Supporting Alphabet Knowledge and Phonological Awareness for

Supporting Alphabet Knowledge and Phonological Awareness for Students with Significant Disabilities Including CVI By Gretchen Hanser , Deanna Kempka Wagner , Caroline Ramsey Musselwhite Date: August 3, 2020

literacy

Part 4 of 5

Supporting Alphabet Knowledge and Phonological Awareness for Students with Significant Disabilities Including CVI CAROLINE MUSSELWHITE, Dr. Caroline Musselwhite is an assistive technology specialist with more than 40 years of experience working with children and adolescents with significant disabilities in a variety of settings, including Head Start, clinics, developmental day programs, homes, and the public schools. Dr. Musselwhite has written a number of textbooks and “how-to” books on a range of topics, and has also authored many books and software programs for youth with disabilities. She has presented thousands of workshops throughout North and South America, Australia, Europe, and Africa, and is a founding member and Fellow of the International Society for Augmentative and Alternative Communication. Honors include: Foundation Fellowship (West Virginia University), Educator of the Year (Association for Retarded Citizens, North Carolina), Honors of the Association, (North Carolina Augmentative Communication Association), and DiCarlo Outstanding Clinician Award (North Carolina Speech-Lan- guage-Hearing Association), and ISAAC Fellow. DEANNA K. WAGNER, MS/CCC-SLP, is a speech-language pathologist with over 30 years experience providing consultations and training in the area of assistive technology with an emphasis on augmentative commu- nication. She works with educators and families to achieve goals in the area of AAC selection and implementation through a contract with TherapyOne (nominated two years in a row for the McLean-Yoder Award for Professional Excellence). She has been recognized for volunteer efforts and AAC support services to adults at the non-profit organization VALLEYLIFE, including various Stories of Ourselves literacy projects. She is co-director of Out and About: AAC in the Community. She has presented at local, national, and international conferences. GRETCHEN HANSER, Gretchen has worked in the field of assistive technology and literacy for students with significant disabilities for over 20 years. She is an educator and an occupational therapist. She has worked in a variety of educational settings developing model classrooms, developing school based assistive technology centers, providing teacher and related service provider trainings, participating in assistive technology assessment teams and working directly with students and staff in the classroom. Her primary focus has been on augmentative and alternative communication and literacy for students with the most significant disabilities. Gretchen has a masters in occupational therapy from the University of North Carolina in Chapel Hill and received her doctorate in education from the University of New Hampshire. She presents at local, national, and international conferences. Gretchen works at the International Academy of Hope in New York City.

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INTRODUCTION This series of articles is specifically focused on the importance of providing emergent literacy instruction to student with signif- icant disabilities including cortical vision impairments (CVI) and complex communication needs (CCN). Emergent literacy instruc- tion is quite different from conventional literacy instruction. Con- ventional literacy instruction focuses on areas such as sight word identification, phonics, spelling and learning formal comprehen- sion strategies. Emergent literacy focuses on all of the foundation- al skills that precede conventional literacy, such as simply learn- ing that print carries meaning, how books work, what it means to be a writer and alphabet knowledge and sound awareness skills. Due to their vision, verbal and physical issues, students with CVI have had extremely limited experiences with reading, writing and language. Many of them clearly need rich emergent literacy com- prehensive instruction. Erickson (2017) suggests that emergent literacy comprehensive instruction should include: shared read- ing, independent reading, independent writing, alphabet instruc- tion and shared writing. Communication opportunities using AAC must be woven throughout each of these areas. Instruction needs to be designed in such a way that CVI does not become the gate- keeper, limiting literacy learning. This article, along with previous articles, focuses on how to provide such instruction for each one of the areas outlined by Erickson (2017) and expanded by Erick- son & Koppenhaver (2020). OVERVIEW OF CORTICAL VISION IMPAIRMENT CVI is a neurological disorder that impacts the visual process- ing of information in the brain. It is frequently undiagnosed or unrecognized due to multiple physical/cognitive impairments. In the past decade, knowledge about CVI has grown rapidly (Ro- man-Lantzy, 2018, 2019; Lueck & Dutton, 2015). Roman-Lantzy (2018) describes visual function through 10 CVI characteristics: color preferences, visual field preferences, need for light, need for movement, problems with visual complexity and visual nov- elty, problems with using vision to guide their reach, visual laten- cy, atypical visual reflexes and problems with distance viewing. Students can be assessed for the level of impact of each charac- teristic using the CVI Range Assessment Tool. The 10 character- istics can be used to guide intervention and instructional adap- tations. Each student will have different needs based on their characteristics. Students’ abilities within and across the char- acteristics can be used to describe the severity of CVI. In broad terms, Roman-Lantzy (2019) refers to three different phases of severity of CVI. Phase I, Building Visual Behaviors, describes students who have little functional use of their vision and are learning to simply use their vision to look at something. Phase II, Integrating Vision and Function, describes students who are learning about what they are looking at and attaching meaning. Phase III describes students who have a great deal of vision but require specific instructional support as they are Developing Vi- sual Curiosity. To date, this series on providing emergent literacy

