Strategies for Students with Cortical Visual Impairment (the handout)

Strategy to See

Strategies for Students with Cortical Visual Impairment (the handout)

Formally titled, “Encouraging Efficient Use of Vision in Students with CVI”

The following are suggestions to use with infants, young children, and students who have Cortical Visual Impairment (CVI) or who are suspected to have some other form of brain damage related vision loss.  These suggestions are intended to encourage students with CVI to use their vision more efficiently and consistently.  The suggestions are broken down into basic, Level 1 Strategies, intermediate, Level 2 Strategies, and more advanced, Level 3 Strategies.  These 3 levels of strategies correlate loosely with the 3 visual functioning Phases of The CVI Range described by Dr. Christine Roman in her book, Cortical Visual Impairment – An Approach to Assessment and Intervention.  It is important to read through all suggestions and strategies, as some students may benefit from suggestions from two different levels.  For example, if a student is visually functioning in Phase I on The CVI Range, he/she may benefit not only from Level 1 Strategies, but possibly also Level 2 Strategies.  Use the suggestions, especially the Strategies in Level 1, in conjunction with regularly occurring activities in daily life such as feeding, toileting, grooming and amusement activities.  These are general guidelines; no individual student with CVI will ever fit into any one category.  More importantly, these suggestions will hopefully spark ideas of your own so that you can modify materials and create individualized lessons specially tailored for your specific student or child.

The following is only a partial listing of strategies.  Please see Diane Sheline’s book, Strategy to See: Strategies for Students with Cortical Visual Impairment for a detailed listing of strategies (with color photos of materials), the CVI Skills Inventory and Strategies Worksheet, strategies for literacy, Interview Forms, SpotLIGHTing Techniques and more.

Level 1 CVI Strategies

General Considerations – Level 1

Students who benefit from Level 1 Strategies are generally just starting to use their vision.  They often alert to light (or light sources), single – brightly colored objects, slow moving targets and bright walls.  Environmental and sensory competing input often needs to be eliminated (or at least reduced) when the student is trying to use his/her vision.  The visual target often needs to be close, within arm’s reach and usually the student needs the viewing array limited to one or possibly 2, widely spaced targets only.

Students who benefit from Strategies at Level 1 often need high contrast between a single target and its background.  They often alert most frequently to targets presented at their far left or far right, eye height.  Rarely do they alert to targets in their lower visual field.  Often, they prefer to look at objects and targets that they have looked at over and over again (familiar targets). Visual fatigue is often a problem and many students have difficulty with eye/hand use.

Repetition, repetition, repetition: use the same objects and the same process each time to provide familiarity, reduce latency period, and shorten “warm up” time

Having the same individual(s) working with the child in the same way, again and again is often helpful.

See, “Steps for Incorporating Activity Routines into Your Practice” at: http://www.tsbvi.edu/seehear/fall02/activity-routines.htm

Repetition and practice is how a child with CVI learns to integrate new knowledge, remember it for a future session, and put it to use.

Use the CVI Skills Inventory & Strategies Worksheet to help you determine the best strategies to use with your student.

Interview the primary caretaker or parent

If the assessment or evaluation occurs away from home, encourage the caretaker/parent to bring the student’s favorite, most viewed targets from home.

Be aware of prescription medications the student takes; some may cause the student to be drowsy and/or have visual side effects.

Watch for signs of visual fatigue, overstimulation and/or stress.

Slow down presentation of visual objects and targets.  Allow the student time to process what is being seen and respond to what is being presented.

Allow for intermittent break times.

Plan activities for the time of day when student is alert, ready to learn.

If student is not alert, ready for action, help to wake him/her up by using voice or tactual stimulation (my favorite is a tubular vibrator or vibrating “snake”).

Proper positioning is crucial.  Work closely with the student’s PT and/or OT to determine the best position for your student to be in.  The student needs to feel safe and secure but also in the best position to allow him/her to interact with visual targets.

If your student is starting to become mobile, use lights (or lights shining on objects or mylar objects) to encourage reaching behavior and movement.

Environmental and Sensory Input – Level 1

Reduce auditory distractions when visual learning is taking place – turn off the TV, turn off the radio, move away from neighboring students who are very vocal/loud, turn off cell phones, encourage quiet from other adults/caretakers in the room.

A student who uses his/her auditory learning channel quite efficiently, but who has to work very hard to use their vision and make sense of what they are seeing, will often just listen to auditory input rather than work hard to use their vision.  For example, if the television is on and a singsong program is playing, it may be that the student with CVI will want to only pay attention to the auditory and ignores or “shuts out” what is presented to him/her visually.  If the television is turned off, he/she may then use the vision channel.

