CVI: Visual Guidance of Upper Limbs

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 Visual Guidance of Upper Limbs?

Visual guidance of upper limbs (arms, hands) is part of the broader category of visually guided movement of the limbs and body. People with CVI may:

have difficulties with visual motor tasks that involve eye/hand use.
rely on their hearing or touch to determine the location of an object.
have difficulty or the inability to reach while maintaining visual attention, reach and place items while looking, reach accurately while looking, and look while exploring an object.
display reaching that is sweeping, slow or guided by physical contact with a surface area.
not accurately modify their hand or arm shape to collect something or catch a ball.
have difficulty placing one item in correct positions related to other items (next to, on top of, or on) using solely their vision.
show increased difficulty with visual motor skills when there is increased visual clutter, if the item or task is unfamiliar, when fatigued, or in response to an environment that is not appropriately adapted.

Dinner is a messy affair at our house. My son either knocks over his drink or puts the cup too close to the edge and it falls off. We’re used to it!
Rachel, CVI Parent

What are some compensatory strategies related to Visual Guidance of Upper Limbs?

Many with CVI build strategies to compensate for difficulty with visual motor skills. Some of these strategies include:

using sweeping arm movements (reaching from around the side) and exaggerating the shape of their hand and arm positioning
using tactile cues and skills to gain information
relying on memory
guiding a trusted adult to find and pick up an item
using auditory cues to gain information
using vision and motor skills separately to complete a task (i.e look at an object first then reach while not using vision; touch object first, look at it, reach while not using vision)

[Regarding not being able to look while reaching or with other sensory stimuli:] What I don’t agree with is that [people without CVI] usually refer to this like it’s a bad thing… What people who don’t have CVI don’t realize, is that I only look at things when I absolutely need to. I look at things when I’m reading, for instance, but most daily activities don’t require looking.
Teenager with CVI, Yellowstone Blog 1 on CVIScotland.org

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

When it comes to observing visual motor skills, take into consideration how these skills are impacted by color, motion, field, clutter, light, recognition, competing sensory information, the familiarity of object or environment, in addition to fatigue and time of day.

Does your child look while reaching for an object? Look when manipulating an object? Does your child use tactile and auditory skills to reach for and manipulate objects?
How does your child reach for something? Is it fast and efficient or slow and cautious? Do they reach to the side and beyond the object and then sweep it closer to retrieve it? Do they bring their hand slowly in from the side or from the top? Do they often overreach or underreach?
Does your child knock things over a lot?
What does the hand position look like when your child reaches for an object? Do they approach the object with an open flat hand and then close their hand around it? Do they adjust their hand position when picking up items in different orientations or sizes before tactilely engaging?
To what extent do they use tactile cues to support guidance of arms and hands? For example, do they reach for an item but use tactile cues to identify the exact location?
How does your child do with placing objects into openings, containers, or slots? Are they able to place an item in a big opening? What about placing an item in a small opening? Do they have difficulty orienting puzzle pieces to fit in their corresponding spots?
If your child is a handwriter and/or a drawer, what do you notice about this process? Do the printed words veer upwards or downwards? Are the letters or words or images stacked on top of each other? Does the writing lack spacing? Is the placement of the writing utensil inaccurate?
Does your child reach accurately for targets in their environment? For example, door handles, railings, elevator buttons?

My son has a difficult time using visual-motor skills. He’ll reach past something, around it, or stop short of it. He often uses tactile skills when searching and reaching for something. He rarely looks and reaches at the same time. And that’s okay! He has strategies that work for him. He uses his vision when he wants to. When the task and environment allow visual access (reduced clutter, noise, and movement, and accessible materials), he’ll visually guide his arm and hand. But after a certain point that still becomes fatiguing.
CVI Parent

What are some examples of adaptations and accommodations?

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

A team must consider all the other CVI visual behaviors when supporting visual motor tasks, along with the student’s whole-child needs. What compensatory skills can we leverage to make sure the full learning task is accessible? The goal isn’t simply for the child to look while reaching, the goal is to make learning accessible. If visual motor tasks are fatiguing (i.e. cutting out letters to stick on a worksheet or handwriting a paragraph), it’s essential to always go back to the learning goal—do these visual motor tasks need to be a part of the learning activity in order for the student to learn a new concept or skill?