instruction for students with significant disabilities, including cortical visual impairment, has introduced readers to compre- hensive emergent literacy instruction (Hanser, Musselwhite, & Wagner, 2019a), provided strategies for one component of com- prehensive emergent literacy – predictable chart writing (Hans- er, Musselwhite, & Wagner, 2019b), discussed setting the stage for augmentative communication (Wagner, Hanser, & Mussel- white, 2020) and delved more deeply into complexity issues for students with CCN and CVI (Howery & Barros, 2020). ALPHABET KNOWLEDGE AND PHONOLOGICAL AWARENESS OVERVIEW Alphabet knowledge and phonological awareness instruc- tion are two components of comprehensive emergent literacy instruction (Erickson & Koppenhaver, 2020). These two areas are grouped together because they are highly connected and both are crucial to becoming conventional readers and writers. Developing alphabet knowledge supports phonological aware- ness and vice versa. Alphabet Knowledge Alphabet knowledge includes a range of understandings about the alphabet: the ability to distinguish letter shapes, name them, write them and identify the sounds they represent (Erickson & Koppenhaver, 2020, p. 34). As Sheldon & Erickson assert, ‘Knowledge of the alphabet is the foundation of conven- tional reading and writing' (2020, p. 17). Phonological Awareness Phonological awareness is a multilevel skill of breaking down sounds in words into smaller units and has been described as the single best predictor of early reading performance’ (Gillon, 2018). This term represents the conscious sound awareness of words in a sentence, syllables, rhymes, first letter or blends in a syllable (onsets), word families (rimes) and then of each indi- vidual sound (phonemic awareness). Erickson & Koppenhaver explain that it ‘refers to the ability to identify and manipulate sounds in spoken language’ (2020, p. 34).

INSTRUCTIONAL CONSIDERATIONS

Don’t Let Vision Become the Gatekeeper Vision is not a prerequisite for participation in emergent liter- acy activities. It is important that professionals do not limit liter- acy activities to only what the student is working on seeing. A wide range of emergent literacy concepts can be learned with- out vision. Sighted communication partners and students with- out visual impairments use shared referencing through visual channels. For students with CVI, interactions that foster learning and growth will need to reflect how they process information and share what they know. Individual letters (or words that have been outlined in a preferred color) can be used as single objects

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when following guidance for vision adaptations throughout the day. It is critical that all learners spend time talking about letter names, playing around with letter sounds and physically manip- ulating writing tools. Teach – Don’t Test Make it real, not rote. Include interactive materials and infor- mative feedback from knowledgeable others. Help students un- derstand when their responses are unclear and that how they respond does affect the outcome. Mastery is Not Needed The concept of mastery is closely connected to constant test- ing and repeated trials-based instruction – neither are necessary or desirable. Emergent learners with disabilities are building skills across time, and their abilities will and should fluctuate – just as these skills fluctuate across time for learners without dis- abilities. Check for Understanding Some students with CVI will be able to directly point (using a body part or a computer that reads eye movements) to make a selection from complex arrays (such as all 26 letters of the al- phabet), when provided with appropriate distance/spacing/size and visual features that make targets distinguishable. The same students may need to have items presented another way when there are more environmental distractions, or if s/he is fatigued. In this situation, the instructor can check for understanding by either asking the student to respond with their best YES or NO, or to pick an item from a list by using a signal that indicates, “That’s the one!” For more information about alternate access techniques, see Hanser, Wagner, & Musselwhite (2020) and view this webinar from Project Core: Supporting Individual Access to the Universal Core Module http://www.project-core.com/sup- porting-individual-access-to-the-universal-core-module/. Balance Explicit Instruction and Embedded Instruction While teachers talk about the alphabet and sounds embed- ded in daily shared readings and writing activities, separate ex- plicit instruction on the alphabet and sounds is also needed. The term explicit instruction refers to specific, organized lessons that target a particular skill. In the following sections, we will discuss explicit instructional activities, as well as ideas for embedding instruction throughout naturally occurring daily routines. We refer to the term ‘immersion’ to refer to activities that give stu- dents rich language experiences with supportive materials (e.g., alphabet books, poems, songs) without targeting specific alpha- bet knowledge or phonological awareness goals. Provide Daily Opportunities for Reading & Writing Activities. Alphabet instruction and phonological awareness are just two components of literacy instruction. Daily instruction must

also include opportunities for students to apply their growing skills during real reading and writing activities. Keep in mind that many of these beginning learners are emergent readers and writers who need to have opportunities for simply exploring books and experimenting with writing. Learners with signifi- cant disabilities, including CVI, may be perceived as not being ready for books and writing because they can’t visually process the text. However, professionals must push past this and provide highly interactive activities with rich auditory input supported by the appropriate visually modified materials which is available for students to look at, however, is not mandatory. GENERAL STRATEGIES TO SUPPORT LEARNERS WITH CVI Strategies and tools can increase success for students with CVI across literacy instruction, including instruction to build al- phabet knowledge and phonological awareness. When adapt- ing materials, it is essential to consult with your TVI. This cannot be overstated enough. The TVI can give specific recommenda- tions for specific learners regarding text needs such as font, size, color and complexity of array. As discussed in-depth in Hanser, Wagner, & Musselwhite (2020), sample strategies include: Use of Occluders Occluders can reduce visual complexity by covering up extra- neous pictures, symbols, letters, etc. For example, the occluder in this graphic shows how the OT calls attention to the target letter on a learner’s alternative pencil by covering up competing letters. (See Image 1: 3 Location Print Flip Chart, next page). Use of Black Backgrounds Visual complexity can also be minimized by presenting mate- rials on a black surface, such as the large tri-fold board from Aug- mentative Resources (www.augresources.com). See Image 2.

