February / March, 2021 Closing The Gap Magazine, Volume 39,…

Dec 22/Jan 23 Closing The Gap Solutions - Collaborating With Augmentative and Alternative Communication (AAC) Users Gains A New Perspective To Best Support Clients By Lydia Dawley

Closing The Gap Assistive Technology Resources for Children and Adults with Disabilities February / March, 2021 Volume 39 - Number 6 Solutions ANNUAL RESOURCE DIRECTORY

A guide to the latest assistive technology products for children and adults with disabilities. It is the culmination of an extensive search for the latest software, hardware and other assistive technology products that are on the market today, as well as their producers. 2021 Edi t ion

EDITOR’S NOTE: There is no charge for inclusion in the Resource Directory. Listings are based on editorial questionnaires, phone interviews and materials provided by producers. Listings are not advertisements nor is their inclusion in the Directory an endorsement or guarantee by Closing The Gap. Descriptions are edited materials submitted by producers. They are not product reviews. Information provided is as current as possible at publication time.

STAFF

contents volume 39 | number 6

february / march, 2021

Megan Turek ......................................... PRESIDENT Marc Hagen ........................................... VICE PRESIDENT MANAGING EDITOR Becky Hagen.......................................... MEMBERSHIP MANAGER REGISTRATION MANAGER Mary Jo Barry......................................... MEMBERSHIP DEVELOPMENT

35 Upcoming Live Webinars

Helping every student do their best work with Google accessibility solutions By Laura Allen

37 Product Spotlight

A guide to nearly 1,500 Assistive Technology Products!

Callie Boelter.......................................... SALES MANAGER

43 RESOURCE DIRECTORY 44 Producers 56 Hardware Product Matrix 64 Hardware Product Listings 86 Software Product Matrix 97 Software Product Listings 133 Other AT Product Matrix 142 Other AT Product Listings 172 Membership Information

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11 Can Eye Gaze Technology Improve Visual Skills and Participation with Children Who Have Cortical / Cerebral Visual Impairment? By Tammy Bruegger

Student Membership 1-yr. $125 Standard

Visit www.closingthegap.com/membership for complete details and pricing. PUBLICATION INFORMATION Closing The Gap (ISSN: 0886-1935) is published bi monthly in February, April, June, August, October and December. CONTACT INFORMATION Please address all correspondence to Closing The Gap, P.O. Box 68, Henderson, MN 56044. Telephone 507-248-3294; Fax 507-248-3810. Email <info@closingthegap.com>; Website <www.closingthegap.com>. COPYRIGHT Entire content is copyright 2021 by Closing The Gap, Inc., all rights reserved. Reproduction in whole or in part without written permission is strictly prohibited. EDITOR’S NOTE The information provided by Closing The Gap, Inc. in no way serves as an endorsement or guarantee by Closing The Gap, Inc.

19 Let’s Interact with Google Jamboard By Cheryl Farley

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accessibility & UDL

Helping every student

do their best work with Google accessibility solutions

LAURA ALLEN , is the Head of Strategy for Accessibility and Disability Inclusion at Google. She works cross-functionally across teams to improve the accessibility and usability of Google products and processes, and to make Google a more accessible and inclusive place for people with disabilities. Due to her personal experience with low vision, she believes that technology has more power now than ever to transform lives, and progressing accessibility and disability inclusion is her true passion. Prior to her role as Head of Strategy, Laura was the Senior Accessibility Program Manager for the Chrome and Chrome OS teams at Google. For 6.5 years, she collaborated with engineers, designers, product managers, and researchers to make the Chrome family of products accessible and usable across platforms, for people of all abilities. She also leads various accessibility workshops and trainings around the United States for teachers of the visually impaired, advocacy organizations, and special education classrooms. In addition, Laura helps to manage Google’s presence at major accessibility conferences, as she believes that connecting with the community and gathering hands-on feedback is critical. Laura also represents Google in the Teach Access organization, where various technology companies, higher education institutions, and disability advocacy organizations come together to drive the inclusion of accessibility in core computer science, design, and human centered interaction programs. As of 2020, she serves as the Chair of the Teach Access Executive Committee. Since 2017, Laura has also served on the board of directors for the San Francisco Lighthouse for the Blind and Visually Impaired. As of June 2020, she serves on the board of the Alphapointe Foundation, an organization centered around empowering individuals who are visually impaired to achieve their goals and aspirations and gain meaningful employment. Prior to her role in accessibility, Laura worked as an Account Manager in Google’s Large Customer Sales division where she advised business-to-business technology companies on their advertising and marketing strategies. For her undergraduate education, Laura studied International Business, Marketing, and Music at Georgetown University. She is also undergoing an Executive Leadership graduate program at Stanford University through spring 2021.

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INTRODUCTION Every student and educator, in every learning environment, deserves access to the tools and skills they need to succeed academically and build the future they want—inclusive of their needs and learning styles. There are 93 million children living with a disability worldwide, according to UNICEF. “Many are invisible, hidden by their families and abandoned by their governments. We believe that regardless of ability, all children have a right to reach their full potential,”UNICEF says. In addition to those with diagnosed disabilities, there are many students who may not have a defined disability, including those with specific learning disabilities. For this group as well, accessibility solutions can help them achieve their full potential.

In this article, we’ll share many of the accessibility features that are built into Google for Education solutions such as Chromebooks and G Suite for Education.

