How do you center CVI in O&M assessments? Strategies for CVI and O&M: Part 3

Yalissa walks down a sidewalk with a female Perkins staff member.

How do you know when a student with CVI needs O&M instruction?

The first step toward incorporating O&M into an Individualized Family Service Plan (IFSP) or Individualized Education Plan (IEP) of a student with CVI is a comprehensive, CVI-appropriate assessment. The functional vision assessment (FVA), learning media assessment (LMA), and environmental assessment provide a foundation for the O&M assessment.

“A CVI assessment should already have been completed with the O&M assessment,” says Susan Abu-Jaber, TVI, COMS, in an Expert Q&A on CVI and O&M. “This will give a lot of information about where to start, and the kinds of CVI supports the child needs throughout the day.”

Learn more about CVI-specific tools a TVI may use to complete the FVA, LMA, and environmental assessment.

Emily Price, CVI-certified COMS at Perkins School for the Blind, explains that the ultimate goal of an O&M assessment is to get “a full picture of what a student can do and what they need to work on. I think collaboration with the team is a really important part, especially with the family. The family knows their child the best, they know what they can do, and what might need some development.”

Every child with a visual impairment has a right to an O&M assessment. This includes children with CVI, even if they have co-existing disabilities or limited independent mobility. Under US law, O&M is a key related service for students with visual impairments and is “provided to blind or visually impaired children by qualified personnel to enable those students to attain systematic orientation to and safe movement within their environments in school, home, and community…” (Individuals with Disabilities Education Act Sec. 300.34 (c) (7)) It is also one of the nine areas of the Expanded Core Curriculum (ECC), which is a fundamental part of educating students with visual impairments.

“Fundamentally, kids with CVI are kids with visual impairments,” says Allie Futty, TVI, COMS, CATIS, and Program Manager at Northeast Resource Center for Vision Education. “And if you said, ‘This kid with a visual impairment doesn’t need O&M,’ I think that is very concerning if you haven’t done an orientation and mobility evaluation.

I have yet to meet a kid with CVI who doesn’t need some level of O&M support.
Allie Futty, TVI, COMS, CATIS

Price agrees that we should consider O&M for every student with CVI. O&M “was designed and is designed for people with visual impairments. And CVI is a visual impairment. Students with CVI can’t acquire travel skills incidentally from observing their peers, which is what we look at with students who have just ocular impairments. They need direct, purposeful instruction.”

Explore the many reasons why a student with CVI needs tailored O&M instruction.

Grace, a student with CVI, sits in her power chair and works with teacher Alivia Gorman who shows her a purple light.

Referrals for O&M assessment

Often, O&M assessments occur after a referral based on an eye report, a process that inadvertently excludes some kids with CVI who do not have an official diagnosis.

Regardless, an O&M assessment is warranted if the student can’t travel in an age-appropriate way in any environment in the same manner as their peers. At the end of the day, an O&M assessment should be conducted “if anybody on the team has concerns about the child’s ability to independently travel in the environment – and that’s not just in one familiar environment,” says Futty.

Parents know their kids best and see them in a broad range of environments, while educators are mostly limited to day-to-day on-campus observation. Therefore, parents can help build a strong case for O&M assessment by documenting their observations.

Valery Kircher, TVI, COMS, and Education Coordinator for the Virginia Department for the Blind and Vision Impaired, suggests a few prompts to help a parent get started with documentation:

Will your child hold your hand or arm in a busy environment such as a large store?
Have you noticed that they are not independent when going up or down steps?
Are they unable to notice moving cars when you are crossing a street together?
Are they upset when you go to a busy place?

Abu-Jaber notes that video can be another powerful form of documentation.

“Video could be very helpful in explaining your concerns,” she says. “Are there particular environments or times of day when your child has greater difficulty? Can you show the contrast between safe and less safe travel?” (Expert Q&A: CVI and O&M)

Family documentation can round out the information about the child’s skills across settings. “An evaluation can go quickly,” Price explains. As an O&M specialist, “You don’t always know the student as well as you would wish. Videos show all these other environments that we don’t get to see because maybe they are great in a school environment but they need help out in the community or just even outside the school building itself.”

What if your school pushes back because your child ‘isn’t ready’ for O&M?

Parents may encounter resistance when advocating for an O&M assessment. Team members may not think the student is ready for O&M for many misguided reasons, including limited independent mobility, cognitive delays, or co-existing disabilities, none of which should be used as grounds to deny a student access to O&M.