Image 2: Large Tri-Fold Board

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for activities such as letter identification, due to visual latency.

Consider Background Noise Background noise which may be filtered out by typical learn- ers may compete for attention for individuals with CVI. Be Aware of the Visual Battery Individuals with visual impairment, including CVI, have a ‘visual battery, meaning that they cannot use their vision for learning throughout the entire school day. Consider the visual battery when scheduling activities that require maximal visual attending (Tietjen,2019). Offer Visual Breaks Based on the concept of the visual battery, learners may need to take frequent visual breaks. Use Tablets to Address Visual Distance Issues IPads or other tablets can be extremely helpful for learners who struggle with visual distancing. Partners can take up-close pictures of materials or simply use the tablet as a viewing tool, so that teacher materials are enlarged and close up. Help Students Develop an Inner Voice Speaking students will verbally name letters during instruc- tion. Students with complex communication needs who are unable to clearly articulate letter names or sounds should be reminded to ‘say the letter (or sound) to yourself while I say it aloud (or out loud).’ CHECKING FOR UNDERSTANDING For both alphabet knowledge activities and phonological awareness activities, partners will need to check for understand- ing. For typically developing students, many tasks (e.g., letter naming, judging rhymes or initial sounds, matching rhymes or initial sounds) rely on speech or using a movement such as plac- ing one picture card next to another. These may be difficult or impossible for some students who have CCN, physical impair- ments and CVI. Hanser, Wagner, & Musselwhite (2020) have de- veloped a chart to show how to use strategies such as multiple responses, yes/no and single message partner assisted scanning with students with significant disabilities, including CVI. Follow- ing is a brief description of the three types of student responses. Examples of each response type, concerns regarding students with CVI and helper tips for success are summarized in this ar- ticle and described in more detail in Hanser, Wagner, & Mussel- white (2020). Remember that we should focus on teaching not testing. That means that checking for understanding should be intermittent, not used for every item we are presenting! 1. Multiple Possible Responses The partner shows several items, says the target (if appropriate for the task) and asks the stu- dent to indicate through direct selection (pointing or eye

Image 1: 3 Location Print Flip Chart with Occuluder (By Gretchen Hanser)

Use of Light One of the CVI characteristics is defined by the need for light. Using a flashlight or a backlit screen can help focus vision on a specific area. Flashlights can be used to spotlight a target – such as a letter on an alternative pencil – and/or to add movement to gain attention. Use of Neon Tape Neon tape may have reflective qualities, which can draw visu- al attention in the same way movement does. Movement does not necessarily trigger visual processing of details, but it can help a student identify basic boundaries (such as the location of a space bar or the edges of a tablet). Pause Time Learners with CVI may need additional pause time for pro- cessing, especially when we are asking them to use their vision,

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gaze) or partner-assisted scanning. Concern: This may in- crease the difficulty for students with CVI, as they must look at multiple letters, increasing the visual demands of the task. Tips for the Helper: Depending on the severity of the CVI, a student may have difficulty visually perceiving the differenc- es when offered a group of items during randomized multi- ple choice tasks. When asked to focus on the cognitive task of naming letters, students need to have automatic recognition of the array of choices as well as the physical skill to point to the letter. Performance may be affected by the number of items an individual student can process at once, the amount of time it takes to look at all the choices, trouble seeing all items at once if they are presented outside the limitations of their visual field, and difficulties the student may have with visual novelty when a few items are selected at random. Performance data should reflect how choices of items are presented, and provide guidance as to how to group items when necessary to accommodate for vision challenges. 2. Two Possible Responses . The partner shows an item, then asks a question (e.g., “Is this a C?”) or shows two items and asks a question (e.g., “Do these two rhyme?” or “Do these start with the same sound at the beginning?”). The student can answer with a gesture (e.g., head nod or shake, look up for yes, down for no) or through partner-assisted scanning. Some tasks might ask the student to indicate if two items are the SAME or DIFFERENT. The same approach could be used. Tips for the Helper: This technique depends on partners who are skilled at recognizing the learner’s signals without giving additional cues or trying to assign YES/NO responses to behavior that is unclear. In addition, performance data may be unreliable based on 50% probability of getting an answer right (or wrong). 3. Only one thing to say - “That’s It!” For this strategy, the partner gives the verbal target (“Let me know when you see the <tar- get>”), then shows only one item at a time, placing less visual demand on the student. When the student sees the target s/ he touches a symbol or uses a device to say “That’s it!” Tips for the Helper: This strategy presumes accurate and timely device activation. Identifying the target requires thinking through the options (cognitive processing) as well as the physical task of activating the device (motor coordination and timing). If student activations of the switch are not yet automatic performance data may be affected. ALPHABET INSTRUCTION FOR STUDENTS WITH CVI Students with significant CVI are likely to encounter access barriers to developing alphabet knowledge, but strategies are available to support their success. While learning the alphabet can be a highly visual task, it is important to strike a balance for students with CVI between the visual demands and the need for learning through auditory channels. When the tasks are too vi- sually taxing, learners will need auditory input in order to get