MAKING THE WORLD’S INFORMATION MORE ACCESSIBLE

Google strives to make the world’s information universally accessible to everyone, including all learners, in every classroom. We do this with built-in accessibility features that let students and educators personalize their learning tools, and that create inclusive learning environments so students can learn individually and as a group. Our accessibility features help educators forge strong connections with students while encouraging students to learn in a collaborative fashion. We’re committed to continuing to offer powerful accessibility features across our products, including Android, Assistant, G Suite, Chromebooks, and more, that help everyone access information in a way that works for them. FEATURES AND CAPABILITIES Educators can empower and enable learning, by building expertise in using technology to address every student’s needs. And by giving all students equal access to tools and capabilities that can help them learn at their best, we can all work to close the accessibility gap. At Google, accessibility is a core value: we believe in organizing the world’s information and making it universally accessible and useful. That’s why tools like Chromebooks and G Suite for Education are built with every learner in mind. The accessibility features in Chromebooks and G Suite for Education run the gamut from tools for visual support, features that help students with reading comprehension, and captioning to help students better understand audiovisual presentations—as well as tools to help IT administrators manage accessibility settings. Below is a selection of some of the newest features for accessibility, including

HOW EVERYONE BENEFITS

When everyone can participate fully in learning—with each person bringing their own unique skills, talents, and perspectives to the table—everyone benefits: • Students gain access to the tools to express themselves in ways that work for them, and can collaborate more freely and easily with peers and educators. • Educators are empowered with tools and features that allow more time for student instruction, and benefit from using the tools themselves. • IT teams can reduce technical support calls with built-in accessibility features that are intuitive and easy to set. • Parents, guardians and families can support students learning from wherever they are, and continue the learning at home.

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colors and shading that help students read and navigate when online; use captioning for better comprehension during live classes; and tools for students who are blind or low vision.

Listen in different languages. The ChromeVox Voice Switching feature built into Chromebooks automatically changes the screen reader’s voice based on the language of the text being read, which is helpful for students when pages contain multiple languages. Better Braille support in Google Docs. Students who are blind or with low vision can use a Braille display to read and edit documents, spreadsheets, presentations, and drawings. Throughout 2020, Google made several improvements to Braille support in Google Docs, including keyboard shortcuts, faster typing echo and screen reader navigation, and improved handling of punctuation and spaces. Read more about recent Braille improvements in this Google blog post. Export more accessible PDFs in Chrome. Students and educators can export websites as tagged PDFs in the Google Chrome browser on any device, including Chromebooks. The ability to export content to PDFs, complete with auto-generated headings, links, tables and alt-text, are a boon for people who are low vision or blind, since they are easier to access with a screen reader.

VISUAL SUPPORT

Choose colors for cursors on Chromebooks . Choosing different colors for cursors can help students better navigate text and webpages. Students can choose from seven colors—red, yellow, green, cyan, blue, magenta and pink—in addition to black. They can also increase the cursor size for even more visibility. The cursor- size tool can be accessed in the“mouse and touchpad”section of Settings on Chromebooks. Use high-contrast mode for easier reading. Turn on high- contrast mode in G Suite for Education tools or on Chromebooks to invert screen colors. This can be very helpful for students with visual impairments, especially those with light sensitivity.

AUDIO AND CAPTIONS

Live captioning in Google Meet. When students attend a Meet session, such as a live class with teachers, they can choose to turn on captioning to improve comprehension. This is especially helpful for students who are Deaf or hard of hearing. Captions are available in English, as well as Spanish, French, German and Portuguese. Closed captioning in Google Slides. Just as captioning in Meet can help students who are Deaf or hard of hearing, captions in Google Slides can improve students’understanding of content. With this feature, everything that students and teachers say during a presentation in Slides can be shown as a caption on viewers’screens. You can customize where the captions appear, as well as the size of the text.

ALTERNATIVE INPUTS

Switch access for Chromebooks. Navigating around a screen can be difficult for students with motor and dexterity challenges. With Switch Access, students can use external devices connected via Bluetooth or USB, or the built-in keyboard to scan options and choose them by pressing a button. Going hands-free in G Suite for Education. Students can use voice commands to carry out actions such as navigating, selecting, writing and editing in Google Docs, sending emails in Gmail, and joining or leaving Google Meets.

SCREEN READING SUPPORT

ADMINISTRATOR AND EDUCATOR FEATURES

Accessibility features available in kiosk mode. Administrators can place Chromebooks into kiosk mode, so that exam apps can run in full-screen mode on a device. When using kiosk mode for testing, Chromebook accessibility features are readily available and custom- izable, including screen readers and magnification. In addition, some testing providers allow access to third-party accessibility tools from Google partners such as Don Johnston and Texthelp. Helpful accessibility apps on the App Hub . The Chromebook App Hub is a useful resource for admins looking for accessibility apps for their schools and review data policies. An ideas carousel offers inspiration for new and creative apps to try.

Tools for improving reading ability are easy to access in both Chromebooks and in G Suite for Education. On Chromebooks, students can turn on the built-in screen reader called ChromeVox, which helps people with visual impairments to use the Chrome operating system with audio spoken feedback or braille. Chromebooks also offer Select-to-speak, which can read specific text or sections of the screen out loud. Shade background text when using Select-to-speak. When students use Select-to-speak to hear text read aloud, they can add shading to background text that is not being spoken aloud. It’s a useful feature for students with low vision or learning disabilities such as dyslexia. The shaded-text feature can be enabled in Chromebooks’Select-to-speak settings.

