Paper presented at the 5th World Congress on
Conductive Education
20-22 June, 2004,
Integrating teaching strategies for
cortical visual impairment
in the programmes for children with severe multiple
disabilities
By Clare Cheng Yuk Kwan, Edith Yeung Yuk Shan and Lam Wing Na,
SAHK
Characteristics of children with cortical visual
impairment
The Teaching Environment and Material
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This
is a presentation of a project on cortical visual impairment at the Jockey
Club Marion Fang Conductive Learning Centre of the SAHK (Fig. 1). The Spastics
Association of Hong Kong has adopted the principles of Conductive Education
for almost 20 years. The Centre
is one of the special nurseries of the Association catering for preschool
children, aged from one to six, with cerebral palsy and spina
bifida. The children’s abilities
range from normal to being severely mentally challenged. |
Fig. 1: Main
entrance of the Jockey Club Marion Fang Conductive Learning Centre. |
Two years ago,
four spastic quadriplegic children with cortical visual impairment (CVI) as
well as with severe physical, oral-motor, cognitive and communication
impairments were admitted to the Centre at the same time. In spite of the multiple challenges, the
team of staff including the childcare worker, the physiotherapist, the
occupational therapist, the speech therapist and the nurse decided not to
undermine the focus on creating maximal amount of learning opportunities for
these children based on the fundamental belief that every child can learn.
In planning
their learning programmes, their visual problems were specifically targeted.
Expertise in visual assessment from the Visual Assessment Team of the Child
Assessment Service under the Department of Health and professional advice from
the training team of an early intervention programme for the visually impaired
children were recruited. The aim was to incorporate visual training strategies
in the CE programmes.
Characteristics of children with
cortical visual impairment
Children with
CVI are known to exhibit some specific visual characteristics. They have preference for colour like bright red and yellow. Vision may be better when either the
visual target or the child is moving.
The majority of them are light gazers. One third of them are photophobic. They may experience a “crowding
phenomenon” which means difficulty in differentiating between background and
foreground visual information.
Close viewing is a common strategy the children will use to reduce
crowding. They have poor tolerance
to visually complex target. They
tend to shut off their vision from overstimulation or
competition with other sensory inputs such as sound. They have visual field preference. They often use their peripheral
vision. When presented with a
visual stimulus, they appear as if they are looking away from the target. They show a particular visual-motor behavior,
e.g. they look at an object momentarily and turn away as they reach for
it. Novelty is another special
visual behaviour of these children. That is they prefer to look at familiar
objects rather then new things, behaviour totally
opposite to normal children. There
is latency between the presentation of visual stimulus to the child and his or
her response to it.
The multiple
impairments of this group of children entail the expertise of multiple
disciplines which are now often available in a special childcare centre in
1.
All the professional staff forms a transdisciplinary team to tap on one another’s expertise to
plan and implement a holistic learning programme which integrates the different
elements as a whole. In this way,
the interconnectedness of the different challenges is attended to and
consistency in handling is achieved.
2.
The classroom is the stable and familiar
learning environment for group learning.
Interruption for taking each child to different departments for training
is avoided. The classroom
environment is specifically set up to meet the visual characteristics of CVI.
3.
Learning in context is emphasized with a
well-planned daily routine (Fig. 2).
With consistency and repetition, the children can gradually anticipate
and comprehend what is going on around them. The sequence of introducing visual,
tactile and sound stimulation was carefully designed. Looking is encouraged and precedes
physical exploration and sound stimulation.
Fig. 2: Staff and parent together walking with a child with CVI during
routine.
4.
Learning is made conscious with
well-structured task series linking up with rhythmical intention. Care is taken to allow a time of silence
between rhythmical intention and the presentation of the teaching material.
The Teaching Environment and Material
Taking into
account the visual characteristics of CVI, measures are incorporated to
re-arrange the room. For example, visual
complexity is reduced to avoid overstimulation in a
free play corner by covering a wall with a black curtain (Fig. 3). The black curtain serves as a
contrasting background for targeted visual foreground. Toys are attached to the curtain by Velcro
so that they can be removed easily.
The child can then focus on one toy at a time (Fig. 4).
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Fig. 3: A free
play corner covered with black curtain to reduce visual complexity. |
Fig. 4: A child
looking at a suspended florescent spring in the free play corner. |
The teaching
material used is carefully designed to arouse visual responses. Purposefully
modified material is prepared including toys which can produce visual movement
effect by using reflective material (Fig. 5) or suspending targets (Fig. 6), covering
the rungs of the ladder frame with bright red (commonly preferred color)
cartoon paper (Fig. 7 & 8), placing a shiny sheet on top of a floor mat to
encourage the children to look at their own reflection (Fig. 9 & 10), blacking
out the bottom of a tray to highlight the hand (Fig. 11 & 12) or the object
(Fig. 13) in front, using white eating utensils against a black background
(Fig. 14 & 15) to reduce complexity.
