"CVI and AAC: Using Objects"

CVI and AAC: Using Objects Functionally by Lori Dahlquist, October / November 2023, Closing The Gap Solutions Magazine. Volume 42, # 4

alternative augmentative communication (AAC)

CVI and AAC: Using Objects Functionally

Over 55% of communication is visual (1). This includes the things we see like gestures, facial expressions, body movement, and objects in the environment. The presence of any visual im- pairment must be a major consideration in communication inter- vention including AAC. Cortical Vision Impairment (CVI) is the most common form of visual impairment in children (2) CVI is vision loss due to damage or malformation in the brain that interferes with the child’s ability to understand the visual information coming from the eyes. It is a visual processing deficit. Other visual impairments we are more familiar with, stem from problems in the eyes themselves. It is estimated that 10.5% of children with developmental dis- abilities have CVI (2) Some top causes of CVI are: encephalopa- thy, intraventricular hemorrhage, infection, trauma, and various genetic disorders. These conditions are also common in children with multiple disabilities. The good news is that unlike other types of vision impairment, with the right intervention, CVI can improve over time (3). Many of the causes associated with CVI, also impact commu- nication. In other words, CVI can impair the vision of someone who might benefit from augmentative and alternative commu- nication. (AAC) This is why we must take a closer look at how to approach AAC when CVI is also a factor. It may mean rethink- ing some of the strategies commonly used in AAC intervention. Whenever possible, include a Teacher of the Visually Impaired (TVI) as an integral part of the intervention team. The informa- tion they provide is critical when developing an intervention plan. Collaboration is key to success. Children with CVI experience a range of impact on their vision.

No two children will manifest their CVI in the same manner. They must be evaluated and observed individually to see how best to meet their communication needs. It is worth repeating, col- laboration is key!! The TVI offers wealth of information regarding children’s use of their vision. This information can then be used in designing a functional AAC system. A TVI that is trained to assess CVI is very helpful. The CVI eval- uation process is very detailed and breaks down critical informa- tion into very distinct areas (4). • Learning Media Assessment: determines whether the prima- ry mode of learning is visual, tactile, or auditory • Appearance of the eyes: do they were glasses, do the eyes work together, presence of nystagmus or strabismus • Movement of the eyes during visual tasks: can they shift their gaze or require full head movement to move to a new item • Impact of space and clutter: how much visual background can be tolerated, impacts the number of items that can be visually regarded at the same time • Form Accessibility: determines whether they recognize 3D or 2D items • Integration of Competing Sensory Information: is the use of vision impacted by the amount of noise present • Access to People and Faces: difficulty making or maintain- ing eye contact or regarding faces (when present, can cause difficulty interpreting body language, gestures and sign lan- guage) • Impact of Light: Can be either distracting or can help draw attention, could also be light sensitivity

LORI DAHLQUIST has a background in the fields of Speech Pathology and Audiology with over 35 years of experience in Augmentative Alternative Communication (AAC) and Assistive Technology (AT). Since 1999, she has worked at Adaptivation Inc. as the Speech/Education Coordinator. She has presented at many conferences and has authored Adaptivation, Inc.’s reference books, Recipes for Success and Adapt This..

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• Impact of color: may rely on color to support finding and rec- ognizing an item • Visual field functioning: looks for limits in visual field as well as preferences • Attention to movement: could be used to support or distract • Visual guidance: integrating visual information with motor activities Each of the above-mentioned assessment areas gives import- ant information in developing an AAC intervention that best meets a child’s needs. It will help clarify the specific needs of the child. If we just assume the answers in some of these areas, we can hinder progress and actually make communication more dif- ficult. For example, let’s take the most common intervention strate- gy used when a child has CVI and needs an AAC system— use of high contrast symbols. In general, high contrast symbols are sim- ple images, usually red or yellow on a black background. They have been incorporated as symbol options in many of the high- tech voice output devices. They are also readily available in other symbol programs such as Boardmaker and on the internet. There are many other teaching resources that have been adapted using the high contrast symbol. Sound great—right? The answer—not always. This is actually a common misconception. We need to remem- ber, children with CVI have difficulty UNDERSTANDING what is seen. High contrast symbols may attract students’ attention but it does not help them understand what they are viewing. We need to be sure our students are at a visual level where they are interpreting what they see. In actuality, high contrast symbols can increase visual complexity of an AAC system because they have multiple colors and many of the symbols are the same color. These symbols also do not portray the actual color of the object in real life. For example, cows aren’t yellow. All of this can lead to more confusion for the user. Even more of a problem—present- ing 2D symbols when in actuality, the child needs objects! Again, I repeat, the TVI can help determine how to use color functionally and if the child is ready for 2D symbols. This brings up another area that is often misunderstood when it comes to AAC intervention— the representational hierarchy (listed below). For those in the field of AAC, the use of the visu- al hierarchy (objects, photos, symbols) does not need to be fol- lowed. In other words, a child doesn’t have to be introduced to objects before 2D photos or pictures. Research has shown that for children with CVI, it is critical to find where they are on the hierar- chy, and start there. With intervention, children can improve their ability to visually process what they are seeing.