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PARTNERS CREATE CHROME EXTENSIONS AND APPS FOR ACCESSIBILITY Google has partners that understand how to develop technology tools that foster accessibility. Most of the tools take the form of extensions that can be added to the Chrome browser for additional functionality. In most educational settings, IT administrators can push out extensions for users of enrolled Chromebooks; educators can also request extensions that can help students. There are many accessibility tools found on the Chromebook App Hub: Don Johnston : The company builds tools for people with all types of learning styles and abilities. Their core products are Co:Writer for word prediction, translation, and speech recognition; Snap&Read for reading accommodations, PDF annotation, translation, and study tools; and Quizbot, an automatic quiz generator for Google and Google Forms. Texthelp: Texthelp provides literacy and learning software tools to support students with reading, writing, math, and language learning, including EquatIO for typing, writing, or dictating equa- tions, formulas, and graphs; Fluency Tutor for making reading aloud more fun and satisfying for students learning or struggling to read; and Read&Write, which makes documents, PDFs and files more accessible, especially for students with dyslexia.

• Clicker Communicator from Crick Software: One of the first augmentative and alternative communication (AAC) apps specifically created for Chromebook users. • Capti Voice: Reading support tool with a Classroom integration which allows teachers to accommodate different learning needs and make tests accessible to more students. • Grackle Docs: Create accessible Google Docs and PDFs with Grackle Docs. • Stay Focused: Limits time spent on websites—helpful for students with ADHD. • MagicScroll Web Reader: Allows readers to scroll websites in the same way they read books, helping to maintain focus. • BeeLine Reader: Reduces eye strain, assists with eye tracking, and offers a dyslexic-friendly font. • Dualless: Splits screen on a Chromebook like a dual monitor to help students improve their focus.

HOW STUDENTS AND SCHOOLS USE GOOGLE ACCESSIBILITY TOOLS

Around the world, students and educators are adopting accessibility solutions to learn with confidence and collaborate in an inclusive learning environment—like the students below. GAINING CONFIDENCE IN READING SKILLS Mikael, a 7th-grader, has dyslexia and mild visual impairment. He uses the screen magnifier on his Chromebook to enlarge images and

Here are even more accessibility apps and extensions:

Dyslexic font in Google Docs

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Clicker Communicator by Cricksoft

HOW SCHOOLS USE ACCESSIBILITY TOOLS

RAIGMORE PRIMARY SCHOOL, INVERNESS, SCOTLAND Raigmore’s Primary 6 students pitched in to help Primary 2 students learn to sing “Over the Rainbow” for a school assembly. The older pupils noticed that one of the younger children was non-verbal and couldn’t sing along. The younger students had been learning some Makaton sign language to communicate with their classmates, so the group devised a plan to also“sing”in Makaton. To speed up the learning, students used the front-facing cameras on their Chromebooks to play Makaton YouTube videos while watching their hand signs on screen. This way, they were able to improve their movements by watching themselves practice Makaton signs in real time. Other pupils recorded themselves signing using the Flipgrid app from Microsoft, and watched the videos to further refine their signing. During the performance, the young students both sang and signed“Over the Rainbow”along with their non-verbal classmates. “They all went with Makaton for that one child,” explained their teacher, David Crooks. “The child was able to be included, and felt that they’d contributed something to the assembly, instead of just standing with classmates.” UPPER GRAND DISTRICT SCHOOL BOARD, ONTARIO, CANADA With about 15 percent of its students identified as those with special needs, Upper Grand wanted to invest in resources to help students with disabilities reach their full academic potential. To find more flexible and budget-friendly classroom tools, Upper Grand tested several laptops and tablets, including Chromebooks. With built-in accessibility tools like high-contrast mode and spoken feedback, Chromebooks offered far more choices to teachers seeking to personalize students’learning experiences. The district initially purchased 3,500 Chromebooks for students with disabilities. Upper Grand DSB now has 20,000 Chromebooks, primarily for K-8 students. Students with disabilities can also take their Chromebooks home.

Don Johnson: Locked mode

text when required. Using Open Dyslexic Font, a Chrome extension, he converts text on websites he visits to a dyslexic-friendly typeface that’s easier to read. With the Color Enhancer extension for Chrome, Mikael improves the visibility of web content he’s viewing. During group activities, he uses the Snap&Read Chrome app from Don Johnston to read background web pages. The app reads the written content aloud, and even dynamically adjusts the vocabulary to suit his comprehension. ASSISTANCE FOR READING AND WRITING AFTER AN INJURY When Rochelle, a 9th-grader, fractured two fingers and a forearm bone after a vacation accident, her arm was in a cast. Because she had limited use of her hand and arm, she used voice-controlled typing in Google Docs. To navigate around her Chromebook, where some features required her to press keys simultaneously, Rochelle used the“sticky keys”feature, allowing shortcut keys to be typed in sequence, without pressing multiple modifier keys at the same time. MAINTAINING FOCUS WHILE LEARNING REMOTELY When Kira, a 6th-grader, signs in on her Chromebook at home, all her personalization settings are automatically applied so she can get straight to work. She manages her tendency to get distracted by negotiating which apps she can use during the day—her mother can manage app access through Family Link, which helps families set digital ground rules to help guide students as they explore online. If there are distractions while Kira is learning from home, she can turn on real-time captioning during live classes on Google Meet so she doesn’t miss any part of the conversation.