access to the broader, richer literacy concepts. Roman-Lantzy (2019) coined a technique called “word bub- bling” to help students with CVI learn to quickly recognize the shape of whole words by drawing around the outside using a color that glows (https://roman-word-bubbling.appspot.com). This technique is not recommended for use during alphabet in- struction, as it does not support learning the important concept that words are made up of individual letters as well as identify- ing the letters themselves. The following sections address each of the goals of alphabet knowledge instruction, and suggest possible supports, followed by sample tasks for explicit instruction and embedded all-day instruction. EXPLICIT ALPHABET INSTRUCTION: OVERCOMING ACCESS BARRIERS TO INSTRUCTION FOR STUDENTS WITH CVI Erickson & Koppenhaver recommend an approach to ex- plicit alphabet instruction based on the work of Jones & Reut- zel (2013). This approach is also integrated into all units of the Readtopia curriculum Don Johnston Inc, Readtopia as Learn- ing Letters (Erickson et al, 2019). This routine provides about 10 minutes of instruction per day of rapid cycling through the alphabet (one letter per day), allowing for at least seven cycles during the school year. The order of the cycle changes based on research (e.g., 1st – letters most frequent in student names; 2nd – alphabetic order). Within each cycle, the routine emphasiz- es: letter name ID, letter-sound ID, recognizing the letter in text, and producing the letter form (by writing or using an alternative pencil). See Erickson & Koppenhaver for a detailed explanation of this instructional routine (2020, pp. 36 – 40). The following section discusses access barriers related to at- tending to letters, naming letters and identifying sounds that letters represent. We also suggest ways that students who have both CVI and CCN can ‘show what they know.’ Remember that assessing what students know should be ongoing, and students should not have to give responses to every item. The goal must be teaching, not testing, and partners should be writing down observations, rather than constantly checking to make sure that students are getting the ‘right’ answers. In addition, the errors that students make often give us important information about what they do not understand, which can help us modify our in- struction. Below are suggestions for overcoming barriers and identifying possible ways in which students with CCN and CVI can show what they are learning. In general, the amount of al- phabet instructional time should be brief, taking into consid- eration the amount of visual effort required. Alphabet instruc- tion is one small component of daily literacy instruction and students need to have enough visual endurance for a range of literacy tasks. For example, the Learning Letters component of the Readtopia curriculum (based on Jones, et al., 2013) is only suggested to take 10-15 minutes per day.

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had materials presented at the front of the room by the teacher. His TVI suggested making duplicate materials for his aide, Joe, to present to him, greatly increasing Jamal’s visual attention. This way Jamal and Joe are able to joint- ly attend to a specific letter, picking it up and moving it around against an uncluttered black background. Name Letters Letter naming is (relatively) easy for students who are able to talk. However, as Howery & Barros point out, ‘. . . many chil- dren with CCN have problems with their vision’(2020, p. 42). This means that students who are already struggling to distinguish letter shapes may also need to find a way to name them other than using their voice. Remember that when reporting progress and discussing performance with the team, compounding com- plexities of CVI must be considered. Mini Example: Jacob is a high school student with CVI who is nonspeaking. Jacob is able to use his hand to point. The teacher starts by naming the letter M, and asks students to say it with him. Jacob’s aide Mr. Dario quietly reminds him to ‘say it to your- self.’ The teacher then shows three lowercase letters placed on a black background and asks Jacob to ‘find the M.’ When Jacob is not successful, Mr. Dario says the prompt again and uses the black background, but presents only one letter at a time, hav- ing Jacob indicate yes /no (by using head gestures) to indicate whether each one is the letter M. Then Mr. Dario shows Jacob the uppercase M and names it, asking Jacob to ‘say it to yourself’, but does not have him try to find it. Mr. Dario does not check for understanding each time the teacher presents a target letter, but instead quietly tells Jacob 'That’s the letter S. Let’s say it to- gether. S.' as he shows Jacob the target letter, again against the black background. Mr. Dario uses both the lowercase and the uppercase version of each letter. Write Letters Many students with CVI have motor problems that make let- ter formation difficult if not impossible. Some students might be able to use keyboards, especially if they are modified by add- ing tactuals, removing un-needed keys (e.g., function keys, print key), enlarging letter labels, adding colors or using occluders. Many students with CVI will need ‘alternative pencils’ or uncon- ventional tools that give students access to all 26 letters of the alphabet, even if they can’t hold a pencil or type on a keyboard. Hanser (2020) has created a number of alternative pencils spe- cifically designed for use by students with CVI. Students can use different approaches (eye gaze, partner assisted scanning using gestures, vocalizations & facial expressions, or partner assisted scanning using a single message device) to indicate their letter selections. These alternative pencils differ based on features such as: • Colors : Both the color of letters and the color of the back- ground should be considered, based on input from the TVI

