Article
Why O&M is essential for students with CVI: Part 1
Discover our guide to CVI-centered orientation and mobility — and why all students with a visual impairment benefit from O&M.
Where am I? Where do I want to go? How will I get there safely and efficiently? What will I do if I can’t find my way or if I encounter an obstacle? These are crucial questions for anyone learning to travel independently. For people with CVI, these questions are more difficult to answer.
That’s where orientation and mobility (O&M) comes in. O&M provides people with visual impairments with the mental and physical skills they need to navigate from point A to point B and to move through space efficiently, safely, and independently in familiar and unfamiliar places.
In the US, a Certified Orientation and Mobility Specialist (COMS) conducts O&M lessons and assessments. These instructors are certified through the Academy for Certification of Vision Professionals (ACVREP). In other countries, instructors may be called habilitation specialists or rehabilitation specialists.
People with CVI have different visual experiences from people with ocular visual impairments. The O&M instructor should have a good working knowledge of CVI and its holistic effect on the student, using this understanding to offer tailored assessments, instruction, and accommodations based on the student’s specific CVI visual behaviors.
For example, “CVI impacts many of the skills we use to orient ourselves, make a travel plan, and move,” says Valery Kircher, a teacher of the visually impaired (TVI), COMS, and Education Coordinator for the Virginia Department for the Blind.
It “can affect motion perception, the ability to discern objects in a complex scene. It affects the visual guidance of movements. It can affect the ability to identify objects or shapes, colors, or faces. Sometimes individuals will have a lower field loss and it certainly affects the ability to route find.”
Individualized and intentional instruction that is appropriate for the student’s CVI needs and present levels will help them build agency, confidence, and skills needed to access their world.
O&M is “essential for individuals with CVI to be able to function with the greatest level of independence and attain skills required for self-determination,” Alisha Waugh, CVI parent and COMS, and Dr. Christine Roman-Lantzy, Chief of The Pediatric View Program, write in CVI: Advanced Principles (2019).
One of the realities of CVI is that it’s extremely underdiagnosed, even though it is the leading cause of childhood blindness and low vision. Some with CVI may not get a diagnosis until their teens or into young adulthood. All with CVI, no matter when they are diagnosed, have a right to O&M instruction to learn the skills and tools they require for safe navigation.
If you are a CVIer, you have the right to reach for tools that allow you to travel independently, that eliminate unnecessary and avoidable suffering, and that identify the true level of your disability to the public, regardless of the fact your blindness happens to be entirely or mostly in your brain.
Nai, author of the CVI Perspective
While this list is not exhaustive, here are a few examples of what O&M lessons might entail:
- Understanding position in relation to other people, objects, or landmarks
- Paying attention to what other senses tell us
- Identifying body parts of self and others and learning how they move
- Turning the head toward a person
- Learning about colors, shapes, numbering systems, and cardinal directions
- Recognizing objects and landmarks in familiar and unfamiliar places
- Reaching out to grab an object
- Discussing elements of an environment, like doors, stairs, and hallways
- Comparing layouts and features of commercial areas
- Understanding traffic patterns and rules of the crosswalk
- Estimating time and distance
- Using maps to preview and navigate a route
- Establishing mental pictures of a place
- Practicing with a human guide, trailing, early mobility devices like push toys, or a white cane
- Rehearsing self-advocacy and social interactions
CVI and the brain: Dorsal and ventral streams impact O&M
Just as we take different routes to work or school based on various factors like time of day, traffic patterns, or errands we must run, visual information takes different routes through the brain depending on the type of information being processed.
These routes — the dorsal stream and the ventral stream — work together to make sense of the visual world. “Think of the streams as two highways that have multiple connectors between the two, or as two rivers that separate,” says Dr. Lotfi Merabet of Harvard’s Laboratory of Visual Neuroplasticity. “There are many tributaries that exist between the two.”
When one or both of these streams are impaired, as is the case with CVI, travel can be incredibly difficult and sometimes unsafe.
The dorsal stream, our “where” and “vision for action” visual system, processes information about object location or visual guidance of motor activities. Dorsal stream dysfunction can make it hard to:
- Know where you are in space
- Perceive complex movement
- Distinguish between multiple objects at the same time
- Process a scene or shift attention from one element in a scene to another
- Figure out what — and what not — to look at
- Sustain attention
- Complete motor activities like reaching, grasping, and navigating obstacles
The ventral stream, our “what” visual system, helps us identify objects through details like color, shape, size, and texture. Think of the ventral stream as your child’s visual library, aiding in recognition and memory.
