How does O&M address CVI visual behaviors? CVI and O&M: Part 2

Next up in our guide to CVI-centered O&M: How the CVI visual behaviors impact a student’s ability to orient in space and move independently.

A young adult dressed in black with a black cap stands outside with his O&M instructor. They both are smiling holding white canes.

People with CVI exhibit a range of visual behaviors that an O&M specialist must take into account during assessment and instruction. While contrast, acuity, more light, and stable targets are important concepts to consider when working with people who have ocular diagnoses (and many people with CVI will have co-existing ocular conditions), the CVI visual behaviors are important concepts to understand when teaching a child with CVI. 

These visual behaviors will show up differently for individuals, even among those with similar medical histories or comorbidities, and they will present in different ways depending on the environment and the student’s inner state (e.g., illness, fatigue). The CVI visual behaviors are closely linked and, therefore, impact each other. Throughout assessment and intervention, instructors seek to understand the following CVI visual behaviors and their interplay with the student’s ability to orient in space and move independently.

Susan Abu-Jaber, TVI and O&M Specialist, summarizes in an Expert Q&A on CVI and O&M

For children with CVI to learn O&M skills, we need to “identify the child’s unique visual needs, make visual information accessible, connect new visual experiences to familiar, provide repeated and consistent access, encourage self-advocacy.” 

Click each visual behavior below and jump to that section, or keep scrolling.

Brooke stands outdoors with her white cane.

Visual attention

The ability to look and maintain gaze in order to recognize objects or places, even in cluttered, unadapted environments or when sick or tired. In most schools and public places, there is a tremendous amount of visual input to sort through. One of the most difficult tasks for people with CVI is to figure out where to look – and where not to look. 

“There’s no visual recognition without visual attention,” says Emily Price, a CVI-certified COMS who instructs the O&M Through the CVI Lens course at Perkins. “So think about if you’re in a parking lot, and you’re looking for your car. You not only have to find the correct colored car but also find the correct object, the car itself, while also filtering out all the other cars even if they’re the same colors as the car you’re searching for.” 

If I was walking with a friend and talking to them, I couldn’t use my vision at the same time.

Nai, adult with CVI

Visual recognition

The ability to recognize items, people, places, landmarks, or known classes of items. Students with CVI build recognition through fully experiencing their learning and their world, and with intentional and direct instruction. Many with CVI use different sensory channels (auditory, tactile, movement, visual) to learn and help build a visual library of images to rely on as they work to interpret the world around them.

“As our brains develop, more connections form because the information is being exchanged by both [the dorsal and ventral] streams,” says Jennifer Siff, COMS, who teaches alongside Price in the Perkins O&M and CVI course. “The more information is exchanged, the more efficient our brain becomes at identifying and interacting with objects in our visual worlds.”

Recently, someone asked a group of fellow CVI parents “Does anyone have a kid who does not want to walk outside or in unfamiliar environments?” This parent was not alone in her observations. Kids with CVI often react differently in or try to avoid new, unfamiliar environments.

O&M instruction can build a child’s confidence in exploring new places and items. Previewing and repetition are key strategies for bolstering a child’s visual recognition of routes, landmarks, and more. 

Impact of clutter

Difficulty understanding visually complex, crowded environments or arrays of objects. People with CVI might have difficulty finding a target amidst visual clutter at near and in the distance. Reducing visual clutter can improve a child’s visual attention and visual recognition.

For example, “people affected by clutter and crowding will often bring visual targets like products in the store or a menu… very close to their face to read it and see it,” Siff explains. “Even if their acuity is not significantly decreased or affected, they just need to shut everything else out in the world, so they can focus on one letter at a time or one small specific visual target at a time.” (O&M Through the CVI Lens

In a CVI and O&M presentation to the Edmonton Regional Learning Consortium (ERLC), Dr. Christine Roman-Lantzy describes the impact of complexity this way: “When somebody does O&M with a child in a school and they say the child’s really good to go, we’ve practiced this in the hallways a million times, they can get to any of their classes, they know the numbering system, my questions would be:

Keep in mind when selecting landmarks and targets that they must be visually distinct and presented in a way that meets the child’s tolerance for clutter. For example, the number on a classroom door may be important information, but gets lost in the clutter of seasonal decorations rendering it useless.

Other sensory input can also distract and reduce visual perception. It is important to teach O&M skills in a variety of busy environments and to remember that changes to a familiar environment, such as a bus stopping or a siren wailing on the street, can impact the student’s ability to navigate safely, even if they have extensive practice in that setting.

When I’m in crowds, I get confused when there are a lot of people. I can’t tell where I am or who is around me. When faces are mixed in with a crowd, they all disappear.

Albie, adult with CVI, from Albie’s CVI Perspective

Visual field abilities

The ability to recognize targets in specific visual fields, like left and right peripheral fields, upper visual field, or lower visual field. 