Developmental Sequence of Visual • Real Objects • Miniature Objects • Partial Objects • Real Photos • Line Drawings (e.g. Boardmaker, Symbolstix) • Bliss Symbolics • Text

CVI Order of Complexity

• Single color objects • Multi-colored objects

• Patterned Objects • 3D Visual Symbols • 2D photographs of familiar ob- jects • Photographs of unfamiliar ob- jects • Realistic color illustrations • Abstract colorful cartoons • Realistic black and white illustra- tions • Abstract black and white draw- ings

Children with CVI that are learning to visually process objects still need access to a robust language system. How can we incor- porate objects into functional activities that reinforce communi- cation? Again, COLLABORATION IS KEY! Let’s take what is known about developing and reinforcing functional communication and mesh it with the information and intervention of the TVI. In discussing how to begin teaching object identification, a big question is, “What objects do I start with?” The answer is to use things common to the child’s environment such as a cup or a ball. From a communication perspective, also consider what concept that object might be used to represent. For example, can the cup be used to represent “drink“ and the ball be used to represent “play,”“PE” or the sensory room ball pit? Looking at object iden- tification and communication together is helpful. When using objects that are the same or bare a strong resemblance to what they represent, one runs the risk of the user confusing the symbol with the referent. To avoid this problem, objects can be attached to a material such as a 2D card. This helps establish a clear bound- ary for the symbol. The size can be determined by the needs of the user and the size of the objects. This also aids in attaching the “symbols” in other areas of the environment such as on tables, walls, doorways, on switches and communication devices. To this end, Adaptivation offers the Tangible Object Cards. There are a total of 65 cards. The plastic cards are 5x7 inches and come with objects attached. There is also room for a 2D symbol on the card if needed. PLEASE NOTE: THESE CARDS WERE NOT DEVELOPED WITH CVI IN MIND! That being said, there is a lot we can learn from their development and use. At the time of their development, there were two schools of thought on developing a more “standard” system of objects, Shared or Individualized (5). The Tangible Object Cards were developed with the “shared “approach in mind. In the world of AAC, we try not to have a different set of symbols for each user. For practical purposes, it is much easier to house, maintain and keep track of a shared set of symbols. The use of a standard set of symbols also offers continuity within an organization. For ex- ample, if a school uses a shared set of symbols, students moving from classroom to classroom will not encounter a symbol they are unfamiliar with.

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that represent these core words. The objective was to find ob- jects that looked more like the symbol the user would eventually use. Again, it must be clarified that the core vocabulary tangible symbols were not developed for students with CVI. The question is, “Can this concept be used successfully, keeping the CVI level of the child and his or her personal needs in mind?” -picture of core vocabulary cards Look at the core word, “go” for example. The most common symbol for “go” is an arrow. In some symbol sets it is green and in others it is red. The Adaptivation object card for“go”is an attached wooden green arrow (see below). For teaching the object, a large wooden arrow was found at a craft store and painted green. This was used during the initial “teaching“ of the object. Arrows were cut out of green sand paper and attached throughout the child’s environment including the walls and floors. The concept of “go” was reinforced multiple times throughout the day. The hope was to move from the large arrow to the small attached arrow. Think outside the box when establishing an object symbol representing a core word. Again, always consider the CVI level of your students. If the color that attracts their attention is yellow, there is no reason the arrow can’t be yellow. You don’t have to limit your choice of object to something within the 2D symbol. As a team, brainstorm what vocabulary you want to reinforce and what you can use for the child that meets his or her CVI needs.

Using an Individualized approach ensures that the objects chosen have meaning and are motivating to the user. The Indi- vidualized approach is the preferred approach for children with CVI. Below you will see two examples of how the Adaptivation “shared” approach Tangible Object Cards were modified to meet the individual needs of a child with CVI.

As AAC interventionists, we continue to hear the importance of teaching Core Vocabulary. Core Vocabulary refers to the small number of words that make up 70-90% of what we say. These words are relevant across contexts and have many meanings. Their importance is not disputed, but how does one represent this vocabulary, mainly verbs, using objects? Adaptivation took on this challenge with 15 of the most common core words. The goal for any AAC user including those with CVI is to move from 3D symbols to 2D symbols and then on to a more “shared” symbol set. Adaptivation looked at the most commonly used symbols Two examples of how the Adaptivation "shared" approach Tangible Object Cards were modified to meet the individual needs of a child with CVI.

Examples of the Core Word, "Go".

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In summary, the expertise brought by the TVI and the AAC in- terventionist should be used in tandem to establish the best in- tervention strategies for children with CVI. There is still so much to learn in both areas but collaboration is key! 0nline resources and classes are available in gaining more information in both areas. REFERENCES Haddon, L. A. (2011). Visual Strategies for Improving Commu- nication: Practical Supports for Autism Spectrum Disorders, Troy, MI Nielsen, L. S., Skov, L., &Jensen, H. (2007). Visual dysfunctions and ocular disorders in children with developmental delay. I. Prevalence, diagnoses and etiology of visual impairment. Acta Opthalmologica Scandinavia, 85(2), 149-156. Don:10.1111/j. 1600-0420.2006.00867. Cortical visual impairment: Symptoms & Causes: Boston Chil- dren’s Hospital. (N.d.). Retrieved March 25, 2021, from https:// www.childrenshospital.org/conditions-and-treatments/condi- tions/c/cortical-visual-impairment/symptoms-ands-causes Cortical Visual Impairment: An Approach to Assessment and Intervention, 2nd ed. (2018) Roman-Lantzy, C., Louisville, KY: APH Rowland, C., & Schweigert, P. (2000). Tangible Symbols, Tan- gible Outcomes. Augmentative and Alternative Communication, 16, 61-78. RESOURCES Adaptivation Inc. www.adaptivation.com Perkins School for the Blind. https://www.perkins.org Praaticalaac.or

Children with CVI benefit from “back up” communication during times when other factors preclude them from using their vision to the fullest. Environmental factors such as visual clutter, time of day and complexity of the activity are just a few of the factors that can lead to visual fatigue. During times of fatigue, stu- dents benefit from using simple AAC technologies and commu- nication devices. Such devices include Adaptivation’s Sequencer, Randomizer and Medley which can easily be incorporated into lit- eracy and play activities. These devices accommodate real objects and offer voice output.

Adaptivation’s Sequencer, Randomizer and Medley.

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