Ventral stream dysfunction can make it hard to:
- Recognize landmarks or people
- Find someone in a crowd
- Read signage
- Follow a route
- Perceive depth
“It is easy for us to forget, for those of us with typically functioning vision, how much work goes into processing what we see and moving safely through our environment with that information,” Jennifer Siff, COMS, explains in a tutorial on supporting CVI during O&M.
She adds, “It has been helpful to me to move away from thinking about visual functioning as a bucket brigade, where the information is passed from the eyes to the optic nerve through the optic chiasma to the occipital lobe to the dorsal and ventral streams — to thinking of it as a massive communal effort that needs to happen in perfect sync for things to function typically.”
Learn more about these higher-order pathways and the CVI brain.
O&M can benefit anyone with CVI
No matter their visual abilities, mobility challenges, or coexisting disabilities, “all students with a visual impairment — whether ocular, brain-based, or both — would benefit from O&M instruction,” says Kircher.
Sometimes families may encounter a lack of awareness in the O&M field, which leads to misconceptions about whether their child needs O&M instruction. Misconceptions may include:
“Some professionals may assume that individuals who are not ambulatory do not require O&M instruction,” write Waugh and Roman-Lantzy. “Some may be uninformed about how an individual with multiple disabilities can receive any benefits from O&M instruction. A provider may believe that an individual with cognitive delays would not benefit from such instruction, or that if an individual can travel from one location to another without unintentional contact, no O&M instruction is needed.” (CVI: Advanced Principles, 2019)
Moreover, every child with a visual impairment — including those with CVI, co-existing disabilities, and limited independent mobility — has a right to an O&M evaluation. 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.
O&M is a conduit to learning, independence, and effective social interaction, which CVI Scotland names as three key rights for people with CVI.
- The right to learn: People with CVI have limited access to incidental learning. O&M skills allow them to get closer to the action where they have a better chance of perceiving and understanding what is happening in the distance or a complex environment.
- The right to independence: People with CVI need intentional instruction to navigate, access public spaces, and have agency over their day-to-day routines.
- The right to effective social interaction: Social interactions can be challenging for people with CVI. O&M instruction may include skills for self-introductions, identifying people, asking for assistance, or declining unwanted help, to name a few examples.
“The most significant way that all CVIs will affect learning is the way that it prevents the building of visual memory,” Siff explains. “People with typical vision are constantly accessing their visual memory, both consciously and unconsciously, to move through the world safely, efficiently, and fluidly. We do this all the time without even realizing it.”
She adds an example, listing some questions we intuitively ask ourselves when we pick up a coffee cup. We try to figure out:
- How much is in the coffee cup?
- How hard do I have to lift up on it?
- How quickly can I move it to my mouth without splashing it on myself?
“And we visually rehearse these movements in our head before we do them, again, often unconsciously. So if the creation of this type of visual memory is prevented or impaired, this will have global effects on the individuals. It’s going to be pervasive throughout their life and throughout different settings,” says Siff.
O&M instruction is an intentional, iterative process that takes time, given challenges with visual memory and the impact of CVI visual behaviors.
“Learning about the world and how to navigate through it is a developmental process. Each new experience builds on previously acquired knowledge. Each new piece strengthens an overall understanding and broader sense of increasingly larger environments.” (What is Orientation and Mobility? APH)
All students with a visual impairment — whether ocular, brain-based, or both — would benefit from O&M instruction.
Valery Kircher, TVI, COMS
Here are a few reasons why people with CVI need tailored O&M instruction.
Purposeful movement for the body and brain
It may seem obvious that encouraging a child to move with purpose will develop their gross and fine motor skills. However, in its Benefits of Orientation and Mobility handbook, the Texas School for the Blind and Visually Impaired (TSBVI) reminds us that “purposeful movement may not occur naturally for children with a visual impairment.” They miss the incidental learning opportunities to watch others demonstrate active, planned movement.
For babies and toddlers, this work is done informally through play. As the child moves into the education system, the team may develop goals for the Individualized Family Service Plan (IFSP) or Individualized Education Plan (IEP). Some children may have more difficulty moving due to low muscle tone or other physical disabilities. This is a prime opportunity to collaborate on goals with a physical therapist or occupational therapist. (APH Connect Center)
Additionally, purposeful movement gives children with CVI the chance to get out in the world, providing more learning opportunities that build connections in the brain and bolster processing abilities. It also gives educators and parents more information about how the children we serve make sense of their surroundings. What visual information, like landmarks, do they notice and recognize? What compensatory skills do they use? What sensory input seems helpful — or overwhelming?
Experiential learning
Hands-on learning experiences can help bridge gaps that exist due to a lack of incidental learning. Kids with CVI miss a lot of what happens at a distance or in a cluttered environment, so it’s important to intentionally teach the child skills to move closer to life for real learning experiences.
