CVI for Board Certified Behavioral Analysts (BCBAs)

Written by: Kayla Matthews, M.S., BCBA

What is CVI?

Cerebral/cortical visual impairment (CVI) is a brain-based visual impairment caused by damage or interruption to the visual processing areas of the brain. With CVI, the brain has difficulty recognizing and making sense of the visual world. CVI impacts every aspect of life. The CVI visual behaviors are a framework for understanding the impact of CVI on access and is rooted in current CVI research.

CVI is the leading cause of childhood blindness and low vision, but it is alarmingly underdiagnosed. Less than 20% of kids in the US have a CVI diagnosis. CVI often co-occurs with neurological, neurodevelopmental, or genetic conditions. Those with healthy eyes and without other conditions can still have CVI.

How might CVI impact behavior?

Students with CVI struggle with visual attention and visual recognition, which results in a lack of access to understanding the world around them. Some with CVI show various behaviors that can look like attention and behavioral issues, leading to intervention from a Board-Certified Behavior Analyst. It is critical that a learner’s caregivers and school team understand that behavior is communication. It is likely that a student with CVI is communicating, “This is too much,” “I am overwhelmed,” “This is hurting me,” or “I don’t feel safe,” and typical behavior strategies will not address the underlying neurological and physiological reasons a student is behaving the way they are.

Often, students with CVI are doing their best to navigate a world that was not designed for them and understandably, they may experience frustration, anxiety, and are frequently in fight-or-flight mode.

When might you suspect a student has CVI within your work in Applied Behavior Analysis?

CVI has diverse manifestations, and no two individuals with CVI are exactly alike. You may suspect a student has CVI if previous behavior strategies and interventions have not been effective in changing a behavior to meet a student’s needs. While behavior analysts typically hypothesize the function, or “why” a behavior is occurring based on observation, interviews, and data collection, students engaging in a behavior due to neurological and physiological functions will require a different, more nuanced approach.

CVI manifests differently in every student. Common “challenging behaviors” that may be misinterpreted in individuals with CVI include:

Avoiding tasks, covering their eyes or ears, “non-compliance,” frustration leading to aggression, lack of eye contact or the appearance of ignoring others, running out of a room, bringing items up close for visual inspection or lining items up (may be seen as “stimming”), clearing tabletop surfaces, dumping bins or containers, looking away from materials, or putting their head down.

A young student wearing glasses completing a literacy task on a blue slant board puts his head down on the desk. — Picture courtesy of Paths to Literacy

It is also crucial to acknowledge the student’s ability to process, integrate and organize sensory information. Students with CVI may find it difficult to use (or prefer not to use) their vision simultaneously with other sensory inputs, which may lead to more subtle changes in behavior including:

Repeatedly asking to leave a loud, crowded, and busy area
Increased anxiety during certain times of day or particular learning activities
Commenting or asking questions more frequently as an attempt to adjust the lesson mode to auditory
Insisting on wearing their hood up throughout the day

A young student in a pink shirt wearing a pink bandana around their neck and purple glasses is seated next to an adult staff member on their left. The student is moving their eyes towards the left while their head remains facing forward.

Learn more about when to suspect CVI.

What strategies and interventions might be helpful to use in Applied Behavior Analysis with students with CVI?

Always remember: Behavior is communication.

Behaviors can be a reaction to CVI difficulties and are termed “CVI meltdowns”. Learning more about the student’s visual difficulties related to the CVI visual behaviors and accessing solutions for these difficulties can reduce these behaviors.

Observable and perceived behavior that surrounds inattention, non-compliance, or avoidance/escape behavior must also consider implications of CVI as possible antecedents.

Follow the data! Once you have operationally defined the behavior(s) your student is engaging in, take careful data to determine:

What environment/setting is the behavior taking place in? How many people are in the room? Is it loud? What is the lighting like? Is the room cluttered and does it have a lot of decorations?
What time of day is the behavior happening at? Is it usually before lunch? Is it always after a morning meeting? Are afternoons more challenging than mornings?
What activity, task, or materials are being used when these behavioral difficulties occur? Is it group work? Does the student need to follow more than one instruction? Is the student being asked to use more than one sense at a time (i.e., looking and listening, writing while listening, eating their snacks while the lesson continues?)