Reduce visual clutter and crowding. Simultaneous visual information may disrupt visual attention and recognition. If something can’t be seen or recognized, then the act of reaching for it will be difficult. Incorporating systems for organization and storage can be a great support.
Leverage color, contrast, and light. Use bright, bold colors to support visual attention and recognition while using visual motor skills. The incorporation of color should be strategic as adding too much color to the environment can increase the impact of crowding. For example, bright blue tape around the rim of a container, green tape on the washer start button, or yellow highlighted writing lines. Make sure color is used to support increased contrast to help the target pop and stand out. Use backlit devices or task lighting to support the guidance of hands and arms.
Consider the impact of motion. Sometimes, slow methodical movement of an object can support visually guided reach. But the fast motion of objects can make the use of visual motor skills extremely difficult. Consider using tactile and auditory cues when engaging with faster-moving objects (i.e. throwing and catching a ball).
Present materials in accessible visual fields. Does your child see best at left, right, or central? Place items on a slant board with a magnet or velcro board if your child has difficulty with their lower visual field. Raise items up to eye level using a dark color plain box.
Reduce noise and distracting light and movement. Allow the student to focus on one task at a time (i.e. writing, listening, or speaking). If the student prefers, work on challenging motor tasks in a quiet space with minimal distractions (background noise, light, movement). Ensure that the student is fully physically supported using the equipment that matches their needs. Consider fatigue and time of day when engaging in challenging visual motor tasks.
Allow use of compensatory skills and non-visual learning methods. Allow the person with CVI to choose how they want to guide the movements of their arms and hands. More and more people with CVI report that they can’t rely solely on their vision to guide reaching and often use tactile guidance for visual motor tasks. Build in opportunities for cultivating tactile and/or auditory skills during fine and gross motor tasks. What are some blindness skills that can support these motor tasks when the person with CVI is visually fatigued or chooses not to use their vision? For example, when wetting the toothbrush under the faucet, use touch to find the brush head, turn on the water, find the water pouring out of the faucet, and tactually guide the brush head under the water. Or use assistive tech devices like a vibrating liquid level indicator when pouring something into a cup or bowl.

Find more examples from A Guide to Common CVI IEP Accommodations in the CVI Now IEP Guide.

Following the science

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

Optic Ataxia is impaired coordination and accuracy of visually guided movements of limbs and body not related to motor complexities. Optic Ataxia results in difficulty completing visually guided tasks. This impacts the ability to judge distance, depth, and weight, which is needed for motor action. Damage or interruption to the posterior parietal cortex is connected to optic ataxia.
Object constancies (ability to continue to recognize an object, even when the position, size, angle, viewpoint/shape, lighting, or color changes) impact visual guidance of goal-directed actions: 1) When reaching out to pick up an object, the hand’s in-flight opening correlates with the size of the goal object. 2) Computing object distance is crucial for size constancy and grasp aperture scaling.
Visual-spatial mapping: The dorsal visual stream (particularly the posterior parietal lobe) plays a major role in creating an unconscious 3D map of the world around us. Why is this important for the visual guidance of limbs? When this 3D mental map doesn’t match the reality of the surrounding environment, the result is Optic Ataxia. According to Dr. Gordon Dutton in CVI Scotland’s lesson on Optic Ataxia: “This 3D map matches where things are in the real world, in terms of how far away they are, and gives every visual detail the properties of depth and distance in your mind. To move through the real world without bumping into people and things and to reach for things with accuracy, these two worlds (world 1 is the reality of the surroundings, and world 2 is the non-conscious mental copy of them) need to match.”

Learn more about the development of the Perkins CVI Protocol.

References

Atkinson, J. (2017). Visual Brain Development: A review of ‘‘Dorsal Stream Vulnerability’’—motion, mathematics, amblyopia, actions, and attention. The David Teller Award Lecture, 2016. Journal of Vision, 17(3): 26, 1-24.

Atkinson, J., & Braddick, O. (2011). From genes to brain development to phenotypic behavior: “dorsal-stream vulnerability” in relation to spatial cognition, attention, and planning of actions in Williams syndrome (WS) and other developmental disorders. Progress in Brain Research, 189, 261–283.

Chokron, S. & Dutton, G. N. (2016). Impact of cerebral visual impairments on motor skills: Implications for developmental coordination disorders. Frontiers in Psychology 7(1471), 1-15.

Chokron, S., Klara, K., & Gordon D. (2021). Cortical Visual Impairments and Learning Disabilities. Frontiers in Human Neuroscience 15, 573.

Goodale, M. A. (2013). Separate visual systems for perception and action: a framework for understanding cortical visual impairment. Developmental Medicine and Child Neurology, 55(4), 9-12.

Greulich, R. S., Adam, R., Everling, S., and Scherberger, H. (2020). Shared functional connectivity between the dorso-medial and dorso-ventral streams in macaques. Sci. Rep. 10, 1–17.

Kelly, J., Phillips, J., Saneto, R., Khalatbari, H., Poliakov, A., Tarczy-Hornoch, K., & Weiss, A. (2021). Cerebral visual impairment characterized by abnormal visual orienting behavior with preserved visual cortex activation. Investigative Ophthalmology and Visual Science, 62(6), 1-11.

Lueck, A. H., & Dutton, G. N. (2015). Vision and the Brain: Understanding Cerebral Visual Impairment in Children (pp. 497-536). New York, New York: American Foundation for the Blind Press.

Philip, S.S. and Dutton, G.N. (2014), Cerebral visual impairment in children: a review. Clin Exp Optom, 97: 196-208.

Roman-Lantzy, C. (2018). Cortical Visual Impairment: An Approach to Assessment and Intervention. 2nd ed., New York, NY: AFB Press.

Van Polanen, V., and Davare, M. (2015). Interactions between dorsal and ventral streams for controlling skilled grasp. Neuropsychologia 79, 186–191.

Whitwell,R., Sperandio, I., Buckingham, G., Chouinard, P., Goodale, M. (2020). Grip Constancy but not Perceptual Size Constancy Survives Lesions of Early Visual Cortex. Current Biology. Vol 30, Issue 18. https://www.sciencedirect.com/science/article/pii/S0960982220310186