A child with CVI may not be able to scan for a favorite toy across the room. Though seeing the toy would be a typical motivator for a child to make a plan of action and move, the child with CVI does not have incidental access to that visual information, missing the opportunity to play with and learn from that toy.
TSBVI states that “O&M instruction provides real experiences essential to all children. The skills learned reduce isolation by giving students a ‘common ground’ for interacting with family, friends, and future employers. O&M instruction brings the general curriculum to life.” (Benefits of Orientation and Mobility)
Safety
There are numerous safety concerns for students with CVI traveling through school or in the community, due to CVI visual behaviors like the impact of motion, visual field loss, visual guidance of limbs, difficulty with clutter, response interval, and more.
When crossing the street, they may not have the ability to discern where the traffic is coming from, how far away it is, how many cars and pedestrians are nearby, and where the curb or other obstacles appear, not to mention the visual latency they experience when trying to sort out all of this information.
They may walk right in front of a child swinging, not noticing the movement until it’s too late.
Their visual fields may be impacted, making it harder to detect curbs, steps, or objects in the periphery.
They may experience motor challenges, as well, particularly with the visual guidance of limbs. For example, they may have difficulty with stairs or using hand-eye coordination to press a crosswalk button.
Kircher describes an experience assessing a student with CVI and auditory processing disorder who had great difficulty detecting motion.
“I worked with a student who was considered higher functioning with his CVI and was headed off to college. It became an ‘aha’ moment when I observed him — he crossed in the middle of the street. He could not tell me that there was an oncoming car and if I had not been standing there to put my hand out, he could have potentially gotten injured.”
Because he had not received CVI-centered instruction in crossing the street, he was not equipped to listen for traffic, scan, or even ask for assistance. However, after instruction and the introduction of a white cane, he learned to do so independently.
Reducing anxiety
Moving through both familiar and unfamiliar spaces can be anxiety-provoking for students with CVI. Whether the child is ambulating or being pushed in a wheelchair, they must be given instruction, materials, and environmental adaptations that provide visual access to the location, lesson, routines, and people around him.
Remember, it can be extremely disorienting for someone with CVI to assimilate competing sensory information, understand where they are in space, follow a route without getting lost, and even know who is sitting next to them. That’s a lot of uncertainty to deal with day-to-day!
Sometimes anxiety may be mistaken as a behavioral issue warranting discipline or reward systems. Parents and educators should first consider what the behavior tells us about the impact of their CVI on the task at hand.
Allie Futty, TVI, COMS, and Program Manager at Northeast Resource Center for Vision Education shares an example:
“I had a student who would get absolutely stuck at the top of certain stairs in the school but not at the top of other stairs. I realized the certain stairs he wouldn’t go down had one of those black nonskid rugs at the bottom. So this kid was getting down on his hands and knees and crawling to the edge of it, touching the rug and he wouldn’t go any further. He thought ‘I’m going to drop off the face of the planet if I stepped into this.’
“And it was definitely being treated as a behavior problem. The teachers were trying to give him tokens to walk across this mat, which wasn’t working because no amount of tokens would get me to walk into a hole of nothingness. So I introduced a cane, slowly but surely, he started to trust the cane and that he could accept the information he was getting from his cane and really carefully move all the way across the rug and know, ‘Okay, I’m not going to die.’”
Waugh and Roman-Lantzy reiterate that “O&M instruction also aims to decrease the frequency and intensity of anxiety-provoking situations by providing individuals with a greater understanding of their environments and a framework for analyzing them.” (CVI: Advanced Principles, 2019)
This provides the individual with some level of control, leading to more opportunities for independence and self-determination.
Independence and self-determination
“I’m a big supporter of the dignity of risks,” says Futty, “because I think it’s something that is held back from a lot of our students. It’s the foundation of self-esteem and self-concept. It’s the ability to take a risk and find the genuine outcomes of that risk. Sometimes you’re going to surprise yourself and you’re going to have a wonderful experience, and sometimes the outcome is going to be disappointing.
“Of course, we have a responsibility as adults to keep the child physically safe, but I think we do way too much intervening over and over again.”
Ultimately, we want kids with CVI to live with as much independence as possible. And that applies to everyone, regardless of physical or cognitive ability.
For example, “even if a person is being pushed in a wheelchair, they have a right and a need to know where they’re going and to anticipate what’s next and find their way back,” Roman-Lantzy shares in the Paths to Literacy video on CVI and O&M.
There’s much more to understand about CVI and O&M. This is the first article in our series on CVI and O&M linked below.
