What do you need to know about CVI, complex communication needs, and AAC systems?

We spend our lives learning how to communicate with one another. In the video above, Sylvia Mangan, M.S. CCC-SLP, and Amelia Willcox, M.S. CCC-SLP, shed light on multiple case studies where children with CVI want to do just that — And they succeed.

Sylvia and Amelia, both speech-language pathologists at Perkins School for the Blind, discuss Cerebral/Cortical Visual Impairment (CVI) considerations for designing a total communication approach for children with CVI and Complex Communication Needs (CCN). They also dive into case studies to illustrate how they use assessment, data, and a whole-child understanding to develop an accessible and individualized communication approach. These powerful case studies prove that every child can learn, especially if given access to a total communication approach.

CVI parents need access to resources, too. If you’re a parent of a child with CVI, use this page as a hub of resources for navigating CVI and communication.

What are AAC systems?

If your child has CVI compounded with other disabilities, communicating their needs may require the use of AAC, or Augmentative and Alternative Communication. AAC supports include a wide variety of actions and systems that a person can use to communicate. They’re often referred to in categories related to their use of technology, like no tech, low-tech, mid-tech, and high-tech devices. All of these AAC systems usually co-exist within a greater system of communication to form total communication.

Low-tech communication supports are single and sequential message communicators, also called recordable switches, where you can record a message and activate the switch to express it. Also included are picture communication boards and books.

Mid-tech communication supports are simple, leveled speech-generating devices, dedicated dynamic screen devices, and tablets with communication applications. An example is a Go Talk Nine, with pictures or visual, tangible symbols paired with a recorded message on a device.

High-tech communication supports also include the use of tablets with a wider array of vocabulary, as well as eye gaze devices and text-to-speech devices and applications. High-tech communication supports are typically a computerized device that will speak the message.

In addition to devices, individuals use no tech or unaided communication support, which is the person’s use of their own body to help them communicate, and aided communication supports, which is the use of additional supports to help a person communicate.

Josian works with Sylvia during speech class.

Can you adapt AAC systems for CVI?

There are many ways for an individual with CVI to use AAC systems, and both Sylvia and Amelia have a lot of experience adapting these systems to fit the needs of each individual. Because CVI is not a one-size-fits-all diagnosis, the journey to identify, build, and evolve an appropriate AAC system is different for every individual, especially if they are living with other diagnoses that can impact communication.

Variables to consider when supporting the communication needs of individuals with CVI include elements like backlighting, portability, form accessibility, adapted signs, impact of spacing and clutter, contrast, visual fatigue, motivation, and much, much more. We expand on how to include a few of these variables when developing appropriate AAC systems for individuals with CVI.

Impact of spacing and clutter: This assessment determines when background stimuli interferes with the individual’s ability to look at something (visual attention) and their ability to know what they’re looking at (visual recognition). Here, we must consider how to balance the amount of spacing needed and still provide a robust AAC system that includes a robust vocabulary.

Closely spacing items together may impact visual recognition because of simultanagnosia. We must look at how many items someone can visually regard at the same time, and how closely items can be packed together.

Form accessibility: This assessment determines which materials are visually recognizable to the individual with CVI and what they recognize. It also determines the most accessible learning form for the individual. Usually, single-color familiar objects are the first and most easily recognized. Then, multicolored and patterned objects are generally a little harder to regard and recognize. Types of forms that we consider include 2D photographs with familiar objects, photographs of unfamiliar objects, realistic color illustrations, and 2D abstract black and white drawings.

We must look at how to craft an AAC system that aligns with form accessibility recommendations, such as 3D materials, but still introduces abstract concepts, such as verbs, which make up the majority of core vocabulary.

Use Matt Tietjen’s 2D Image Assessment to evaluate what your child’s most accessible two-dimensional images are for learning. The assessment helps to determine whether photographs, drawings, colored forms, iconic, or symbolic pictures are the best recognized.

Visual fatigue: Using your vision is hard work when you’re an individual with CVI. As a result, individuals with CVI experience significant visual fatigue. They might need breaks and other ways to communicate throughout the day. Some visual tasks might be comfortable in one environment but quite challenging in another due to clutter, noise level, or distracting movement and light. For many with CVI, there are moments or long parts of the day when they can’t rely on their vision. By integrating different methods into a child’s communication system, we can ensure that there are multiple tools and approaches available to continue communication in any environment.

Use Matt Tietjen’s What’s the Complexity? Framework to accommodate for visual fatigue when you’re structuring the school day.

In the webinar above, the students in the case studies illustrate many different examples of communication. All of the children use different supports based on their visual readiness and how they’re feeling. For example, Schroder uses unaided communication — like smiling and open vocalizations — in combination with a switch that is paired with a voice output switch. Yalissa uses the app, TouchChat, on her high-tech device, but moves over to adapted signs when she’s fatigued and unable to use the device. In a practice setup, Savannah uses switches that are placed on stands so that she can visually access them. This same setup is replicated later when she’s learning how to use her eye gaze device.

Learn more about the CVI visual behaviors.

Millie works with Megan, an intern, during speech class.

AAC systems must grow with the child.

Clearly, AAC and developing a total communication system is a dynamic process. It needs to grow and adapt with the individual. The progression we see in the webinar’s case studies make it clear: AAC systems must evolve with the individual. Furthermore, as advocates and caretakers, we must continually assess what’s working, what’s not working, what the family is asking for at home, and what has not been addressed yet. Most importantly, we must ask: What is the student showing us they’re ready for?

There is significant value in multi-modal communication and having multiple AAC systems to reflect that. Because there is no one-size-fits-all approach to AAC, we have so many different communicators using so many different methods. A collaborative, interdisciplinary team is critical to developing and implementing appropriate AAC systems with and for individuals with CVI.

Every child with CVI can learn, and they each have the right to life-changing access. The goal with AAC systems is total communication, for learners to be able to communicate all day every day, using whatever AAC system is needed in the moment.

More CVI and Communication Resources

Find more information about CVI and communication needs below.

A child uses Augmentative and Alternative Communication

5 essential steps to finding the best AAC system for a learner with CVI

Kickstart your journey to finding the right AAC system.

CVI considerations for AAC systems

Watch an SLP and TVI discuss CVI and the implications for AAC systems for a better understanding of how CVI can impact communication.

Watch here

Girl with CVI sitting on mats during a PT session, holding her AAC device

Two examples of how learners with CVI use AAC

Learn more about how CVI learners can use their individualized AAC systems.

Barbara and her son, Logan, hug and smile

Logan’s total communication approach

Find out more about a parent and CVI child’s journey in creating a total communication approach, which includes ASL, gestures, and high- and low-tech AAC.