Drop-offs like stairs, curbs, and surface changes can be particularly dangerous due to lower visual field impairment, which CVI Scotland notes “is common with CVI, and varies in severity. Typically, affected children don’t like going down things, like stairs and slides (which the child may be happy to climb up, but will only go down head first because they can see this way using their upper vision). They dislike uneven ground and often trip over obstacles or bump into things that are low down. Some children may not be aware of their feet as they walk. A child cannot easily learn to avoid hazards in a part of their visual field that does not exist for them.” (Sharing & Developing Our Understanding of CVI: Guide for Parents, CVI Scotland)

Other factors impacting visual field access include:

O&M instruction supports students with visual field issues by providing strategies for orienting to an environment and moving through it safely even when every aspect of the space is not visually accessible. For example, a white cane can increase awareness of drop-offs or surface changes not detected in the lower visual field. Other non-visual techniques like trailing, lightly touching the wall along a path, provide a tactile connection to the space as the person moves.

Impact of color

How a person reacts to different colors, including black and white. A person’s attraction to color can be used to their advantage as a visual anchor or to highlight important information. Strategic, judicious bright color highlighting can draw visual attention to an object or landmark. Apply it to the salient feature of the target, such as the edge of a cubby. 

“Color in the environment is just as important as color on materials and math papers and so on,” Roman-Lantzy shares in her ERLC presentation. “Color anchors visual attention… It can also help sustain visual attention and it can assist in identifying salient environmental features.” 

Form accessibility

It’s important to identify and use the best media format for all activities, for example, 2D images vs. 3D objects, color vs. black and white photos, or illustrations. Matt Tietjen, CTVI, developed the What’s the Complexity? Framework and 2D Image Assessment to help determine which media suit a student’s needs, depending on the setting and task. For example, you might use an object map for a student who can most easily access information in a 3D format, or simple realistic photos of landmarks for a student who works best with color photographs.

Visual guidance of upper and lower limbs

The ability to accurately reach and maintain visual attention and to step or place the foot. A child with CVI may be described as “clumsy” or “accident-prone.” Perhaps they accidentally knock things over or trip over things left on the floor. Maybe they are fearful of recess because they can’t kick or catch the ball coming their way. Sometimes they’d like to pick up an item that is highly patterned and colorful, but they can’t look at it while they reach for it because it’s just too visually complex. 

Millie walks outdoors with her white cane.

People with CVI may have difficulty with visually guided reach, establishing motor patterns, stepping over uneven terrain or navigating obstacles, and modulating speed and force. This can affect their ability to take the arm of a human guide, grasp door handles, flip light switches, push buttons on the elevator, sweep a cane in a consistent arc, take the stairs, and navigate obstacles. When going up or down stairs, some with CVI will rely on the railing, drag their heel, or toe tap to check if there is another stair at the top or bottom of the staircase. 

Siff shares how she has shifted her thinking about the difficulty her students have with the visual guidance of their limbs. Instead of thinking, “How can they not see it every time? You have to think, that it does not exist to them because you can’t learn or map space from your visual memory if you cannot build the visual memory in the first place. Again, it’s not that they can’t see it. It just really does not exist to them. So we have to be a little more explicit in teaching those things and making sure they can build a visual memory.” (O&M Through the CVI Lens

Navigating steps, sidewalks, patterned surfaces, and patterned carpets are almost impossible for me if I don’t use a cane. Patterned carpets are a nightmare.

Dagbjört, adult with CVI, from Why music is my vision

Access to people

Many people with CVI will use coding or visual shortcuts to identify people, perhaps by hair color, gait, stature, or the sound of their voice. It can be difficult, if not impossible, to recognize faces, interpret facial expressions, or make eye contact. If the student with CVI can do any of those things, it may only happen in certain familiar, non-complex settings. 

While the student may have compensatory strategies for identifying people, the best thing you can do to ease their visual burden is introduce yourself every time you approach them or engage in conversation. O&M lessons are a great opportunity to teach the student how to ask someone to identify themselves, to request help, or to politely decline help. A white cane or other mobility aid can act as a visual identifier in the community, which should indicate to the public that this person has a visual impairment, smoothing social interactions.

Impact of light

Light can be used to bring attention to a target or important element of an environment. Yet, light can also be a big distraction for kids with CVI. Some will need light or backlighting to view targets. Some will experience photosensitivity.

“The brain interprets light as movement,” says Siff. “And some people with CVI will require light to ‘activate’ their vision in a similar manner. The source and the direction of the light make a difference. Backlighting is not quite the same as illuminating as far as what alerts the vision. Some folks are really compelled to light gaze, even at extremely bright lights like the sun. Some people with CVI are very sensitive to light and glare. So as opposed to staring up at those overhead lights, they’ll want to keep their head down.” (O&M Through the CVI Lens

Some recommendations for working through the impact of light:

Response interval

Many with CVI have a delay in visual attention and delay in visual recognition. This visual latency is a major safety concern. The response interval can be impacted by other visual behaviors, like difficulty with clutter, visual fields, and motion processing.

Take swings, for example, a common fixture on any playground. 

“Most of us notice the rhythm of someone moving and we either move far enough away that we’re not going to get hit or we judge when we think that person is going to encounter us based on time and space – temporal relations,” Roman-Lantzy explains to ERLC attendees. 