Distinguish Letter Shapes With regard to letter shapes, students must be able to distin- guish both lowercase and uppercase letters, as well as recogniz- ing letter shapes in various fonts. Students with CVI, especially Phase I and Phase II, will struggle to distinguish letter shapes. Professionals need to take great care in not letting letter shapes be the only alphabet instruction provided, as students also need other alphabet activities in parallel to help them understand what letters are for, even if instruction is primarily via auditory channels. Adaptations include: 1. Modify Size, Font, and Color: Ultimately, students will need to rec- ognize a range of type fonts, plus letters of various sizes and colors. For initial learning, these features can be manipulated to make letter learning as easy as possible. A functional vision assessment by the Teacher of the Visually Impaired (TVI) may give guidelines on ideal font size, color, background, font type, etc. for initial instruction, specific to individual students. 2. Reduce the Complexity: Even if we make letters as visually salient as possible re: size, simplicity of font, colors, etc. they may not be accessible if they are presented against a busy background (or in a busy environment). Placing a letter card on an appro- priate background (often, a black non-glare surface such as a Velcro board) may increase the possibility of distinguish- ing the shape. For some learners, reducing complexity also involves reducing all sounds and movements in the environ- ment (like other students talking or moving around) in order to visually focus on a single item. 3. Consider Other CVI Characteristics: Refer to the chart in Hanser, Wagner, and Musselwhite (2019a, p. 4) showing the literacy implications of CVI characteristics. Consider factors such as: • The Need for Movement: Mini Example: Roger observes visual stimuli best if moved from his peripheral to central vision, with occasional shaking. His teacher understands that movement helps initiate and direct his gaze, but he may not be able to see details until he engages his central visual system. Explicit instruction on the shapes of dif- ferent letters must be brief, taking into consideration the amount of visual effort required. • Visual Latency: Mini Example: Alejandra needs at least 10 seconds to look at a stimulus (such as a letter). Her aide knows to wait quietly and not to give a verbal directive until Alejandra has had enough time to look at the letter first. • Difficulty with Distance Viewing: Mini Example: For Hana, the Smartboard might as well be on Mars! With every- thing so far away, she couldn’t tell what was important to look at and could not see individual letters. When the teacher found an app to reflect the Smartboard on an iPad (e.g. Team Viewer, or simply using the iPad camera), her visual engagement grew significantly and she was able to visually attend to the same letters as the others in her class. Mini Example: Jamal’s classroom typically

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to enhance their visual salience for the individual student. • Number of Items: Some students may have an alternative pencil with all 26 letters showing, such as an eye gaze dis- play. Other students may have a limited letter set (e.g., 3 - 6 letters) showing at a time, in a flipbook format. Students with Phase I CVI (who are still learning to use their vision) may benefit most from a tool (high tech or light tech) that presents only one letter at a time. • Font Type, Effect and Size: As with showing letters for shape identification, partners should carefully consider the type font. Letters should be presented in simple fonts such as Century Gothic. For example, Hanser (2020) provides al- ternative pencils with letters that have a glow highlighter around the edges of the letter (made using the Glow text option in Microsoft Word). See Image 3 and 4 below.

ters C and K, and /m/ represents the letter M. To check success, the adult says: “What sound does this letter represent?” as s/he shows a letter. This is a tricky task for students with a combina- tion of CCN and CVI. For this task, students can identify words that begin with the target sound. Strategies from the ‘name let- ters’ task can be used to identify target sounds. The complexities and concerns for students with CCN and CVI that are notewor- thy for the letter naming tasks will persist when applying these strategies to identifying sounds that the letters represent. Mini Example: Lissie is a 5th grader in a classroom that is using the Readtopia Curriculum. Lissie’s group is using the Learning Letters part of that curriculum. During the activity, the leader fol- lows a script to tell students the sound that the letter represents and shows how the sound looks (on the speaker’s mouth) and feels when she is making it. Lissie can’t see the leader’s mouth, but her aide Yvette makes the sound to show her how it is made. Students are asked to practice making the sound, and Yvette re- minds Lissie to ‘say it to yourself.’ Then the class goes on a sound hunt. Yvette gets three objects (drink, hat and book) and quickly records ‘That’s it!’ into a single message device and gives it to Lissie. Yvette asks Lissie ‘Does this start with the /b/ sound like bat and best?’ Yvette offers one item at a time and names it then waits to see if Lissie answers ‘That’s it.’ Lissie says ‘That’s it’ after the hat and Yvette says ‘/b/ hat. Is that the same? No, /b/ /h/ - those are different sounds. Let’s try another.’When they get to book, Lissie says ‘That’s it.’ Yvette waits to give her a high five, first saying, '/b/ book. Yes, book starts with the /b/ sound like bat and best.’

EMBEDDED ALPHABET INSTRUCTION: CONSIDERATIONS FOR STUDENTS WITH CVI

Musselwhite, Wagner, & Hanser (2020) share a wide range of instructional activities intended to be used throughout the day, at school, at home and in the community. Embedded alphabet instruction consists of opportunities for students to move be- yond just identifying letters and sounds and forming letters or choosing them on an alternative pencil. Embedded instruction helps students learn the why of letters and sounds – that they are used for reading and for writing, and that written letters rep- resent speech sounds. This is the basis of the ‘alphabetic princi- ple’which is essential in learning to read and write. The following section highlights a few alphabet activities that are highly ap- propriate for learners with CCN and CVI. Alphabet Immersion Through Alphabet Books Alphabet books are great for all learners, and help students build an ‘ear print’ for the letters of the alphabet. Musselwhite, Wagner, & Hanser (2020) suggest finding alphabet books that connect to the curriculum and to learner interests. Ideas for sup- porting learners with CVI: • Write Personally Meaningful Alphabet Books Connecting students' personal experiences to the alphabet is an ex-

Image 3: 3 Location Print Flip Chart with font using Glow Text Option (By Gretchen Hanser)

Image 4: Single letter per page Print Flip Notebook, by Gretchen Hanser (Idea from Linda Burkhart)

Identify Sounds That Letters Represent The final explicit alphabet knowledge task is to identify sounds that letters represent, such as /k/ represents the let-

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• Find Alphabet Books on Tar Heel Reader. A wealth of free accessible alphabet books can be found on Tar Heel Reader (www.tarheelreader.org). Among the thousands of easy- to-read books are hundreds of alphabet books that are ap- propriate for older learners (e.g., Fashion A-Z, Sports ABCs) as well as alphabet books related to the content areas (e.g., ABCs of African American History, Places A-Z). In the Tar Heel Reader Settings, the page color and text color can be changed to a black background with a choice of neon text colors. Another big bonus is that you can download your favorite Tarheel Reader books into PowerPoint. See image 7 below.

tremely effective way to link what students know to some- thing new.