Reduce tactual distractions when visual learning is taking place – resist the temptation to give a rub on the back or a pat on the arm as a “good work” gesture; Care should be taken not to bump into a wheelchair or bed. When there is a need to encourage the student to touch something, use hand-under-hand technique – more information at: “The Language of the Hands:  Hand-Under-Hand Technique” http://nationaldb.org/NCDBProducts.php?prodID=47

Reduce or eliminate visual distractions that may interfere with visual attending behavior (i.e. sudden movement off to the side).  Use a 3-panel curtain or room divider to block off distractions or use positioning techniques.  For example, turn the student so they are not facing the visual distractions.

Use a white or black cloth to cover distracting background items.  A black king sized sheet works well for this.  Keep one in your Functional Vision Evaluation kit or handy to use during lessons.

Walls and bulletin boards should be simple and free from clutter.  Use 3 or 4 paneled curtains or room dividers to block busy visual input or cover with a black sheet when visual learning is taking place.

Carpets should be plain, no pattern.  Toys and materials often “blend in” on a patterned carpet and the student can’t locate them. Use a solid colored mat or a large piece of black headliner fabric, which is Velcro-compatible and washable.

Turn the student away from sunlight streaming through windows or blinds.  Non-purposeful light gazing may distract the student.

Care should be taken that no bright sparkling or flashy jewelry is worn, distracting the student from the visual target.

Teacher or caretaker/parents should wear plain colored clothing, preferably black.  Glittery fabrics or sequined clothing will be visually distracting.  Use a black smock to wear while testing or working on skills.

Eliminate strong smelling odors or harsh perfumes.  This includes strong smelling foods cooking in the kitchen, which may be difficult when working in the home environment of some children.  Some perfumes, aftershaves and deodorants are particularly strong smelling and may not only distract a student who is just beginning to use their vision, but also become offensive.

Maintain a comfortable room temperature.

Reduce or eliminate oral distractions such as finger sucking or use of a pacifier.

Near/Middle/Distance Viewing – Level 1

Students who benefit from Level 1 Strategies, generally benefit from all visual targets presented at near or no more than 12 to 36 inches away.

Use of a custom made slant board, reading stand, felt covered tri-fold board or angled dry erase board are helpful in bringing targets into the near visual field (and also creates contrast).

Present visual targets in the preferred, near visual field, usually far left or far right, at eye height.

Often students have difficulty detecting visual targets in their lower visual field – raise targets up to eye height in the near visual field.

Using a magnetic cover/protector on the iPad flipped backward and over the All-In-One Board (attaching it to the white magnetic side) allows the iPad to “hang” from the All-In-One Board at a slant.  This will allow the student to get close to the iPad*.

*Caution: Very near viewing of an iPad by any student who has a programmable valve setting in their shunt should be avoided.  Since external magnetic programming tools can change programmable valve settings by interacting with a magnetic rotor inside the valve, use of an iPad at close range (less than 3 inches away) is not advised.  Several studies have suggested that exposure to tablet devices, such as an iPad, may alter programmable shunt valve settings.

Gradually increase the distance the student is viewing targets when using their favored toys or objects during play or typical daily routines.  Adding movement will help the student visually attend for a longer period of time.

Visual Target – Level 1

Use single colored objects, especially in the colors red or yellow.   Sometimes, other bright primary colors including fluorescent colors, work well.

Pair visual target with movement (i.e. a solid colored slinky), especially in the peripheral fields; sometimes, movement of the object helps the child to see it better.

Use visual targets with light qualities, either SpotLIGHTed or lighted within.

Use visual targets with reflective qualities (i.e. a mylar pom pom).

Use visual targets that have movement qualities (i.e. slow moving slinky).

Present one visual target at a time.

In some cases, pairing visual targets with sound will initiate looking behavior (i.e. an auditory cue).

In some cases, pairing visual targets with a touch cue will initiate looking behavior (i.e. a touch cue).

Use real objects whenever possible.  When using an Anticipation Calendar, use real objects that the child has had a meaningful experience with (see http;//www.tsbvi.edu/Outreach/seehear/archive/Let Me Check My Calendar.htm) For example, use a real cup rather than a picture of a cup.  Relate what is being seen to function, whenever possible.

Present real objects against high color contrast (light colored foods against dark plates with a contrasting background color)

Watch for subtle response cues to visual targets including; shifts of gaze or body positions, changes in breathing patterns.

