or direction of attention. This extended system includes the amygdala, insula, inferior frontal gyrus, and orbitofrontal cortex. (Nagy et.al., 2012; Bergland, 2019)
Prosopagnosia (face blindness or facial agnosia) is a “neurological disorder characterized by the inability to recognize faces.” Prosopagnosia from occipitotemporal damage is associated with right or bilateral loss of the fusiform and/or occipital face areas (Barton et al, 2021). It’s important to note that other CVI behaviors can also cause difficulty with facial recognition, including simultanagnosia, the impact of clutter, visual field loss, reduced visual acuity, and reduced contrast sensitivity.
Biological motion perception is the “ability to perceive the moving form of a human figure from a limited amount of stimuli, such as from a few point lights located on the joints of a moving body.” (Wang, Z. et al, 2016) Biological motion can involve hand, eye, lip, or whole-body movements, which, together with faces, constitute crucial ingredients of social cognition and interaction. If biological motion is impaired, it can be difficult to perceive body language, hand gestures, or the actions of a person moving in space.

Learn more about the diverse ways CVI can impact face and object recognition from Dr. Corinna Bauer’s webinar on Ventral Stream Functions in CVI: Object and Face Perception.

Until I learned about my son’s CVI, I never knew why he didn’t recognize me when I came into a room or came to pick him up at school. Why he went up to strangers thinking they were me or his dad. If I’m standing in a group of people, he’ll go up to each of us until he can find me. If I stay quite in a room at home, he won’t know I’m there until I say something.
CVI parent

A short video about face blindness. Filmmaker James Robinson shows us how Paul navigates social interactions, his strategies for managing face-blindness and how society can better respond to the needs of people living with the condition. Paul uses secondary traits to support recognition of people like how they walk and their pitch and tone of voice. But he also needs someone to introduce themselves and say how they are connected; for example, “We met at the Blue Moon restaurant or talked about Ulysses for an hour.”

References

Barton, J., Davies-Thompson, J., Corrow, S. (2021). Prosopagnosia and disorders of face processing. Handbook of Clinical Neurology. Vol 178 pp 175-193. Retrieved April 26, 2022 from https://www.sciencedirect.com/science/article/abs/pii/B9780128213773000064
Behrmann, M. & Plaut, D. C. (2013). Distributed circuits, not circumscribed centers, mediate visual recognition. Trends in Cognitive Sciences, 17(5), 210-219.
Bergland, C. (2019). Digital Image: Facial Expressions. Psychology Today. Retrieved April 26, 2022 from https://www.psychologytoday.com/ca/blog/the-athletes-way/201901/35-facial-expressions-convey-emotions-across-cultures
Chokron, S., Klara, K., & Gordon D. (2021). Cortical Visual Impairments and Learning Disabilities. Frontiers in Human Neuroscience 15, 573.
Dalrymple, K. A. & Palermo, R. (2016). Guidelines for studying developmental prosopagnosia in adults and children with CVI. WIREs Cognitive Science, 7, 73-87.
Duchaine, B. C. & Nakayama, K. (2006). Developmental prosopagnosia: a window to content-specific face processing. Current Opinions in Neurobiology.16, 166-173.
Dutton, G. (2015). “Disorders of the brain and how they can affect vision.” In: A. H. Lueck & G. N. Dutton (eds). Vision and the Brain: Understanding Cerebral Visual Impairment in Children (pp. 39-82). New York, New York: American Foundation for the Blind Press.
Hadders-Algra, M. (2022). Human face and gaze perception is highly context specific and involves bottom-up and top-down neural processing. Neuroscience & Biobehavioral Reviews, 132, 304-323.
Haxby, J. V., Hoffman, E. A., & Gobbini, M. I. (2000). The distributed human neural system for face perception. Trends in Cognitive Sciences, 4(6), 223-233.
Lange J, de Lussanet M, Kuhlmann S, Zimmermann A, Lappe M, Zwitserlood P, et al. (2009) Impairments of Biological Motion Perception in Congenital Prosopagnosia. PLoS ONE 4(10): e7414.
Nagy, K., Greenlee, M., Kovacs, G. (2012). The lateral occipital cortex in face perception network an effective connectivity study. Front. Psychology. Retrieved April 26, 2022 from https://www.frontiersin.org/articles/10.3389/fpsyg.2012.00141/full#B34
Roman-Lantzy, C. (2018). Cortical Visual Impairment: An Approach to Assessment and Intervention. 2nd ed., New York, NY: AFB Press.
Shinskey, J. & Jachens, L. (2014) Picturing Objects in Infancy. Child Development, 85(5).