Price reminds us that there is so much more to O&M than moving from point A to point B by ourselves – much of which can be addressed whether or not a student is ambulatory. “We’re looking at sensory awareness, body image, concept development, spatial awareness. I think a lot of that gets forgotten. We think O&M is all about learning how to use a cane or crossing the street. I look at the goal of O&M instruction for students who are not moving independently as having them be an active participant in their travel.”

APH also mentions five areas an O&M specialist will assess that go beyond movement, yet are crucial to developing O&M skills:

Activities of daily living
Social skills
Planning
Literacy skills
Use of optical aids and assistive technology

In some cases, Futty says, there are more steps on the journey to an O&M assessment – but this should not be rationale to exclude a student. “Sometimes kids who have complex learning needs, other priorities will rise to the surface. That doesn’t mean that kid doesn’t need O&M.

“For example, it’s hard to engage in O&M regardless of how you access mobility, whether it be through your legs or some kind of wheelchair or power mobility device if you don’t have good trunk support and you haven’t found a piece of equipment you can travel in yet,” Futty explains. “So there are sometimes situations in which there are just bigger priorities. But that being said, every kid with CVI has a legal right to an orientation and mobility evaluation, and anybody who says that’s not true just doesn’t understand that CVI is a visual impairment.”

What if your school district says they don’t have an O&M instructor on staff?

“Under US federal law, IDEA, a school district saying, ‘We don’t have an orientation mobility specialist,’ is not an acceptable answer,” says Kircher. “Fortunately there are now contract companies who will provide an orientation mobility specialist who can come into a school district, complete an assessment, and then go from there.”

Ideally, the evaluator will have CVI knowledge. Kircher recommends that, before conducting an O&M assessment, the O&M specialist should have “at least a basic understanding of what CVI is and understanding how both the dorsal and the ventral streams impact the student.”

Elements of an O&M assessment

An O&M specialist with CVI knowledge should conduct the assessment over several sessions to see the student in various environments and, ideally, on different days and times to account for potential visual fatigue or other factors that may impact the student’s abilities (e.g., ill, tired, overwhelmed by sensory input).

An O&M assessment includes:

Records review
Observations in different environments and times of day
Stakeholder interviews with members of the team, including parents and the student, if possible
Observation
Direct assessment

It’s important to take a team-based approach. Team members will see the child in different environments and, therefore, notice other behaviors.

“I assessed a student who was in school, and the teachers couldn’t figure out why he always had to run all over the playground,” Kircher recalls. “Well, one of the reasons he had to run all over the playground was because he had to be in motion to see.”

In this case, the teachers noted the behavior and the O&M specialist was able to explain it in terms of CVI visual behaviors.

Observation and direct assessment must be based on a working knowledge of CVI. Kircher provides examples of what she might look for in an elementary school student with CVI, which come from Dr. Gordon Dutton’s Visual Skills Inventory:

Are they able to locate a rolling ball? What about a thrown large ball (non-beeping)?
Are they fearful when traveling in crowded spaces when the fear is not due to another disability or health concern?
Are they able to independently locate steps or curbs or do they miss these?
Do they bump into doorframes?
Are they able to travel independently from their class to the school cafeteria after being in school for about a month?
How does the child do on the playground? Do they avoid other children? Are they only able to locate the teacher if he is wearing a specific color? Do they bump into things or trip? Do they tend to run quickly across the playground because of the impact of motion on their functional vision?

Pro tip

During the direct assessment, “Questioning should be conducted without offering cues to avoid the possibility that the individual will simply look for a target that is similar to the one requested,” write Alisha Waugh and Christine Roman-Lantzy. “Unlike a verbal prompt that includes the name of the target object, prompts such as ‘Tell me what you see’ or ‘Can you find all the toys that have been placed in the hallway?’ require the individual to notice something novel and unprompted.” (CVI: Advanced Principles, 2019)

Taking a CVI-specific approach

Abu-Jaber describes the CVI-specific O&M assessment as “a synthesis of that O&M information, that CVI information and how it relates specifically to each child, and an analysis of the complexity of both the environment and the task the child needs to accomplish.” (Expert Q&A: CVI and O&M)

She lists three important areas the O&M assessment covers:

How CVI impacts accessible vision in ideal conditions as well as challenging conditions
What O&M concepts and skills the student uses in ideal conditions as well as challenging conditions
How environmental complexity impacts the child’s ability to access vision to use current skills and develop further O&M skills

Visual behaviors

An O&M specialist with CVI understanding knows to look for the impact of the CVI visual behaviors on the student. For example, “we’re looking at visual guidance of lower limbs because that’s often a big indicator that a student may need to learn how to use a cane, as well as visual fields,” Price explains. “There’s so much that’s impacted with visual behaviors when it comes to O&M. If there are difficulties with the complexity of the environment, that impacts travel, like a busy hallway. How can we teach a student to negotiate that?”