Use color:

  •   Keep color of common objects consistent until an association is established (if the student is attracted to red, use a red cup during meals; at school and at home)
  •   Encourage looking at faces by creating sharp, contrasting “edges”; use bright red lipstick, red steady light or blinking glasses, or use red, mylar-like material to create a head scarf
  • Bright, primary colors or fluorescent colors often work best; red, yellow, purple and orange often work well

Observing and discriminating the human face is an area students with CVI often have difficulty with.  Researchers have found that newborn infants tend to look at high-contrast borders of objects (University of Michigan, 1970).  When looking at the human face, a newborn might look at the hairline or edge of the face.  But by 2 months of age, infants should start to look more at internal features of the face (the eyes and mouth) and by 4 to 5 months of age, they can generally recognize their caregiver’s face.  Therefore, for our students with CVI, we need to first encourage looking behavior towards high-contrast borders.  If mom or dad has very light hair, maybe use of a dark color headband or head wrap would help.  Once the child starts to look at the hairline or edge of the face (the high contrast edge or “border”), accentuate the eyes with light up glasses, the nose with a red, foam clown nose or mouth with bright red lipstick.

Spatial Window of Visual Attention or Visual Array – Level 1

Students who benefit from Level 1 Strategies, will need to have a very limited array – one or no more than two visual targets at a time.  Usually, it is helpful for the target to be brought up into the field of view.  Do not present the targets flat on the table until you are certain that the student is able to successfully view targets in the lower visual field.

If two visual targets are used, there should be wide separation between the two targets.

Work surface should be free of visual clutter.  This includes cell phones (and turn off the ringer so the auditory does not distract the student), car keys and other miscellaneous items.

The work surface behind the target should be a solid contrasting color.

Contrast – Level 1

Teacher and caretaker should wear plain colored clothing that creates contrast behind the target being presented.

Wearing a black smock or black apron works well.

Use a black cloth or king size black sheet to cover distracting items in the background.  For example, you would want to cover a full bookcase when it is behind a visual target; cover the “visual clutter”.

Use a black felt board, APH Invisiboard or APH All-In-One Board when targets need a Velcro compatible background.

Using a white cloth or white sheet will also create contrast for darker targets.

Create a “CVI Den” to reduce visual distractions and create contrast.  A CVI Den can be made from a variety of black, tent like structures.  For example, a child’s pop up tent, lined in black headliner fabric often works well.  Visual targets are then placed inside and on the sides of the CVI Den.

Do not present objects or materials in front of busy patterns with complex colors.

Preferred Visual Field – Level 1

Present visual targets in the student’s preferred visual field – this is usually the far left or far right peripheral field for students who benefit from Level 1 strategies.

Students using Level 1 strategies generally do not prefer targets to be presented in their central field of view.

Students using Level 1 strategies often have difficulties when targets are presented in their lower field of view.  When students have difficulty-detecting targets in lower visual field – raise targets up by using an All-In-One Board from APH.

The student may turn his/her head to one side or the other when reaching for an object; it appears as if they are looking away from the visual target, but they may be using their peripheral vision.

Lighting – Level 1

Provide additional, supplementary light shining on target of interest; 100 LED bright flashlights work well or flashlights with at least 250 lumens.

Use SpotLIGHTing Techniques (See the book, Strategy to See).

Shine light on target of interest without attracting student’s attention to the light source.

Do not shine a bright light into the eyes of the student, only on the target.

Use of plug-in, natural desk lights work well to shine on targets and workspace (but you are restricted to the length of the power cord).

Use of Light Box (with a Swirly Mat from APH) and other lighted toys/targets are beneficial.

Use of a Perkins LightAide has been found to be very motivating for students who have CVI.

Care should be taken when using blinking or flashing lights (this sometimes sets off a seizure).

Use brightly colored, lighted balls to attract attention.  A red 100 Light Holiday Super Sphere or a colorful Puzzle or Jigsaw Light both work well for the student just learning to use vision.

When using a supplementary light shining on a target to encourage visual attending behavior, dim the overhead lights and reduce natural light coming through windows.

Using black gloves with lighted fingertips has been an excellent way to encourage looking behavior for the student who is just beginning to use their vision.  Use a black colored background (like an Invisiboard) and once the glove is on the hand, slowly wiggle the fingers.  Bring it from the far left or far right slowly towards the central field of view.  Keep this target within 18 inches of the student’s face.  Dimming the overhead lights and wearing a long sleeved black smock really makes the lighted fingertips stand out!

A small number of children with CVI experience photophobia (light sensitivity). Watch for this and reduce the intensity of light if this is a problem.

Familiarity – Level 1

Teachers, parents, caretakers and others working with students who are just beginning to use their vision should have a good understanding of the familiar, favored visual targets the student will visually attend to.  Completing a thorough Parent Interview will be crucial in gaining a good understanding in this area. Using these favored, familiar visual targets will increase looking behavior and can be used to “warm up” students prior to working with them using other visual targets or work on new routines.