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Access fonts to improve speed reading in Google Docs

Teachers now have many more tools to help students overcome their unique learning challenges. Students can use voice typing with Google Docs if they have motor-skills issues; teachers can use the commenting feature in Google Docs to check on student progress and guide them in completing lessons. Other built-in accessibility features like ChromeVox, a built-in screen reader for the visually impaired, and support for devices like Braille displays, help students with disabilities achieve more. The district can now buy 100 Chromebooks for the price of 30 of the previous laptops. Trading offline text-to-speech software for the Read&Write Chrome extension from Texthelp also saved money, with the cost of 10 of the previous licenses being the same as a district-wide Read&Write license. LEARN MORE ABOUT GOOGLE AND ACCESSIBILITY: HELP FOR EDUCATORS AND FAMILIES Every student deserves to reach their full potential. With help from dedicated educators and flexible accessibility solutions, students can gain the confidence to work independently, express themselves in a way that works for them, and collaborate freely with educators and peers. If you’d like to learn more about Google and accessibility, or you’re searching for guides for students and families, check out the resources below.

GENERAL RESOURCES • Teach from Anywhere • Accessibility Training YouTube Playlist • Google Workspace Accessibility User Guide • Chromebook Accessibility User Guide • edu.google.com/accessibility • google.com/accessibility • Accessibility tools one-pager • Flashcards • Apps and extensions for accessibility: g.co/chromebookapphub

LEARNING FROM ANYWHERE Chromebook accessibility features for distance learning

RESOURCES FOR TEACHERS Teacher Center: Tools for Diverse Learners Module

RESOURCES FOR FAMILIES • Guardian’s Guide to Tools for Children with Disabilities During Distance Learning • Family Link • Teach from Anywhere • Add a school account for a Family Link user

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TextHelp Read&Write and EquatIO work in locked mode in Quizzes in Google Forms

VIDEO TRAINING • Google for Education Tools for Diverse Learners • EDU in 90: Chromebook Accessibility • EDU in 90: G Suite Accessibility • EDU in 90: Chrome & Chrome OS Accessibility • Google Accessibility YouTube Series • Google Accessibility Series

HELP CENTER ARTICLES • Get help with Google for Education - Google for Education Help • Turn on Chromebook accessibility features - Chromebook Help • Use a screen reader with Classroom on your computer (for students) - Classroom Help • G Suite user guide to accessibility - G Suite Admin Help • G Suite admin guide to accessibility - G Suite Admin Help • Set up Meet for distance learning - G Suite Admin Help • HC Article on how to use Closed Captions in Meet • Google Classroom Accessibility Conformance Report (VPAT)

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Making Physical Therapy FUN

Motivates achievement of ALL movement Goals Use in Clinic, at Home, Anywhere, Anytime

Remote monitoring by Clinicians 20+ FUN and ENGAGING games

www.lusiorehab.com letsplay@lusiorehab.com 1300 1 LUSIO

blind / low vision

Can Eye Gaze Technology Improve Visual Skills and Participation with Children Who Have Cortical / Cerebral Visual Impairment?

Eye gaze technology is an emerging form of assistive technology that has previously been used both for assessment and intervention of children and adults with visual, motor, and/ or communication difficulties (Borgestig & Hemmingsson, 2017; Borgestig, Sandqvist, Ahlsten, Falkmer, & Hemmingsson, 2017; Karlsson, Allsop, Dee-price, & Wallen, 2017; Karlsson et al., 2018; Masayko & McGowan, 2018). Frequently eye gaze technology is used as an access method for communication or environmental control using a dedicated speech generating device (SGD) or AAC (alternative and augmentative communication) device. Eye gaze technology consists of an infrared camera that is placed at the bottom of a laptop or tablet screen with the user positioned facing the screen. The camera detects the eye movements of the user and can select items on the screen based on where their gaze is located, as well as collect data on the location and duration of their gaze (Masayko & McGowan, 2018). This allows for assessment in areas such as oculomotor control and visual functions (Kooiker et al., 2016).

In a study done by Kooiker et al. (2016), an eye tracking device was compared to the standard visual function assessments used by optometrists, ophthalmologists, and orthoptists. The researchers found the technology could measure vision just as well as the standard assessments and even offered some advantages, including sensitivity to some variables the standard assessments typically missed. This study shows the ability of eye gaze technology to obtain accurate information about visual behaviors in children (Kooiker et al., 2016). In 2019, a study was performed using eye gaze technology to assess the functional visual tasks of looking for a toy in a toy box and locating a specific person in a crowded hallway (Bennett et al., 2019). The researchers in this study created two virtual reality scenes depicting the tasks described above and used eye gaze technology to determine the participants’ proficiency in these tasks. The participants included a control subject, a child with an ocular visual impairment, and a child with Cortical Visual Impairment. The scenes were each presented at times

TAMMY BRUEGGER, OTD, MSE, OTR/L, ATP. Tammy is an Assistant Professor in the Department of Occupational Therapy within Rockhurst University’s College of Health and Human Services. She has been a practicing OT and AT practitioner for many years in the areas of vision, assistive technology, multiple disabilities, developmental disabilities, pediatric and adult neuro-rehabilitation. She has particular interest in access to literacy, complex learners/multiple disabilities, vision, cortical/cerebral visual impairment, sensory processing, motor learning, autism and universal design/accessibility in community settings. Occupational Therapy students who assisted with this article are: Megan Brush, OTS, Laurel Davis, OTS, Karra Kennedy, OTS, Brittany Rorhbach, OTs and Shelby Sutton, OTS, Rockhurst University.