Mini Example: Ale is making a PowerPoint personal alphabet book with his favorite people and things. The adults present choices of things they know he likes. Ale has Phase II CVI. He uses two single message devices to say “yes that one,” and “no, not that.” Only the target letter is highlighted to engage his vi- sion. Reading the words is not the goal. The PowerPoint anima- tion is highly controlled so that one item at a time moves onto the screen. Each page has a digital recording. The book is switch accessible so that he can control the speed through the book when he wants. He has the choice of looking and/or listening when he wants. Because he chose the pictures, they are things he is very familiar with; visual novelty is not so much of an is- sue. The images have been simplified using the “Remove Back- ground” feature in PowerPoint. See both Images 5 and 6 below.

Image 5: Ale loves farts!

Image 7: Tip of the Month: Alphabet Books December, 2014 www.aacintervention.com

• Present Books Auditorily Only. Books – including alphabet books – are a great option when a learner needs a ‘visual break.’ See Howery & Barros (2020), for further discussion of using visual breaks to re-charge a learners’ visual battery. • Present Books in Switch-Operated Format. Some learn- ers will not be able to physically turn pages in a paper book and may need to use a switch to turn pages in digital

Image 6: Ale’s favorite book is the Paperbag Princess

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2. Increase Student Interaction and Support Vision. Make a student version of the song board, so that it is within the op- timal distance for target students. Focus should also be on features previously suggested, such as size, color, font and background to reduce clutter. 3. Present the Song / Chant in Digital Format. The song or chant with visuals can also be made into a video, showing the movement of pointing to letters or removing them, supporting those students who struggle with visual nov- elty and may need multiple repetitions before they are able to comfortably attend visually to an activity. These students may also benefit from adaptations that allow them to control the pace of repetitions (such as offering a way to start and stop). Songboards can also be modi- fied in PowerPoint using the animation feature. This Bingo Name Chant was created in PowerPoint. At the beginning of each verse, an animation is used to make the next let- ter fly off the screen after which it is replaced by a blank. The student used a switch to click through the animation steps at his own pace. Verse: ‘There was a boy named Gabriel and he liked to joke a lot’. See Image 9 below.

books. Learners need the time to process letters, especially individuals with visual latency issues. Using a switch gives learners independence and the control of the timing as they page through a book. Many books can also be read online using switches, including those on Tar Heel Reader. • Use PowerPoint to Write/Customize Your Own Alphabet Books. PowerPoint books can be highly adapted to meet learners’ specific vision needs in regards to color, movement and sound. Page by page audio recordings can be added for times when ‘listen only’ is preferred (Hanser, Mussel- white, & Wagner, 2020). Embedded Alphabet Tasks A wide range of instructional tasks can be embedded throughout the day to build alphabet knowledge (Musselwhite, Wagner, & Hanser, 2020). Following are samples of interactive instructional tasks that can be fit into small amounts of time. • ‘ Bingo’ Songs or Chants . These activities are based on the children’s song, ‘There was a farmer had a dog, and Bingo was his name-O. B – I – N – G – O, etc.’ With each successive singing, a letter is removed and replaced with a clap. Mus- selwhite, Wagner, & Hanser suggest numerous variations on this, using songs or chants for student names and to in- troduce vocabulary for content learning (2020, pp. 30 - 36). Two strategies that they suggest to support students with CVI are: 1. Present Bingo Chants in Light Tech Format. Bingo chants can be as simple as having the name on a strip, with let- ters on Post-its. However, some adaptations will need to be made for students with CVI. In the Bingo Name Chant shown below, individual letter cards are presented on a black velcro sensitive board (from Augmentative Commu- nication Resources). The letters are made with a simple font using the Microsoft Glow text effect. As each verse is sung, a velcro letter is removed from the board. See Image 8 below.

Image 9: Bingo Digital Chant for Gabriel

4. Alphabet Action Man . This activity takes advantage of the fun and movement of actions, connecting them to alphabet letters. Musselwhite, Wagner, & Hanser sug- gest strategies for modifying this activity for students with motor impairments (e.g., having them ‘be the di- rector’), and for students with CVI, such as creating an Action Man book with moving Gifs (2020, pp. 33-36). See Image 10 below.