Once the barriers to the student’s access have been identified, it’s time to address and eliminate the factors that limit the student’s ability to learn.

A staff member points to a word on a page elevated on a slant board. A student in a checked long sleeve shirt leans their face forward and close to look at the words from approximately 4 inches.

Instructional adaptations

Develop an accessible school day matched to what access looks like for the student with CVI.
Implement proactive visual breaks across the student’s day. Of note, this does not mean a break from learning, but rather an opportunity to use a different sense during tasks and activities. At times, a student will need a full break from sensory input, and this must be honored and provided as well.
Use a multisensory approach to learning. All individuals with CVI use compensatory skills, or nonvisual skills to access learning and the environment. A student’s CVI assessment and Learning Media Assessment will provide information about which skills they use- tactile, auditory, kinesthetic, and more.

A learning space with a desk and two chairs against a plain white wall and a cluttered shelf covered by black curtains to reduce visual stimuli. — Covering cluttered shelves with black curtains can reduce visual stimuli.

Environmental adaptations

Develop predictability and routine. Ensure the student has a predictable learning environment (cubby, desk, navigable areas). When a student can depend on the reliability of an item, activity, or a particular session with a service provider, they don’t need to exert extra effort to process all the visual information present at any given time.
Create a learning environment with strong storage systems to reduce extraneous visual clutter (but avoid the use of multi-colored storage bins!). Establish a routine for activity set-up and clean up with these set storage systems to increase organization and reduce clutter while also including the student to increase their independence.
If at times the student’s sensory needs may require dim lighting to help them with sensory regulation, request the learning environment has controlled sources of light.
If motion is distracting for the student, being in the front of the classroom with a wall on one side would place most peripheral movement behind them and reduce movement in at least one peripheral field.
Transition between classes shortly before or following the bell to avoid navigation in highly busy environments.

Collaboration ideas

It is critical to collaborate with a student with CVI’s entire team. This includes their caregivers, service providers, teachers, and most importantly, the CVIer themselves. We can only figure out what a student needs by sharing and seeking out knowledge in each discipline to ensure we are treating the student holistically.

The BCBA can collaborate with the TVI to ensure the student with CVI is able to access their learning materials. When collecting ABC data or doing formal data collection for an FBA/BIP, ask the TVI to join you to help understand CVI’s impact.
The student’s SLP can work with the BCBA to interpret the student’s communicative intent and provide strategies for increasing communication.
The OT can provide activities to address a student with CVIs regulation and sensory system needs.

Resources on CVI and behavior

Note to readers: This article is meant as an overview and brief introduction to CVI, a deep and complex condition with diverse manifestions. It is important to remember that all children with CVI have different needs. The recommendations and suggestions are ideas for a starting point. There is not one size fits all approach for CVI, and interventions and strategies must be match to the student’s individualized needs and comprehensive assessment results.

Explore CVI overviews for various disciplines in our CVI Educator Toolbox.
Visit the CVI Now Educator Hub.

Kayla Matthews, M.S., BCBA
Kayla Matthews (she/her) is a CVI Coordinator and Board-Certified Behavior Analyst (BCBA) in The CVI Center at Perkins School for the Blind. Kayla enjoys working closely with students with high support needs and complex medical diagnoses, centering autonomy and choice. She became increasingly interested in students on her caseload that were diagnosed with CVI that were engaging in “challenging behavior that came out of nowhere.” She realized the maladaptive behavior she was being asked to consult on, such as inattention, impulsivity, and tantrums were her students communicating they were overwhelmed and struggling in their current learning environment. Kayla received her graduate degree in Behavior Analysis from Simmons University and is currently pursuing a Master’s in Education from UMass Boston to become a Teacher of Students with Impairments (TVI).