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with a low number of distractors and at other times with a high amount of distractors. Results were collected by a heat map or visual representation using colors indicating where the participants focused their gaze. This confirmed several characteristics known to be true about children with CVI, such as an increased difficulty locating items in the presence of distractors and the use of broader visual search strategies. Eye gaze technology has also been used as an intervention tool in several studies (Borgestig & Hemmingsson, 2017; Borgestig et al., 2017; Karlsson et al., 2017; Karlsson et al., 2018; Masayko, & McGowan, 2018). In all of these studies, the technology was given to participants to use in their daily lives and incorporate into their typical activities. Participants in every study had disabilities such as cerebral palsy and all but one of the participants were children. The outcomes from these studies included improved activity repertoire and eye gaze performance on the technology itself; increased ADL participation, independence, and quality of life; improved communication skills; and goal attainment. In addition, parents of children who used the technology reported high rates of satisfaction, an improved ability to communicate with their children, and increased hope for their children’s future. Further research has used eye gaze technology as a quantitative measure and has applied this information to the design of alternative communication systems. A study done by Wilkinson, Neill, and Mcllvane (2014) used ISCAN eye-tracking technology to record the point of gaze and latency in a visual search task with 2 different AAC screens. There were two groups that each had seven children without disabilities. In one condition, the symbols sharing a color were clustered in a group. In the other condition, the symbols sharing a color were dispersed across the screen. The study found that participants were quicker to fixate on targets when like-colored targets were closer together. The participants were also less likely to make errors and fixate on incorrect targets. When like-colored targets were spread apart, the opposite happened—participants were more likely to make mistakes and fixate on incorrect targets. The researchers believed this to be due to the increased complexity of the screen design when the like-colored targets were spread apart, making it more difficult for the children to fixate on the target. In addition, this study justifies the use of eye gaze technology as a quantitative measure in research (Wilkinson et al., 2014). Although some of the children in the studies mentioned had CVI, many others had different types of visual impairments or other disabilities. There is a large gap in the literature when it comes to exploring the use of eye gaze technology with children who have CVI and especially whether this technology can help improve occupational performance. This article considers visual skills and uses eye gaze technology as an intervention to determine if both this and occupational performance can

be improved through the use of this technology (McDowell & Budd, 2018; Roman-Lantzy, 2007). Cortical/cerebral visual impairment is a growing epidemic in the Western world. Studies have shown that anywhere from 18% to 48% of cases of significant vision loss or blindness in children are due to CVI. These rising rates may have to do with improved neonatal intensive care, which allows infants who have experienced events such as hypoxic ischemia to have a better chance of survival (Merabet, et. al., 2017). Although perinatal hypoxic ischemia is the most common cause of CVI, other causes include trauma; epilepsy; infections such as malaria; drugs or poisons; cerebral angiography [sic]; and other diseases, most often metabolic or neurological in nature (Baker-Nobles & Rutherford, 1995; Cohen-Maitre & Haerich, 2005). In all of these cases, damage occurs in areas of the brain that participate in higher-order visual processing, and this in combination with the visually guided motor impairments that are often also present in children with CVI, leads to a unique and varied presentation of symptoms (Merabet, et. al., 2017). One symptom that is almost always present in children with CVI is decreased attention and processing of vision, and this is often accompanied by a decreased ability to see in all areas of the visual field, especially the lower fields. Abnormalities in motions of the eye itself may also be seen, such as limited ability to fixate or difficulty in tracking an object (Merabet, et. al., 2017). What most often characterizes children with CVI and helps lead to their diagnosis is a set of behavioral tendencies not typically seen in children with other kinds of visual impairment. Some examples of these characteristics include light gazing (staring at a light source) or photophobia (sensitivity to light), turning the head to use peripheral vision when looking at or reaching for an object, bringing objects close to the eyes to look at them, looking away from complex visual stimuli, and displaying an overall sensitivity to stimuli in their environment. Children with CVI have also been noted to be especially drawn to specific colors (most often red or yellow) and movement in their environment (Baker-Nobles & Rutherford, 1995; Cohen- Maitre & Haerich, 2005; Merabet, et. al., 2017). Even with a proper diagnosis of CVI, it can be difficult for children to receive services based on the current definitions of blindness and visual impairment that are used to determine eligibility for services. The current definitions classify visual dysfunction based on visual acuity and visual field, which do not account for the visual processing symptoms present in CVI (Kran, Lawrence, Mayer & Heidary, 2019). Without these needed services, children with CVI will not likely improve their functional use of vision and may experience delays in their development (Kran et al., 2019). As a result, the children will likely experience decreased participation in their meaningful daily occupations secondary to significant visual impairment.