Image 10: K is for kick gif. M is for mail gif

5. Letter Scavenger Hunts. Letter scavenger hunts are a very interactive way to have friends, family, and others in the en- vironment help find pictures or objects to represent a letter. Ideally, have multiple ‘teams’ each searching for items with

Image 8: Bingo Board for Amelia

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their letter. This should be a social activity, and students should find items that are personally meaningful. Mussel- white, Wagner, & Hanser (2020, pp. 38 - 44) suggest strate- gies to maximize learning through these hunts such as: • Using Alternative Pencils. Students can use alternative pencils tailored to their CVI and motor needs to pick letters for this activity. • Use AAC Systems to Pick Items. Partners can help students explore their light or high tech AAC systems to pick items to share with the group, and judge whether they start with the target letter. • Make A Social Script. Partners can co-construct Social Scripts (Musselwhite & Burkhart, 2001) to support students in asking for items that represent the target letter. • Make A Book. Partners can co-construct a book so that students have their own alphabet books to re-read, either light tech or (ideally) both light and high tech. Alphabet Games Students can engage in alphabet games through card games or PowerPoint games, using LessonPix or Boardmaker Online to show target letters. Students can play ‘I Have / Who Has’ using a voice output aid that announces their letter, and asks a peer for a different letter. Then the student must listen for her letter the next time. LessonPix is a wonderful resource that allows pro- fessionals to build a range of engaging instructional materials, including PowerPoint add-ins, such as game spinners, dice or drawing from a hat. See Image 11 below.

nological awareness may be easier to teach because it allows students with CVI to use their auditory strengths. This section will provide examples of embedded phonological awareness ac- tivities. If interested in information about explicit instructional programs, see: Clendon (2018), Erickson & Koppenhaver (2020), and Schuele (2008). Musselwhite, Wagner, & Hanser review key points regarding phonological awareness instruction including: a) Phonological awareness is a metalinguistic skill, meaning that students must let us know (in some way) that they hear dif- ferences such as syllable beats in a word, words that rhyme, or words that start with the same sound. b) Phonological awareness represents progressively smaller units, starting with dividing sentences into words, progressing to syllables, then recognizing rhymes, dividing a word into an onset (everything up to the first vowel in the syllable) and rime (vowel to the end of the syllable), then phonemes (individual sounds within a word, often referred to as phonemic awareness). c) Levels of phonological awareness are overlapping, mean- ing that this is not a ‘step-lock’ sequence, in which students must master an earlier level before progressing to the next level (Musselwhite, Wagner, & Hanser, 2020, p. 49).

INSTRUCTIONAL CONSIDERATIONS

Pair Instruction with Print, When Possible and Appropriate to the Task Research has found that phonological awareness instruction is more effective for some goals when paired with print. How- ever, for some students with Phase I or II CVI, having the visual and the auditory input is too much. In addition, for some tasks, such as matching initial sounds, adding print is not desirable . Students should match pictures so that they must say the sound (out loud or in their head) for each picture, then decide if the sounds are the same. Use of Pictures Pictures are frequently used during phonological awareness activities to represent sounds and words. Learners who have CVI may not be able to process an image in the same way as their typical peers. This does not mean that they can’t benefit from the activities, however. Carefully assess whether the images need to be adapted to highlight specific visual features, reduce clutter or verbally described. In some cases, an object can be substituted. While students may not be able to visually process the details of pictures, pictures may still be used as a visual placeholder or visual referent to aid the memory of the choices. For more infor- mation about assessing and using 2D images, see Tietjen (2018). Be sure to consult with your TVI regarding the best way to pres- ent print and pictures to your students.

Image 11: Matching letters – uppercase & lowercase: PowerPoint + LessonPix Spinner

PHONOLOGICAL AWARENESS INSTRUCTION FOR STUDENTS WITH CVI Phonological awareness is an auditory skill that requires students to become consciously aware of different sounds in sentences and words. Compared to alphabet instruction, pho-

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troduced several poems, songs and hand claps to her class of 5 – 8 year old’s, showing them on the Smartboard, with one learn- er using her switch to advance slides and activate animations and sounds. Eli has CVI and attends far better with movement added. His teacher sets up the computer with a switch so he can listen and look at the nursery rhymes again during independent reading time. See Image 12 below.

Difficulties with Generalization Learners who are non-speaking may have more difficulty with skill generalization after phonological awareness instruc- tion or intervention (Clendon, 2018). As Clendon noted, ‘Chil- dren with disabilities have a history of receiving splintered liter- acy instruction that focuses on teaching skills in isolation’. She further notes that ‘Children with CCN (Complex Communication Needs) often exhibit significant difficulty applying their phono- logical awareness to literacy tasks (Chapter 11). Thus, partners need to make those links explicit through instruction within a comprehensive literacy program. Learners must be helped to actively use the skills they are learning across reading, writing, and communication. Increasing Complexity of Sound Units Literature reviews (e.g., Erickson & Koppenhaver, 2020; Gil- lon, 2018, Sheule & Boudreau, 2008) have shown an increasing complexity of phonological awareness tasks, starting with ‘shal- low skills’ (e.g., word awareness, syllable awareness, rhyme and alliteration) and progressing to ‘deep skills’ (e.g., segment initial / final sounds, blend sounds into words, segment words into sounds, delete/ manipulate phonemes). Remember that these are overlapping steps. That means that learners don’t need to ‘pass a test’ on one step before beginning instruction with the next. The activities described here target the ‘shallow skills’ of word awareness, syllable awareness, the various levels of rhyme awareness, and alliteration (initial and final sounds). These are foundational skills for individuals who are emergent learners. PHONOLOGICAL AWARENESS IMMERSION In addition to designing tasks to target specific phonologi- cal awareness goals, students should have rich exposure to lan- guage forms that help develop an ‘ear print’ for features such as rhythm, rhyme and alliteration. Students should have daily op- portunities to engage with phonologically rich language forms. Adults need to seek out age-respectful materials, and help learners listen and respond to them. Multiple repetitions with minor variations across the day or week can engage learners in exploring features of rhythm, rhyme, and alliteration. Several examples are provided below. Nursery Rhymes, Songs, Poetry and Hand Claps Reviewers and researchers have stressed for decades (e.g., Adams, 1994; Bradley, 1988) the importance of immersing young learners in forms of language that highlight features such as rhythm, rhyme and alliteration, as each of those features supports the development of phonological awareness. Mussel- white, Wagner, & Hanser (2020) summarize a wide range of ac- tivities and resources for immersing students in these language forms. Sample strategies for supporting learners with CVI are highlighted below. Animated Step-by-Steps by Carol Goossens: Ms. Sara has in-