Read about the CVI visual behaviors and how they impact O&M.

Environment

The evaluator should also look at all that’s happening in the environment: visual clutter, noise, distracting movement and light, temperature, unfamiliar parts. “When the environment changes in its level of complexity (for example, has greater pedestrian or vehicular traffic) and [something unfamiliar] (such as a change in a window display by a known drop-off point), a student can become disoriented and miss the hazard that was previously detected,” Waugh and Roman-Lantzy note. “If the student is not feeling well or is more fatigued, visual latency will have a greater impact on his or her ability to efficiently process environmental hazards in adequate time to respond.” (CVI: Advanced Principles, 2019)

A CVI-specific tool like Matt Tietjen’s “What’s the Complexity” Framework can help ensure activities provide the right level of challenge, balancing the complexity of the environment and the task.

Internal and external stressors

The O&M report must discuss how fatigue, stress, and emotional upset impact skills and skill development because these factors reduce visual access. For example, stress limits a student’s ability to access their catalog of visual imagery in the brain and makes it difficult to learn and employ O&M skills and concepts. Excessively challenging activities can lead to elevated levels of frustration, feelings of failure, and limited motivation, causing the student to shut down or exhibit certain behaviors. (Expert Q&A: CVI and O&M)

Compensatory strategies

An O&M specialist will also look for compensatory strategies the student uses to navigate and learn, which are frequently mistaken as visual recognition. For example, a student may rely on color, auditory cues, memory, routines, context, or verbal prompts to make sense of the world around them.

To illustrate how a student with CVI may compensate with auditory cues, Abu-Jaber shares a story about a young man she assessed. He “really depended on hearing people’s voices to know who they were and he was so good with his social skills that people had no idea that he was doing this. I realized it [was a compensatory strategy] when his dad walked up and wasn’t talking – and he didn’t know his dad.” (Expert Q&A: CVI and O&M)

Impact of other factors

The evaluator must also consider how other disabilities impact O&M skills. Price emphasizes the value of collaboration with other providers, like physical therapists and speech pathologists, to gain a full picture of the student and their needs.

Motor skills

Students with CVI use many different ways to get around, including wheelchairs, mobility aids, and white canes. Before assessment and instruction, it’s crucial to understand how the student travels and their stamina for short and long distances, breaking down the activities accordingly.

No matter their travel method, a student can learn O&M skills to gain greater independence. Price describes some of the things she looks for when working with a student who uses a wheelchair:

“I have a student who can propel herself independently in her wheelchair and we’ve been working on hand trailing because she can propel with one hand and she can reach out her other hand and follow along the wall.

“She’s developed all these great routes in the school building that she wasn’t traveling independently before. She wants to because she’s confident, and says to me ‘I know this. You don’t need to take me anywhere. I can do all of this on my own.’”

Communication methods

During assessment, the O&M specialist will use whatever communication system the student uses, including Augmentative and Alternative Communication Devices (AAC) or other physical methods like hand signals, body movements, or facial expressions. The student’s speech pathologist can provide helpful insights beforehand or tag along for assistance until the O&M specialist learns the system.

No matter their communication method, a student can develop autonomy and agency over their travel. For example, Price says, “I might ask just as we’re starting to travel, ‘Oh, do you remember where we’re going?’ If it’s in the AAC device, I’d ask ‘What direction do we need to turn, left or right?’”

When they stop at a street, “I ask them if it’s safe to cross the street to build safety awareness.”

Price urges fellow O&M specialists not to make snap judgments about what a student can do based on their mobility and communication methods, but rather to seek information from the therapists, teachers, and family who know the student best.

“The collaboration piece is really important to get a whole snapshot so we can understand,” Price says, “because a lot of the time an evaluation is brief… If you’re meeting the student for the first time, you wonder ‘Can I encompass everything they know and need help with in one little evaluation?’”

Checking for understanding of fundamental concepts

Likewise, we must be careful not to make assumptions that a student understands more than they do. Students with CVI often build compensatory skills that mask the challenges they face due to the impact of the CVI visual behaviors. They rely on other senses and on memorizing familiar settings – a big reason why it’s important to assess in unfamiliar places too.