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A recent research study at Rockhurst University was conducted using eye gaze technology with children who had cortical/cerebral visual impairment. The purpose of this study was to describe the occupational performance or daily activities and routines of children with CVI and to utilize eye gaze technology to assess and provide intervention for foundational visual skills (I.e., visual attention or noticing objects), then see how vision impacted their occupational performance or daily activities. Visual processing skills often occur in a hierarchical manner. Therefore, foundational skills such as visually attending to an image on the screen or noticing and locating an image occur first, then more complex visual processing occurs (Warren, 1993). This study utilized both a descriptive case series and pre-post- test experimental component. The descriptive component was a case series design, and the experimental component was a pre-experimental, pre-post design. Occupational performance and satisfaction, CVI range scores and eye gaze technology software using visual attention (attention, quality, consistency, and reaction), and noticing images (ability, attention, reactions, accuracy, completion, and consistency) were used to measure the children’s performance. The sample included five children (2 boys and 2 girls, one was unable to complete the study) with CVI from 0-6 years of age. Due to the Covid-19 pandemic, the setting of the study had to be adaptable. The descriptive portion of the study took place over Zoom video conferencing. The intervention portion of the study took place either at a preschool for children with visual impairments or in a local outpatient clinic in the Midwest. When setting up the location for the eye gaze in either the clinic or school setting, the environmental considerations such as lighting, sound, and visual distractions were adjusted for the best performance of the children. The Canadian Occupational Performance Measure (COPM) was used to determine levels of performance and satisfaction in the occupation categories of self-care, leisure and productivity (Law, M., Carswell, A., Baptiste, S., McColl M.A., Polatajko, H., & Pollock, N., 2014). Parents of the children ranked their child’s performance level and parent’s satisfaction level with their performance in their top five occupational performance problem areas before and after using the eye gaze intervention. The Cortical Visual Impairment (CVI) Range was used as a functional vision assessment of the children as a pre-post measure. This CVI Range measures color preference, need for movement, visual latency, visual field preference, difficulties with visual complexities, light-gazing and non-purposeful gaze, difficulty with distance viewing, atypical visual reflexes, difficulty with visual novelty, and visually guided reach (Roman- Lantzy, 2007). The CVI Range has been established as a reliable measure to assess visual processing in the CVI population (Newcomb, 2010).

The Insight and Learning Curve software provided objective measurements of eye gaze behaviors using eye gaze technology. The software uses engaging and interactive games for children to practice and develop their visual skills. (“Eye Gaze Learning Curve,” n.d.). The game software comes with a variety of difficulty levels, which the researchers used to tailor the intervention to the needs of the children. In addition, the Insight software provided quantitative information after each trial that was used for data analysis. Informed consent was obtained by providing written forms for the parents of participants to sign prior to beginning the study and the study was approved by the Institutional Review Board (IRB) of Rockhurst University. Educational and medical records provided by the parents were reviewed first to obtain previous medical and educational history, testing, goals, and interventions. Other preliminary data obtained included assessments of occupational performance (daily functioning and participation) by using the Canadian Occupational Performance Measure (COPM) scores, American Occupational Therapy Association Occupational Profile Template information (AOTA-OPT), and visual processing skills by using the Cortical Visual Impairment Range scores. The COPM and AOTA-OPT data were obtained through interviews with the children’s parents. The CVI Range scores were obtained through observation and assessment of the children’s visual abilities with additional parent interview questions. One occupational therapist performed and scored the CVI range assessment with the student researcher present to take notes and to observe responses. These one-hour interviews and observation sessions took place during separate meetings using Zoom over a three- week period. For the second part of the study, intervention data collection took place over a four-week period at a school for children with visual impairments or an outpatient clinic in the Midwest. One occupational therapist/assistive technology practitioner performed the data collection due to restrictions from the Covaid 19 pandemic. Using Insight and Learning Curve eye gaze software from Inclusive Technology Inc., baseline data about visual skills of each participant including visual attention and focused looking, were collected a week prior to starting the intervention during an initial session. The eye gaze system was also calibrated to the participants’ eyes at this time. The intervention took place individually in a quiet room with adjustable lighting, and the technology was set up against a plain black background to reduce visual distraction. Set up of the eye gaze technology followed Insight eye gaze procedures—the participants were placed 50-75 cm away from the computer screen, with the screen positioned so that it was level with the participants’ eyes. The intervention consisted of 20 to 30-minute sessions two to three times a week for four weeks and involved playing age-appropriate visual games that focused on practicing and increasing visual

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skills of the participants. The software recorded eye gaze data during the intervention. Although the Insight software records many eye gaze variables, this study only focused on activities of “Visual Attention” and “Noticing Images” provided by the software. Researcher observations were also collected during the intervention using the Eye Gaze in the Classroom Data Sheet. An eye gaze post-test was completed the final week of the intervention, and the COPM and CVI range were performed again a week following the intervention to determine if the intervention was effective in improving the visual skills, occupational performance, and performance satisfaction of the participants. The descriptive portion of the study contributes to a greater understanding of how CVI impacts the lives of children. The participants had difficulty with many daily activities. All of the children’s parents reported that their child had difficulties with communication/social interaction, self-care, learning/literacy and mobility. Other difficulties in daily occupations reported by participants included feeding, play, riding in the car and fine motor activities like crafting. Each child showed difficulty with participation in typical daily routines, occupations, and activities compared to other children their age. Though there were some similarities among participants, each child in the study was also unique in their strengths, abilities, and struggles, such as one child’s difficulty with tactile tolerance and another having excellent tactile skills. CVI has affected each child’s performance in a unique way, and this should be taken into consideration when implementing interventions for this population through individualization of interventions. Data analysis of the information obtained during the study indicates an improvement in visual skills and occupational performance following the intervention (See Table 1). This supports the use of eye gaze technology as an effective intervention to improve visual skills and occupational performance in children with CVI. The improvement of means in most of the eye gaze variables shows the technology has an effect and may be used to assess the visual skills of children with CVI in the future. The lack of improvement in visual consistency can possibly be explained by the known inconsistent visual performance of children with CVI (possibly due to environmental changes or internal sensory processing) and changes in the eye gaze intervention activities to higher level activities as the child improved their visual skills on the software. These results correspond with previous studies which have found that eye gaze technology is an effective intervention for improving visual field awareness (Atasavun & Duger, 2012) and occupational performance (Borgestig, et al., 2017). Although there have been studies on a few interventions and assessments there is limited information about how CVI presents in children in relation to the impact of CVI on occupational performance.