Level 2 CVI Strategies

General Considerations – Level 2

Students who benefit from strategies at Level 2 are generally using their vision more consistently, but often not efficiently or for a purpose.  The parent, caretaker and/or teacher will want to work towards encouraging the student to use their vision during daily routines and activities, such as when eating meals.  Students who benefit from Level 2 strategies often can tolerate low levels of familiar background noise/voices and minor tactual input when using their vision.  Targets can sometimes be up to about 4 to 6 feet away (depending on size of the target and the color/contrast) and students can now attend to several well-spaced targets in more than one color.

Contrast between target and background for the student who benefits from Level 2 Strategies continues to be important, but generally, the student can tolerate more patterns at near.  They also often attend more frequently when targets are presented not only at far right and far left, but also centrally. Lighting continues to draw the student’s visual attention and can often be used to encourage interaction with objects for functional purposes (i.e. Sippy cup that lights up). At this stage, it is often helpful for some quality that the student favored in Level 1 to be carried over to enhance Level 2 Strategies.  Visual fatigue is often still an issue and positioning needs to be monitored.

Many of the same considerations for a student who benefits from Level 1 Strategies applies to a student using Level 2 Strategies, including;

  • Use of Interviews (Parent, Caretaker, Teacher, etc.)
  • Awareness of Rx Medications
  • Awareness of times of day when student is most alert, ready to learn

Since students using Level 2 Strategies now are using their vision for more functional purposes, it will be important to look closely at the student’s daily routines, both at home and at school, to determine appropriate accommodations.

Verbally note salient features when discussing visual targets (“The ball is yellow and round”).

Be careful with, or avoid use of, pictures.  Generally, a student who benefits from Level 2 strategies needs real, tangible targets (3D).  Switching to 2D targets or pictures is often difficult.  Color photographs of familiar, favored targets often work best during this process.

Providing a routine and structure/sameness continues to be important.

Observe student carefully to make sure the presentation of visual targets is not too fast; allow the student time to process what is being seen and to respond to what is being presented.

Use of cues, signals and symbols might be considered at this stage (see “Non-Verbal Communication: Cues, Signals and Symbols” at; http://www.tsbvi.edu/component/content/article/1725-non-verbal-communication-cues-signals-and-symbols

Encourage students to learn through Dr. Lilli Nielsen’s Active Learning http://www.tsbvi.edu/component/content/article/136-intervention/3415-active-learning-resources

Environmental and Sensory Input – Level 2

Reduce auditory distractions; turn off the TV, turn off the radio, move away from neighboring students who are vocal/loud, turn off cell phones, encourage quiet from other adults/caretakers in the room.

When an auditory cue is used/needed to encourage looking behavior (and develop language), use the following suggestions;

  • Clearly explain, in a few simple words, what it is that you want the child to look for and where to look; use “Verbal Cuing” (“The ball is by your foot”).
  • Use descriptive words about the object or visual situation (“Shiny red light”).
  • Use voice intonation that matches the word used
  • Use an interesting noise or a few words of praise, along with a visual target, to increase looking behavior (crunchy/scratchy noise when you shake a mylar pom pom)
  • If possible, try to establish looking behavior first, then give verbal praise or description; make sound a “reward” for looking behavior

Reduce tactual distractions when visual learning is taking place;

  • Resist the temptation to give a rub on the back or a pat on the arm as a “good work” gesture
  • Avoid grabbing a hand to help student touch something

When a tactual cue is needed to encourage looking behavior, keep in mind the following suggestions;

  • Touch the object of interest to the child’s hand to direct visual attention
  • Run the object of interest down the side of the child’s arm to his/her hand, to direct visual attention

Reduce visual distractions when visual learning is taking place;

  • Sunlight through the window or light from a lamp may be a distracter
  • A moving ceiling fan may be a distracter
  • Sudden movements in the peripheral field should be restricted

Work surface should be free of visual clutter, especially bright, shiny objects.

Student may need to move closer to visual targets to reduce environmental competing input as well as auditory and/or tactual distractions.

Near/Middle/Distance Viewing – Level 2

Typically, a student who is beginning to use their vision for more functional purposes often begins to extend their visual attention beyond near space and up to 4 to 6 feet.  They are also starting to move or become mobile.  By using a favored visual object, such as a red mylar pom pom, and placing it just out of reach, the child is encouraged to reach and move forward to retrieve it.

Continue to allow student to get as close to target as needed; this reduces visual complexity.

Continue presenting visual targets in student’s preferred visual field.

Use of a slant board, reading stand, tri-fold black felt covered board, or All-In-

One Board is helpful in bringing target into visual field (black painted clothes pins with Velcro work well on felt covered slant boards, to hold visual targets in place).