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Fig. 5: A
reflective red pon pon
produces good visual movement effect. |
Fig. 6: A suspended
fluorescence spring produces quiet movement effect. |
Fig. 7: Bright
red rung of the ladder frame helps the child to orientate her hand grasp. |
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Fig. 8: A child
grasping the red rung of the ladder frame during walking. |
Fig. 9: Children
rolling over a shiny sheet on the top of the floor mat. |
Fig. 10: Children looking at
the reflection on the shiny sheet. |
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Fig. 11: Washing bowl with a
black bottom draws child’s visual attention to her hand. |
Fig. 12: A child drying his
hands on a black bowl. |
Fig. 13: Looking at a bright
yellow sock on a dark background. |
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Fig. 14: A simple white cup
highlighted by a dark background. |
Fig. 15: A red spoon on a
white plate provides great visual contrast. |
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The holistic
principle is emphasized and every opportunity in the daily routine for using
vision is availed.
The children’s
arousal for using vision is stimulated first thing in the morning (Fig. 16, 17
& 18). The bell and the voice
of the teacher arouses the children’s alertness to the environment, this is then
followed by a minute of silence in order for the children to look at their own favorite
colour.
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Fig. 16: Roll call board:
Each child is presented with his favourite object
to look at. |
Fig. 17: Ringing a bell and
saying, “I’m back.” |
Fig. 18: A silence period
allows time to look at her favourite object. |
Similarly, at mealtime,
looking at the utensil precedes action (Fig. 19 - 25).
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Fig. 19: Looking at a hand
towel before wiping hands. |
Fig. 20: Wiping hands with a
towel on a black board. |
Fig. 21: Tea time routine:
Looking at a white cup on a black board. |
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Fig. 22: Lunch routine:
Presenting a white plate on a black board. |
Fig. 23: Focusing on the red
spoon on a white plate. |
Fig. 24: A child looking at
adult filing his plate with anticipation. |
Fig. 25: Use of vision is
encouraged during feeding. |
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In the task
series and lessons (Fig. 26), class routines to encourage the use of visual
functions are developed.
For example,
children are encouraged to look
at individualized visual material during roll call in the beginning of the
lesson (Fig. 27 & 28).
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Fig. 26: Good posture is
learnt in a hand task. |
Fig. 27: A child anticipating
his turn to look. |
Fig. 28: Looking attentively
at a self-made visual aid. |
Time is allowed
to facilitate the children to look at teaching material in every occasion the
teacher hands out material and collects material after used.
A time of
silence is emphasized during the presentation of the teaching material before
the execution of rhythmical intention so as to reduce competition between visual
and auditory stimulation and thus allows visual processing in the children.
For similar
reason, the sequence of introducing visual stimulation (Fig. 29) before tactile
stimulation or physical exploration is adopted (Fig. 30).
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Fig. 29: Looking at a hand
brush presented on a black board. |
Fig. 30: Hand brushing to facilitate
hand opening on a black board which highlights the hand. |
Taking into
account of the visual characteristic of “Novelty”, modified teaching material
is used consistently to support the use of vision in task series and lessons
(Fig. 31, 32 & 33).
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Fig. 31: A commonly used
visual aid – a black bottom tray. |
Fig. 32: Exploring bright
yellow paint on a black tray. |
Fig. 33: Hand printing with
bright red paint. |
For parents,
the direct relation between learning and daily living skills makes it very easy
for them to carryover their children’s learning in the home situation and
create opportunities for practice.
Creative
parents can adapt their home environment (Fig. 34) and also made their own toys
(Fig. 35 & 36) to encourage their children using vision.
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Fig. 34: A lower deck bed
specially decorated by a mother to arouse her child’s visual alertness. |
Fig. 35: A child looking at a
flashing light board made by her father. |
Fig. 36: A collection of
simple visual aids and toys made by a mother. |
After a two-year
of learning period, two of the children have shown marked improvement in visual
function, from responding to light only to showing visual attention to large
sharp colour objects (Fig. 37). The children have also shown improved
learning behaviour, slowly adjusting to their
environment and accepting the demands of the daily routine and the learning
programmes. The non-temporal nature of visual stimulation was found to be more
apt to facilitate spontaneous exploration of the environment. One of the
children started to show some active reaching movement for bright objects in
front.
Fig.37: The Preliminary Results
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Child |
First Assessment |
Second Assessment |
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CKY |
Light perception only |
Occasional
Fixation on |
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LWK |
Light
perception only |
Visual
acuity around 6/24 |
According to
the medical literature, about 71% of CP children have CVI. Incorporating teaching strategies in the
CE programmes appropriate to the characteristics of these severely impaired
children is a new area that cannot afford to be neglected.
The small
progress that the children in this project have made was still far from
changing their functional level drastically. However, in the process, the children
have experienced the joy of learning which is part of their right no matter how
severely challenged they are.
Baker. Nobles, L., Rutherford, A. (1995). Understanding cortical
visual impairment in Children.
American Journal of Occupational Therapy, 49: 899 – 903.
Good, W.V., Jan, J.E., Burden, S.K., Skoczenski, A. Candy, R. (2000). Recent advances in Cortical Visual Impairment. Developmental Medicine and Child
Neurology, 43: 56 – 60.
Groenveld, M., Jan, J.E., Leader, P. (1990).
Observations on the habilitation of Children with
Cortical Visual Impairment. Journal of Visual Impairment and Blindness. 84(1): 11 – 15