This study shows promise for this type of intervention although it involved a relatively small sample, no randomization or blinding of researchers or participants, possible co-intervention and a single location. These limitations could impact the generalizability; however, due to the new direction of this research, this level of evidence is important to establish and justify further research. The final limitation of the study was the lack of standardization in the amount or frequency of intervention provided to each participant due to the COVID-19 pandemic and mandated precautions, which caused some scheduling difficulties. Children who had more frequent intervention did show more progress in visual skills as shown in Table 1. Statistically insignificant findings can potentially be explained by these limitations mentioned above. A larger sample size and more intervention sessions for the participants could have helped with even greater increases in skills, helping the data reach statistical significance. See Table 1 for results of the study and eye gaze activities.

David Jessica Abby Landon

Number of sessions Average number of Insight trials / session Total Insight Software trials COPM Performance scores COPM Satisfaction scores CVI Score 1

4.45

4.22

2.5

3.66

PRE: 4.4 POST: 5.6

PRE: 2.8 POST: 5

PRE: 2.7 POST: 3.2

PRE: 3.8 POST: 5

PRE: 4 POST: 4.6

PRE: 3.6 POST: 5.6

PRE: 5 POST: 5.8

PRE: 1.8 POST: 2.4

PRE: 5 POST: 8

PRE: 2 POST: 4

PRE: 3 POST: 6

PRE: 4 POST: 8

CVI Score 2

PRE: 6.75 POST: 8

PRE: 2.25 POST: 5.75

PRE: 3.75 POST: 6

PRE: 3.5 POST: 5.75

Table 1:Testing Scores

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Measure Pre-test means

Post-test means

F-value Signifi- cance

Using eye gaze technology and objective assessments of occupational performance tailored to the child’s individual needs and environment is important when working with children who have cortical/cerebral visual impairment. The study of this area discussed in this article is important for educational and health care professionals to consider when choosing interventions for children with CVI. By matching the CVI level of the child to the visual software intervention, outcomes may be optimized. Taking this information into consideration, health care providers can include the use of eye gaze technology, while tailoring their treatment to the unique needs of those with CVI. Using eye gaze technology with children who have CVI is a relatively new concept but shows promise as an assessment and intervention. Although CVI is a condition that is not yet well understood it has a significant impact on the lives of those who have been diagnosed with it. The results of this study demonstrate the specific visual challenges and the impact vision has on the occupational performance of these children. Furthermore, the study discussed provides an effective intervention to help children with CVI improve their visual skills. As demonstrated by the statistically significant increase in COPM and CVI range scores following intervention, improvement in visual skills from eye gaze intervention may improve the overall occupational performance of children with CVI. REFERENCES Abd El-Maksoud, G. M., Mohammed Gharib, N. M., & Diab, R. H (2016). Visual Based Training Program for Motor Functions in Cerebral Palsied Children with Cortical Visual Impairment. International Journal of Therapies & Rehabilitation Research, 5(4), 265–277. https://doi.org/10.5455/ijtrr.000000173. American Occupational Therapy Association. What Is Occupational Therapy? [Brochure]. North Bethesda, MD. American Occupational Therapy Association. (2014). Occupational Therapy Practice Framework: Domain and Process (3rd Ed.). American Journal of Occupational Therapy, 68, S1-S48. doi: 10.5014/ajot.2014.682006. American Occupational Therapy Association. (2017). AOTA Occupational Profile Template. American Journal of Occupational Therapy, 71, 1-3. https://doi.org/10.5014/ ajot.2017.716S12 Atasavun Uysal, S., & Düger, T. (2012). Visual perception training on social skills and activity performance in low-vision children. Scandinavian Journal of Occupational Therapy, 19(1), 33–41. https://doi-org.lib.rockhurst.edu/10.3109/11038128.20 11.582512. Baker-Nobles, L., & Rutherford A. (1995). Understanding cortical visual impairment in children. American Journal of

COPM Performance COPM Satisfaction Visual Attention Visual Attention: Attention Visual Attention: Reaction Visual Attention: Quality Visual Attention: Consistency Noticing Images Noticing Images: Ability Noticing Images: Attention Noticing Images: Reaction Noticing Images: Accuracy Noticing Images: Completion Noticing Images: Consistency

13.293 . 036*

3.43

4.70

3.60

4.60

8.824

.059

22.65% 46.08% 5.822

.095

17.80% 38.08% 8.079

.066

43.13% 78.95% 2.152

.239

53.15% 76.13% 1.089

.373

83.75% 74.45% 1.5.27

.304

70.88% 81.03% .823

.431

83.56%

74.63%

.742

.452

43.88% 59.13% .733

.455

91.63% 95.33% 2.118

.242

65.88% 75.08% .454

.549

64.25% 88.30% 1.643

.290

55.88% 62.75% .321

.611

CVI Score 1 CVI Score 2

3.50

6.50

.005*

2.06

6.38

25.196 .015*

Table 2: Eye Gaze Software (Insight) Data MANOVA Results Note.“*” represents statistical significance at the p<.05 level.