Allow child to avoid visual gaze, if necessary: may turn head away from target when reaching for it or may observe the target by looking off to one side of the target (eccentric viewing).

Continue to use targets with movement to encourage more distance viewing.

Use visual targets with some favored characteristic; if the child favors red mylar, use red reflective material on targets presented at 4 to 6 feet or outline distant targets with preferred color (red reflective ribbon outlining learning material on a black slant board).

Use SpotLIGHTing Techniques to highlight a target at 4 to 6 feet (see the book, Strategy to See).

Work surface should be free of visual clutter (no stick on alphabet strips, name stickers, notebooks, pens, cell phones, etc.).

Use a brightly colored rug or other symbol to highlight a landmark, then gradually withdraw the symbol and just use the landmark.

Use a florescent orange traffic safety cone, with a bright light inside and a red light on top, to mark the next location the mobile student needs to get to; for example, if the student is at Circle Time but the next activity is at the Fine Motor table, use the lighted orange cone to designate where the student is to travel to next.

Visual Target – Level 2

Since students who benefit from Level 2 Strategies are generally just starting to use their vision for functional purposes, taking a close look at eating and grooming routines will be important. Since eating is such a motivating activity, eating utensils, foods, cups, and plates all need to be made “CVI Friendly”, so that the student uses his vision to locate and grasp the items.

Use cutlery that is either a single, bright color or cutlery that lights up.  At the website, www.flashingblinkylights, there are some of these items or you can modify a Munchkin Easy Squeezy Spoon to hold a small flashlight.

Create a “Koozie” made out of red (or any other bright color) mylar-like fabric, and place it around an infant bottle.  This can be SpotLIGHTed with a high powered flashlight if needed.

Create a “Koozie” made out of red (or any other bright color) mylar-like fabric, and place it around snack containers, such as Gerber Graduates Puffs, and encourage reaching/grasping behavior.

Use glittery, sequined stretchy headbands to wrap around cups or any other item, to create a reflective band that can be SpotLIGHTed.

Use toothbrushes that have a blinking light feature, such as the yellow Firefly Light-up Timer Toothbrush (www.firefly.us.com).  Remember to clear the clutter in the bathroom, leaving only the blinking toothbrush presented against a contrasting color, to encourage reaching and grasping behavior.

Use brightly colored bowls and plates presented against a black or contrasting colored placemat.

Use a lighted red or brightly colored cup (Walgrens; seasonal item) or use a blinking, lighted tumbler, available at www.flashingblinkylights.com.

Choose combs and brushes in a bright, solid color and present them against a black towel or contrasting color.  Remember to clear the clutter in the bathroom!

Use single colored recording switches for communication (“yes/no” and “more”).  Use only one or no more than two at a time, with good spacing between the two.

Use common objects in a bright, preferred color (or possibly 2 or 3 colors).

Use reflective/shiny material applied to common objects used daily, to help direct visual attention (red, reflective Contac paper, reflective red wide ribbon, yellow glittery paper, yellow/gold reflective gift bag, etc.).

Use of Anticipation Calendar with familiar objects (see: http://www.tsbvi.edu/Outreach/seehear/archive/LetMeCheckMyCalendar.htm

Spacing of visual targets will be important, when more than one target is used (see Spatial Window of Visual Attention or Visual Array).  Limit number of targets presented (one or two at a time is best).

Use of Routines and keeping information simple, constant and predictable will continue to be important.  For more on Activity Routines go to www.tsbvi.edu and search for, “Getting Started with Activity Routines”.

Providing good color contrast will continue to be important.  Use a solid colored background and continue to avoid backgrounds with patterns.

Primary books that have reflective qualities are often attractive to students who benefit from Level 2 Strategies.

Students who benefit from Level 2 strategies may still have difficulty with identification of pictures and understanding that pictures represent something.  Students at this stage may start to make a transition from identifying their favored 3 dimensional toys/objects to identifying a color photograph of that same favored toy/object.  Presenting the color photo on an iPad works well because of the backlighting provided by the iPad.

Teacher/parent made books with color photographs of the students favorite items work well for this stage.

When pictures are used, they should be simple, familiar and only one to a page.

Use color to highlight specific aspects and salient features of objects, shapes and print.

Spatial Window of Visual Attention or Visual Array – Level 2

Students who benefit from Level 2 Strategies can often view 2, 3 or 4 well-spaced visual targets, especially if they are presented in the student’s best field of view and against a high contrast background. 

Contrast – Level 2

Students using Level 2 Strategies still require good color contrast when working with new to them targets or beginning new routines or lessons.  With familiar or favored visual targets, they generally can tolerate less contrast.  For example, if a student is very familiar with a lighted yellow ball, the ball might be placed on a golden colored carpet (within 3 to 4 feet) and the student would most likely still visually locate it.