Image 12: Nursery Rhyme Poems

Hand Claps & Jump Rope Rhymes: Monique is a third grader with Phase II CVI. She is getting better at integrating vision and learning, but using her vision all day is fatiguing. Recess is in mid-afternoon, when she is often highly fatigued. Her occupa- tional therapist has thought of various ways she can be engaged at recess without stressing her vision. One day each week, they use a Social Script on her TalkSuite app in story mode to help her lead her peers in jump-rope rhymes. Her peers have worked with Monique to program several hand claps that they use, such as Down In the Valley and Ice Cream Soda (‘Ice cream soda/ lem- onade punch/ tell me the name of my honey-bunch/ A-B-C-D . . .’). One peer helps her pick a rhyme each day to use during rope jumping, or as a hand clap. While the student described is a third grader, older students may also enjoy engaging with hand claps and jump rope rhymes.

EMBEDDED PHONOLOGICAL AWARENESS INSTRUCTION

The following section will describe instructional tasks to support students throughout the day in building phonologi- cal awareness for specific targets, such as syllable awareness or rhyme awareness. Order of Complexity of Phonological Awareness Targets. As described previously (e.g., Schuele & Boudreau, 2008; Gillon, 2018), there is an order of complexity of phonological

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awareness, beginning with word awareness, then syllables and progressing to sound units such as onset and rime, through phonemic awareness. The following sections focus on the more ‘shallow’ phonological awareness targets of word awareness, syllable awareness, rhyme and alliteration.

He is not consistently clapping each word, but they continue to work on it. When she sees him tiring of the activity, she tells him, “You can just listen, and I’ll clap the words,” modeling clapping the words for the rest of the book.

TEACHING WORD AWARENESS

Word Awareness Overview Word awareness is an early developing phonological aware- ness skill that does not require good vision. Instruction in word awareness should be brief, and should quickly lead to syllable awareness instruction. Schuele & Boudreau (2008) recommend starting first with one syllable words such as ‘Ann wants a bike’ because they are more obvious. Learners with CVI may also have motor impairments which make it difficult for them to ‘clap each word.’ Adults will need to be creative to identify ways that learners can show that they hear separate words. Learners might: stomp, blink, move head, sway, rock, or hit a tambourine with the elbow to indicate each word in a sentence. Adults and peers in a room can work together to identify the easiest way for each learner to demonstrate word awareness. Below are sample activities to support the development of word awareness. Beat Instructions: Preschool and kindergarten teachers of- ten have chanted instructions that they give, such as: “Line up, line up, everybody line up. Line up, line up, line up NOW!” The adults can begin representing each word with a clap, stomp, slap, etc. This activity does not require vision, but a partner can help the target student figure out a way to indicate each word. ‘ Beat the Words’ to a Short Poem or Nursery Rhyme. For this activity, learners listen to a poem or nursery rhyme while a helper reads it and taps, claps, snaps each word. Mini-Exam- ple: Eliberto had a hard time showing his awareness of different words. After a few days of this activity, Randall (the aide working with him) noticed that Eliberto was making small head move- ments to the right. Randall gave him informative feedback: “Hey buddy, I see you moving your head. You’re showing me that you hear those words. ‘Peas <clap> porridge <clap> hot <clap>.’ Let’s do it together.” Beat the Words in a Book with Short Sentences . Evan, age 15, is crazy about rollercoasters. His Mom downloaded a book about rollercoasters from the website, Tar Heel Reader (www.tar- heelreader.org ). She has printed and laminated the book and sometimes shows it on the computer. They have read the book together several times. For this activity, they are not going to look at the actual book, because she wants Evan to focus on lis- tening to the individual words. Mom tells Evan they are going to clap each word in the book. She reads the first page, clapping every word slowly. On the third page, she invites Evan to join in.

Image 13: Tar Heel Reader book

TEACHING SYLLABLE AWARENESS

Syllable Awareness Overview Gillon (2018) explains that syllable awareness requires aware- ness that words can be divided into syllables. Several complex rules of syllable division underlie this process, but we can keep it simple, and just help learners learn syllable segmentation, or saying the words in drumbeats. Thus, ‘cat’ has one drumbeat, while ‘caterpillar’ has four drumbeats. Syllable Awareness: Name Chants Personal names are a great way to introduce many skills, includ- ing syllable awareness, because they are familiar (students hear their own name and the names of their peers throughout the day), and they are highly personally meaningful. Name songs or chants that highlight the beats in a name can be used at various points in the day, as described below. Roll Call – I Have A Friend: ‘Songboards’ are the brain child of Carol Goossens. The song board ‘I Have a Friend’ was developed by Musselwhite (2019) to provide a visual support for a song that supports name identification and syllable awareness. The lyrics are “I have a friend and her name is Samantha, now we’ll stomp her

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