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Occupational Therapy, 49(9), 899-903. https://doi.org/10.5014/ ajot.49.9.899 Bennett, C. R., Bex, P.J., Bauer, C.M., & Merabet, L.B. (2019). The assessment of visual function and functional vision. Seminars in Pediatric Neurology, 31, 30-40. https://doi.org/10.1016/j. spen.2019.05.006 Borgestig, M., & Hemmingsson, H. (2017). The benefits of gaze-based assistive technology in daily activities for children with disabilities. Studies in Health Technology & Informatics, 242, 1082-1088. https://doi-org.lib.rockhurst.edu/10.3233/978- 1-61499-798-6-1082 Borgestig, M., Sandqvist, J., Ahlsten, G., Falkmer, T., & Hemmingsson, H. (2017). Gaze-based assistive technology in daily activities in children with severe physical impairments–An intervention study. Developmental Neurorehabilitation, 20(3), 129–141. https://doi-org.lib.rockhurst.edu/10.3109/17518423. 2015.1132281 Cohen-Matre, S. A., & Haerich, P. (2005). Visual attention to movement and color in children with cortical visual impairment. Journal of Visual Impairment and Blindness, 99(7), 478-485. Retrieved from https://search-ebscohost-com.lib.rockhurst. edu/login.aspx?direct=true&AuthType=cookie,ip,url&db=c8h &AN=103777194&site=ehost-live Eye gaze in the classroom data sheet (n.d.). Inclusive Technology. Eye gaze learning curve (n.d.). Retrieved from https://www. inclusivetlc.com/eye-gaze-learning-curve Fleming CV, Wheeler GM, Cannella-Malone HI, Basbagill AR, Chung Y, & Day KG. (2010). An evaluation of the use of eye gaze to measure preference of individuals with severe physical and developmental disabilities. Developmental Neurorehabilitation, 13(4), 266–275. https://doi-org.lib. rockhurst.edu/10.3109/17518421003705706 Hamed-Daher, S., & Engel-Yeger, B. (2019). “The Relationships Between Sensory Processing Abilities and Participation Patterns of Children With Visual or Auditory Sensory Impairments.” American Journal of Occupational Therapy, 73(4), doi:10.5014/ ajot.2019.73s1-po7021. IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. Intervention for Children with Disabilities (n.d.). Retrieved from http://www.thecopm.ca/casestudy/intervention-for- children-with-disabilities/ Karlsson, P., Allsop, A., Dee-price, B., & Wallen, M. (2017). Eye-gaze control technology for children, adolescents and adults with cerebral palsy with significant physical disability: Findings from a systematic review. Developmental Neurorehabilitation, 21, 497-505. https://doi.org/10.1080/175 18423.2017.1362057 Karlsson, P., Bech, A., Stone, H., Vale, C., Griffin, S., Monbaliu, E., & Wallen, M. (2018). Eyes on communication: Trialing eye-gaze

control technology in young children with dyskinetic cerebral palsy. Developmental Neurorehabilitation, 22, 134-140. https:// doi.org/10.1080/75184.2018.1519609 Kooiker, M. J. G., Pel, J. J. M., Verbunt, H. J. M., Wit, G. C., Genderen, M. M., & Steen, J. (2016). Quantification of visual function assessment using remote eye tracking in children: Validity and applicability. Acta Ophthalmologica (1755375X), 94(6), 599–608. https://doi-org.lib.rockhurst.edu/10.1111/ aos.13038. Kran, B.S., Lawrence, L., Mayer, L.D., & Heidary, G. (2019). Cerebral/cortical visual impairment: A need to reassess current definitions of visual impairment and blindness. Seminars in Pediatric Neurology, 31, 25-29. https://doi.org/10.1016/j. spen.2019.05.005 Lantzy, C. A. R., & Lantzy, A. (2010). Outcomes and Opportunities: A Study of Children with Cortical Visual Impairment. Journal of Visual Impairment & Blindness, 104(10), 649–653. https://doi-org.lib.rockhurst. edu/10.1177/0145482X1010401010 Law, M., Carswell, A., Baptiste, S., McColl M.A., Polatajko, H., & Pollock, N. (2014). Canadian Occupational Performance Measure (5th ed., pp. 1-45). Canada. CAOT Publications ACE. Masayko, S., & McGowan, J.S. (2018, September). Factors in selecting eye gaze technology for young children: An interprofessional pilot study. OT Practice, 23(16), 21-25. McDowell, N., & Budd, J. (2018). The Perspectives of Teachers and Paraeducators on the Relationship between Classroom Clutter and Learning Experiences for Students with Cerebral Visual Impairment. Journal of Visual Impairment & Blindness, 112(3), 248–260. Retrieved from https://search-ebscohost-com. lib.rockhurst.edu/login.aspx?direct=true&AuthType=cookie,ip, url&db=eric&AN=EJ1182386&site=ehost-live Merabet, L. B., Mayer, D. L., Bauer, C. M., Wright, D., & Kran, B. S. (2017). Disentangling how the brain is “wired” in cortical (cerebral) visual impairment. Seminars in Pediatric Neurology, 24(2), 83–91. https://doi-org.lib.rockhurst.edu/10.1016/j. spen.2017.04.005 Newcomb, S. (2010). The Reliability of the CVI Range: A Functional Vision Assessment for Children with Cortical Visual Impairment. Journal of Visual Impairment & Blindness, 104(10), 637–647. Retrieved from https://search-ebscohost-com.lib. rockhurst.edu/login.aspx?direct=true&AuthType=cookie,ip,url &db=eric&AN=EJ902175&site=ehost-live Novak, I., Cusick, A., & Lannin, N. (2009). Occupational therapy home programs for cerebral palsy: double-blind, randomized, controlled trial. Pediatrics, 124(4), 606-614. Roman-Lantzy, C. (2007). Cortical visual impairment: An approach to assessment and intervention. New York, NY: American Foundation for the Blind. Salavati, M., Rameckers, E. A. A., Steenbergen, B., & van der Schans, C. (2014). Gross motor function, functional skills and

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