Choose iPad apps that offer slow moving targets that stand out from their background.  A good example of an app, which might be used with students who benefit from Level 2 Strategies, would be Tap-N-See Now.

Preferred Visual Field – Level 2

As students become more mobile, use of red duct tape may help to outline doorways, mark the path in corridors as well as highlight steps.

Use reflective strips to make stairs stand out.

Use an Invisiboard (from APH which has a Velcro compatible surface), to affix targets to in the student’s preferred visual field.  Using a piece of dowel (spray painted black), you can affix Velcro on either end and extend it across a “U” shaped set up of the Invisiboard, so that targets can be hung from the dowel into the student’s field of view.

Lighting – Level 2

Lighting continues to be an important factor to initiate looking behavior and to focus attention on the target of interest for the student who benefits from Level 2 Strategies.

Present visual targets on a Light Box (from APH).  Some Light Boxes can be slanted to bring targets better into the visual field.  You can also download a light box app for a tablet or iPad.  Brightly colored window gel stickers work well on the Light Box or app on a tablet.

To encourage mobility, use a lighted orange safety cone.  Use the type that have both a blinking red light on the top and have a light inside.  Move this cone to various locations around the room and turn on the light when it is time to move to the next location.

Use of a 100 LED flashlight (or flashlight with at least 250 lumens) or supplementary desk light shining on visual targets will continue to be important.

Eliminate glare on all surfaces (do not laminate high-use targets such as Window Markers!).

Dim overhead lights to emphasize lighted visual target; this also has the added benefit of seeming to reduce environmental clutter and complexity.

Familiarity – Level 2

Once teachers and others working with the student know of their favored visual targets, they can then take some quality of the favored visual target and “attach” it to a “new-to-the-student” visual target.  For example, if one of the student’s favored, familiar visual targets is a red, mylar pom pom, one could take a wide strip of red mylar ribbon and wrap it around a sip-n-seal cup to encourage the student to find the cup and grasp it, just as he/she did with the pom pom.

Continue to use objects and toys in student’s preferred color and preferred visual field.

Level 3 CVI Strategies

General Considerations – Level 3

Students who benefit from Strategies at Level 3 often demonstrate more typical visual behavior, but may continue to have difficulty with competing environmental and sensory input while trying to use vision, especially when viewing targets at distance.  They may continue to have visual field preferences and often have difficulty viewing targets when presented in their lower visual field.

Students who benefit from Level 3 Strategies often continue to have difficulty with crowding, or the presentation of too many targets in their viewing array, particularly when viewing distance targets.  Having a solid contrasting color in the viewing array is often helpful to the student trying to differentiate between background and foreground visual information.  Lighting continues to be important, especially for mobility purposes.

Students using Strategies at Level 3 will be responding to more varied visual targets and have greater visual demands.  Be careful to watch for visual fatigue and allow plenty of response time, to look at the visual target then respond to it.

Additional response time will especially be needed if the student is tired, stressed, ill, or has just had a seizure.

Be specific about what you want the student to look at.

Good communications between the school personnel and caretakers/parents at home will be crucial.

Use descriptive words and continue to discuss salient features of the visual target.

Continue to monitor pictures for “visual clutter” and use pictures that the student can identify.

When a student benefits from strategies at Level 3, it will be important for all teachers, paraprofessionals and caretakers to follow the same teaching procedures, both at school and at home.  For example, if a yellow highlighter is used at school to mark where the student puts the answer on the answer line, these same techniques should be used at home.

Environmental and Sensory Input – Level 3

A student who benefits from Level 3 strategies generally has more typical visual behaviors, but may continue to have difficulty with multiple sensory input, especially with competing auditory input.  Parents, caretakers and teachers will need to watch carefully to determine how much competing sensory input the child is able to tolerate while still demonstrating efficient visual responses.

Visual complexity and crowding will most likely still be a concern especially if the student is in a Resource Room or classroom setting and using distance viewing to access information on a dry erase board or when mobile.

Student continues to benefit from increased lighting on both near materials and in the general environment (hallways and stairwells).

Student may still have difficulty with additional auditory and/or tactual distractions; limit these as able.

When mobile in a busy, cluttered environment, it may be helpful to follow a line on the floor or hallway wall made with red duct tape or to follow the line of lights on the ceiling.

When in PE, teammates may need to verbalize where the ball is.

Use of yellow or amber/orange-tinted sunglasses help to make outdoor objects stand out.