“If you have latency, by the time you notice something it could already have hit you. That delay in being able to judge where something is in space, that delay can make all the difference between you having an unwanted encounter with it or not, whether a ball is being thrown in the air, or a car is coming, or a child on the playground…” (Roman-Lantzy, Edmonton Regional Learning Consortium presentation)

Given the time it will take for a child to visually attend to or recognize what they see, adults should allow for plenty of quiet processing time.

Impact of motion

Movement can either draw visual attention and enhance perception, act as a distractor, or moving items can be entirely missed. Some people with CVI may need to be in motion to activate their vision. This may look like pacing, head shaking, running, or fixating on things with movement properties like ceiling fans or long hair. (O&M Through the CVI Lens

Aidan wears an Everybody In! shirt and smiles while holding a white cane and sitting in his wheelchair.

Sometimes this attraction to movement is so powerful that it poses a major safety concern. Allie Futty, TVI, COMS, and Program Manager at Northeast Resource Center for Vision Education, describes the impact of motion on a former student:

“You could not bring him near the road. He lost all inhibitions and would just run into traffic. After observing him, I thought: This kid is so attracted to movement that he does not have volitional control over his body. This is not a choice. This is him responding to the movement and that’s it. It took a really long time, but eventually, we got to the place where that kid could cross the street with a paraprofessional next to him while using a cane because we addressed it as a CVI characteristic and not as a behavior issue.” 

In cases like this one, the human guide may act as a physical anchor in space. Remember that for the student who is highly attracted to motion, places with unanticipated sources of movement, like parking lots, will be more challenging. Go at off-peak hours, preview the lesson, and practice, practice, practice.

Movement can also be frightening, especially when something is moving very fast or in the distance where it is not visually accessible until the last moment. CVI Scotland calls the phenomena ‘looming.’ 

“Children with CVI can find it difficult to learn how big and far away things are, especially when they are moving, and it’s even more difficult when they are moving quickly. When things are moving quickly, they may only become visible to your child when they slow down, so they may appear to spring out of nowhere. When a child can’t judge distance, things that may be far away in the real world, can for some children with CVI feel as if they are very close – and could even hurt them. When the child is moving, they can become very anxious, particularly in busy noisy places, but even a car driving past in the opposite direction can be enough to cause a significant fright.” (Sharing & Developing Our Understanding of CVI: Guide for Parents, CVI Scotland)

CVI is like living in an action movie, but you only see stop motion. I miss a lot of things around me.

Tina, adult with CVI

Sensory integration and impact on vision

Sensory input and internal body signals (e.g., thirst, fatigue) can impede visual functioning. 

In the Perkins O&M and CVI course, Siff talks about the global effect of sensory integration issues and how instructors can approach this challenge during O&M lessons: 

“If someone’s ability to integrate internal and external stimuli is impacted, this is going to affect them across all settings. We can’t separate them from their own body and nervous system. And managing our expectations becomes key. We have to find their threshold, we have to work up to it and then try to work past it little by little.” (O&M Through the CVI Lens) O&M also provides a framework for navigation and movement when vision is unavailable due to sensory overload.

Visual curiosity

Incidental visual access to learning in new and unfamiliar environments, near and at a distance. O&M skills allow people with CVI to get closer to the action where they have a better chance to switch on their visual curiosity for things they otherwise couldn’t perceive in the distance or in a complex environment. 

“You don’t have to physically engage with something in order to observe or learn from it,” Price points out during the Perkins O&M and CVI course. “Vision is our distance sense. So visual curiosity can be impacted by all of the visual behaviors.” 

For example, too much or too little motion or noise can disrupt a person’s ability to access their vision. Or perhaps the object or activity of interest is too far away or surrounded by too much complexity to be of visual interest.

“It’s important as O&M instructors to allow for opportunities for learners to actually safely explore the environment with our help,” Price adds. “So some ideas to help aid a learner’s visual curiosity can include sound cues, color coding, predictable placement of items in the environment.” (O&M Through the CVI Lens

I found it difficult to absorb information at a distance simply because much of the distinctiveness was lost. The main things I could absorb at a distance were plain landscapes, like a gray sky on a cloudy day, which I found comforting (more so than on a sunny day because the light was too overwhelming).

Nai, adult with CVI

Appearance of the eyes and movement of the eyes

How the student shifts their gaze and oculomotor function. This impacts how the learner looks for targets or obstacles and whether or not they can trust the visual information they are receiving. O&M instructors look for a favored eye, the optimal head position for viewing, and how a student shifts their gaze to scan the environment, for example.

“For O&M, it can impact how the learner’s looking for places, objects, or obstacles… So consistent placement of objects or landmarks is important. And this will impact the ability to judge distance and speed,” says Price. (O&M Through the CVI Lens

A child with CVI may exhibit some combination of these visual behaviors, which can manifest differently based on the environment, competing sensory input, the activity, or internal conditions (like emotional upset, illness, or fatigue). CVI and O&M assessments will reveal more information pertaining to the individual, and provide a basis for program planning.

Learn more from other articles in CVI Now’s O&M series.

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