“It is important to assess an individual in less familiar environments with less familiar visual targets and in unpredictable locations,” Waugh and Roman-Lantzy write. “In environments, the individual already knows, familiarity and memorization can compensate for and mask the interference of difficulty with visual novelty, difficulties with visual complexity, and visual latency, as he or she may appear to see most everything in the environment.” (CVI: Advanced Principles, 2019)

Futty explains that “even with older kids who seem to be getting around really well, I start with really basic concepts because I find there are gaps in those concepts for kids with CVI that are helpful to evaluate.”

She tests knowledge of concepts like:

Left and right, up and down, in and out, under and on, behind and in front of
Identifying body parts on self and on others (e.g., to be able to identify the elbow of a human guide)
Components of space like doors, walls, and stairs
Following routes with simple directions
Understanding parallel and perpendicular (e.g., intersecting hallways)
Turning 90, 180, 360 degrees
Common units of length and applying the appropriate one in a given scenario (e.g., to determine how long it would take to walk from school to the store)
Mental mapping

Krish stands at a table with his OandM instructor.

“Mental mapping tends to be hard for kids with CVI,” Futty adds. “You can’t just jump into a map of the school. If a student doesn’t understand the two things that intersect are perpendicular, they cannot understand a map. So you have to start with those foundational concepts and just drill them for as long as it takes.”

Many of us take for granted that we understand these concepts without intentional instruction. However, many kids with CVI demonstrate gaps when it comes to the fundamentals.

Futty continues, “I find a lot of times that kids with CVI who look like they’re getting around fine and are doing well–when you start digging into foundational concepts like ‘How do you travel?’ ‘How do you orient yourself to a space?’ These things can often be missing and nobody even knows they’re missing.

“They may be able to move through space well and have zero idea where they are. They can’t get from one place to another. They may get away with this because they always have a paraprofessional with them or are good at following classmates.

“If you start pressing into that and trying to see if a student can get from the office to their classroom independently without following somebody around, they don’t even know where they are.”

For the safety of the student, “O&M specialists need to be cautious about assuming that if a student with CVI traveled without difficulty from point A to point B on one occasion, the route can be repeated without difficulty at another point in time,” Waugh and Roman note. (CVI: Advanced Principles, 2019)

In a presentation to the Edmonton Regional Learning Consortium, Dr. Roman-Lantzy teaches that during the assessment, the O&M specialist must consider the student’s system for traveling – rote, route, large space – in addition to their mobility needs, like whether they move independently and if they use a mobility device.

Roman-Lantzy discusses the difference between rote, route, and large space travelers.

Rote: “The rote traveler is the person who has the most limited skills in travel. They have to use the exact same route every day.” These students often find it difficult to reverse the route so they can get back to where they started. “They memorize it and cannot deviate from that very simple point A to point B travel.”

Route: “If a child is a route traveler…they have a little more flexibility in the way they imagine space. They can not only get from point A to point B one way, they may be able to reverse that route. They may also be able to have an alternative route…all within a fairly limited space.”

Large space: “That person perceives the route, they understand where they are in space in a large, mapped out way. They can imagine the destination… and lots of alternative ways to get back.”

Roman-Lantzy explains, “Kids with CVI are really impacted on their ability to ever become a large space traveler because of things like complexity and novelty and distance viewing. It’s very likely we can teach them to become route travelers, and we always want to help the child be more than a rote traveler.”

Which assessment tools?

Many O&M assessment tools were created specifically for ocular visual impairments, though they may be used with CVI adaptations as long as the assessor keeps the individual’s CVI visual behaviors in mind. Here are some tools the O&M specialist may use:

NMBSVI Orientation & Mobility Inventory
TAPS (Teaching Age-Appropriate Purposeful Skills)
Preschool Orientation & Mobility Screening from AER
CVI-specific: O&M Progress Chart by Dr. Christine Roman-Lantzy

Price reiterates that the O&M assessment must be based on information revealed during the CVI assessment by the TVI. “That breaks down the visual behaviors. And I’m looking at the visual behaviors myself when I’m evaluating.”

Every student with CVI has a right to an O&M evaluation that takes into account these visual behaviors, mobility needs, communication methods, co-existing disabilities or ocular conditions, compensatory strategies, and more.

When it comes to O&M, “with a student with CVI, you’re not only working on safe travel skills but also helping them to understand what they’re seeing and make sense of it… and use their visual understanding to support their travel skills,” Price summarizes.

O&M is more than moving from one spot to another, and the O&M assessment must explore many skill sets and variables impacting a student’s success.

LEARN MORE FROM OTHER ARTICLES IN CVI NOW’S O&M SERIES.