Near/Middle/Distance Viewing – Level 3

A student who benefits from Level 3 Strategies may continue to have difficulty with distance viewing and strategies are often needed when visual learning is taking place.  Often, the student who is visually functioning at this level, will be in a general education classroom setting, Resource Room, and/or Life Skills Classroom where there is often distance learning, particularly at the white board and/or smart board.  When students are in a classroom setting and having difficulty seeing print targets on the dry erase board, use a yellow acetate GlaReducer (from APH) outlined in red duct tape, then place it over the print of interest on the dry erase board.  Alternately, use magnetic strips covered in red mylar wide ribbon to create a box around important information on the board.

Distant targets (10-15 feet) will need to stand out in some way, especially when there is “visual clutter” surrounding the target of interest.

Use Color – A teacher wearing a lighted red hat is easy to locate in a busy cafeteria or a  classmate is easier to find on a busy playground when he/she is in a bright, red shirt

Use Light – A high-powered flashlight shining on hands as they sign an assignment makes them easier to see for the student who has hearing difficulties in addition to CVI

Use Movement – a waving flag at the top of a flagpole is easier to locate than a limp, still flag hanging drooping along side a flagpole

Bright, florescent colors will still draw student’s attention.

Student may need to get up and get closer to materials and targets to reduce crowding and other visual distracters.

Work surface should be free of visual clutter (no stick on alphabet strips, name stickers, notebooks, pens, cell phones, etc.).

When using a Smart Board and Power Point Presentation from the computer, use the movement of the cursor (displayed on the Smart Board) to attract visual attention – it causes a jumpy movement that is easy to spot at distance.

Use color to draw attention to landmarks.  For example, outline a water fountain with red mylar wrapping paper to signal where to turn in a hallway or outline the classroom door in red duct tape or red rope lights to indicate the correct location.

Use black “frames” to attract attention to distance targets (use precut, black mat board frames from craft store; they come in various sizes).  You can outline these in red mylar “garland”.

When encouraging a student to look for a target in the distance, use a verbal prompt and a large visual target to “cue” the student to the chosen target (“Look at the big green tree then the brown building” or “Look where my hand is pointing on white board”).

A student’s table or desk will stand out at distance by attaching a yellow “ink blotter” on the workspace; keep the “blotter” in place with clear Contact Paper.

A student’s chair will stand out at distance by using a different color of chair from the other students or by attaching a brightly colored pom pom on the seat back.

Distant PE equipment that is brightly colored and has movement qualities will be easier to locate and see (i.e. swinging bright blue swing or a fluorescent colored ball or birdie).

Use the camera function on tablets to take pictures of distance targets and then let the student use the zoom feature to look at picture details.

Students who use an iPad will benefit from the camera function, taking a picture of distance targets, such as the notes on a dry erase board, then use the zoom function to look closely at small details.

Students in a classroom or Resource Room setting might benefit from use of a CCTV for distance viewing.  The two I have found that work best for our students are the CCTVs that have a camera that can rotate and move to where the teacher is or to the specific board of interest.  These include the SmartView 360 (www.humanware.com) and the Acrobat (www.enhancedvision.com).

Visual Target – Level 3

Students who benefit from Level 3 strategies will still need books, worksheets, pictures and other two dimensional materials to be modified.

Students may be starting to identify more pictures including color photographs, and simple, black line drawings.

Eliminate details that are not important to the page.  Use correction fluid to eliminate all page numbers or non-important visual clutter, eliminate all but the outer black outline of pictures, etc.

When looking at multiple shapes, numbers or letters, encourage the student to track with his/her finger; point to each symbol and slide the finger from target to target.

Use color;

  • Outline letters or numbers with a red permanent marker
  • Highlight aspects and salient features of shapes, objects, and print with a colorful highlighter
  • Highlight the answer line on worksheets (be consistent in the use of one color on all answer lines/worksheets)
  • Highlight target or word with a yellow overlay or yellow transparency
  • Pastel colored pictures should be re-colored with bright primary colors
  • Brightly colored shoe laces; one color for the left shoe and one color for the right shoe
  • Specific colored tote boxes for specific items; blank paper in one colored tote and completed assignments in another colored tote
  • Clearly mark the beginning and end of a line of print with marker or highlighter (use green marker outlining first letter in line – red marker outlining last letter in line; use highlighter reusable tape; use colored stick-on dots by Dennison, etc.)
  • Use colorful/reflective Contac Paper to stick on and outline targets of interest

Simplify visual targets to help reduce the “crowding phenomenon”;

  • Use window markers to emphasize visual target of interest (cut a “window” in black construction paper to outline target of interest)
  • Use Bright Line Markers (from APH) and/or black paper markers
  • Use correctional fluid to eliminate non-essential details that are distracting and contribute to visual clutter
  • Cut or fold worksheets/papers to allow only small parts to show at a time – reduce the amount of information presented

Student may benefit from modifications in PE equipment including brightly colored balls, beanbags, and birdies, brightly colored bases for baseball and teammates who all wear the same brightly colored tee shirts, making them easier to locate on the field.

Students in a classroom or Resource Room setting often benefit from use of a CCTV for near viewing.  As noted above, the two I have found that work best for our students include the SmartView 360 (www.humanware.com) and the Acrobat (www.enhancedvision.com).  These CCTVs allow the student to enlarge the near target and to adjust the background color to suit their needs.

Spatial Window of Visual Attention or Visual Array – Level 3

The spacing of visual targets in the visual array may continue to be important; teachers, caretakers and parents may still need to reduce crowding and complexity as students are able to view greater numbers of targets.

Special attention will need to be paid to any augmentative and alternative communication (AAC) aid and/or device that the student might be using.  Many commercially made aids and devices have spaces for 9 to 20 small pictures.  Even for a student who benefits from Level 3 Strategies, this array is too busy and cluttered.  In addition, the pictures most often used with these devices are inappropriate (see information on pictures under Targets).  A more appropriate AAC device might be a teacher made aid or a voice output device that only has 2 or 3 windows.  Alternately, black paper can be placed in windows and only a few window choices can be offered, which will create a less busy array (see “Talk Bar” from Learning Resources).

If the student is starting to read, it will be important to use a program with large spaces between words and pictures; The Primary Phonics (K-2) series is an example.

Use books with one clear, simple picture on a contrasting simple background.

Develop custom worksheets and provide good spacing between words and between sentences (easy to do on the computer).

Limit the number of words/sentences on a sheet.

Create more white space by using correction fluid, folding the paper to hide “visual clutter”, enlarge the paper, and use blocking techniques.  For example, use a black piece of heavy tag board and block off non-necessary visual details.

Encourage the student to keep items on the desk to a minimum; emphasize organization.

Encourage the student to keep books and materials organized in color-coded folder inside of the desk.  A battery operated light, attached inside the book storage part of the desk, will help the student locate needed school supplies more easily and quickly.

Contrast – Level 3

Students who benefit from Level 3 Strategies generally can tolerate more complexity surrounding the target of interest at near, but often continue to have difficulty with targets at distance.  They still need for the distance targets to stand out in some way with either color, movement, light or with an auditory cue.

Students using Level 3 strategies who use a CCTV will benefit from the models that allow a choice of background contrasting color.

Students often benefit from PowerPoint presentations when the target on the screen is a bright color and the template used is a darker color.

When creating student specific books on a tablet, use apps, which offer a variety of background colors and text colors.  A good example of an app to use might be Book Creator.

Preferred Visual Field – Level 3

Present targets in student’s best visual field;

  • Allow student to move materials where they can see them most efficiently
  • Allow student to move their body to where they can see the materials most efficiently
  • Determine if student views materials more efficiently in horizontal plane or vertical plane
  • Use a slant board or reading stand

Allow student to tilt or turn his/her head to the best angle for viewing targets and reading.

Students using tablet technology can bring the tablet up into their preferred field of view by using a stand similar to the Tablet Combo Stand by RJ Cooper.

When mobile (either walking or in a wheelchair), the student may need to turn his/her head all the way downward, due to low visual field difficulties.

Position student so he/she is better able to use preferred visual field (if they are better able to use their far right visual field, they should be sitting towards the left side of the classroom).

When mobile and using stairs, watch for lower visual field difficulties; mark stairs with red duct tape or red reflective tape.

When mobile, travel in brightly lit hallways and stairwells.

Work on use of a, “slow, look, check, and go” method combined with verbal prompts, or a tap on the shoulder, when there is uneven ground and/or there is a concern with lower visual field.

Lighting – Level 3

For students in Resource Room settings or general education classroom settings, it is helpful to attach a small battery powered light inside of the book section of the desk, to help the student locate needed books and supplies.

Working in a well-lit environment will continue to be beneficial.

Watch for shadows as student bends over work; seat the student under overhead lights so that shadows are not cast on their near work.

Use of a small, battery-powered desk light is helpful for students moving from class to class (when they need additional supplementary lighting on their materials).

Use a PowerPoint Presentation to teach concepts; dim overhead lights, use programs that have movement, use a cursor that provides movement qualities.

Eliminate glare on computer monitors and workspace.

Seat students who benefit from increased illumination near a wall outlet (to plug in a desk light), when possible.

Familiarity – Level 3

Usually, by the time the student is working with Level 3 Strategies, he/she has little (or at least less) difficulty with Familiarity.

Created by Diane Sheline, TVI, CLVT

diane@strategytosee.com