Scottish Sensory Centre

Devising strategies to optimise home and school life for children with visual impairment due to damage to the brain

Presented on 22 January 2008

Strategies for dealing with visual problems due to cerebral visual impairment

Gillian McDaid
Debbie Cockburn
Gordon N Dutton

Strategies matched to the environment

Strategies for visual problems inside the home environment

Difficulties going down stairs and tripping may be due to a combination of peripheral lower visual field impairment, reduced visual efficiency of the lower visual field, or impaired visual guidance of the feet, in addition to any motor problems which may be present.

• Hand rails at the best height for the child on both sides of the stairs to provide a tactile guide for the height of foot placement
• Plain stair carpet or plain steps without carpet.
• Good lighting to enhance stair boundaries possibly with spotlights at landing and base of stairs, to create enhance depth perception by creating shadows.
• Highlighting of stair treads with bright paint or bright dots on the middle of each step.
• Coloured marker on the floor beyond the last step to indicate the end of the staircase.
• Brief non-distracting verbal prompts to remind child to slow down and hold the handrail.
• Training at looking at the horizon when going down stairs.

Tripping on patterned floor surfaces and floor boundaries may be due to an inability to know whether the pattern, or the floor boundary is flat or is higher or lower than the adjacent areas.

• Remove patterned carpets in favour of plain or laminated floor surfaces.
• Pushing a wheeled toy, or using (for example) a plastic golf club, to provide a tactile guide to the height of the ground ahead.
• Ensure good lighting.
• Talk the child through 'trouble spots' with verbal clues about how to proceed to remember as prompts.
• Clearly highlight changes in floor surfacing.

Bumping into furniture and door frames
Lower visual field impairment leads to collisions with low furniture. Hemianopia and unilateral visual inattention lead to repeated collisions on one side. Impaired visual guidance of movement leads to collisions and frustration when furniture is moved, as it appears that memory has a significant part to play in not colliding with obstacles whose position has been learned.

• Minimise the amount of furniture.
• Enhance the colour contrast of the furniture with flooring.
• No sharp edges or glass furniture.
• Consider 'traffic flow' through each room and allow adequate space.
• Rarely move furniture and do so with the child's involvement.
• Place picture or symbol at the child's eye level to act as a visual prompt to identify the location of an obstacle
• Coloured mark on door frame, or door at eye level on the side that is bumped into.
• Remove doors which are commonly collided into.
• Consider coloured 'room trails' on the wall for child to follow to lead to different rooms or put coloured foot prints on the floor as a foot guide in locations where collisions take place.

Cannot find toys and other possessions
Visual field impairment and dorsal stream dysfunction impair visual search. Visual search in one dimension is much easier than visual search in two dimensions.

• Plain walls, floors and bedspread to eliminate background distraction.
• Organise possessions in 'zones' eg; clothes, toys, schoolbooks.
• Organise storage of possessions in horizontal or vertical boxes or pigeonholes.
• Spotlighting of key areas.
• Child helps to organise her room her way.
• Choose different paint using pastel shades for a calm environment and bright colours to colour code specific locations.
• Keep the content of toy boxes, drawers and shelves to a minimum.

Difficulty enjoying TV programmes

• Large screen TV helps to compensate for poor acuity and visual crowding of dorsal stream dysfunction.
• Flat screen television has good contrast.
• Allow child to sit up close to the TV so that surrounding visual clutter is minimised.
• Try smaller TV if large screen is too much to scan.
• Early cartoons and films are often preferred because they do not zoom and pan, catering for lack of perception of movement, and impaired visual attention.

Strategies for visual problems outside and around the home environment

Impaired visual guidance of movement is assisted by tactile guidance.

Difficulty walking over uneven surfaces

• Ensure good access to garden with handrails if required.
• Minimize height variations or provide safe level area.
• Ensure safe ground cover such as bark and rubber play mats.
• Provide coloured foot steps or hand rails to follow to different areas.
• Have scooters (to walk with) or push toys to provide stability when moving about.
• Allow child to hold onto one’s clothing, pulling down, and when holding hands, extend arm and hold it slightly backwards.
• Highlight differences in surfaces in the garden and in play areas.

Tripping over obstacles

• Use scooter or dolls pram to push.
• Provide safe 'storage zones' for older children to keep toys in when not using (tidy up).
• Encourage a policy of 'slow, look, check, go' using verbal prompts, or a tap on the shoulder when there is uneven ground ahead.
• Plan obstacle courses for fun and to develop spatial awareness and observation skills.
• Encourage use of toys to climb through and over.

Difficulty seeing things in the distance, eg; bird in tree, plane in sky

• Share the zoom facility of a digital or video camera.
• Use verbal prompts and large visual targets to 'cue' child to the chosen target. eg; "look at the red roof, then the blue road sign".
• Give time to process; don't rush on to next object or give up too soon.

Strategies inside the school environment

Difficulty going down stairs

• Handrails at all steps, fluorescent paint to highlight the edge of steps.
• Good lighting, minimal wall decoration around stair wells.
• Allow child to leave early or later from class to avoid the crowd in the corridor.
• Supervision from support teacher with verbal prompts to assist child.
• School 'buddy' for transition time.
• Move classes to ground level (where possible). Use of lift or stair climber.
• Encourage the child to be first or last if they do not wish to be different from the group and leave early.

Cluttered class environment, bumping into desks

• Plain flooring.
• Move furniture to allow 'flow through'.
• Minimise clutter on the walls.
• Place child's desk closest to the classroom door and the teacher.
• Use symbols, pictures or colours to indicate storage areas for materials.
• Mark the child's desk with brightly coloured tape to increase visibility.
• Mark the class floor from the door to the desk, and from the desk to the 'blackboard' with large coloured circles to highlight the easiest route.

Difficulty reading

• Ensure optimal optimal spectacle correction including a near prescription if accommodation is impaired.
• Ensure optimal lighting.
• Measure visual acuity, and ensure text can be seen by enlargement and / or magnification.
• Identify the size and degree of crowding of text, which facilitates maximum speed of access to the information.
• For hemianopia and neglect identify any reading strategy which circumvents the problem.
• Displace the reading material so that it is off centre to the side with intact vision.
• Vertical reading downwards for right hemianopia and upwards for left hemianopia, (so that the patient can read into the sighted visual field) has proved helpful in children with brain lesions occurring after reading has been learned (in our experience).
• Right hemianopia may be associated with a total inability to read (alexia). A small group of such children may learn to read with Braille used simultaneously with text. (They may later be able to relinquish the Braille by using tactile memory.)
• Lower visual field impairment may lead to the material at the bottom of the page being missed. Using the finger to conduct vision to the bottom of the page may establish the habit of doing so. A tilted work station can help.
• In cases with impaired reading due to visual crowding of text, progressively mask off adjacent text until reading is accomplished. Consider using customised masks for text and /or present text of optimal size and background sequentially on a computer screen.
• Covering over the text which has just been read can be sufficient.
• Use a magnifier which magnifies a line of text but masks surrounding text as well.
• Older children can use their hands to mask off surrounding text.
• Small repeated horizontal saccades are required for reading. We have found that acquired disorders of such movements (which can be observed while the patient is reading) can lead to difficulty reading small print but not large print.

Difficulty focussing on blackboard and teacher

• Place child at front of class facing blackboard and teacher to prevent the distractions of looking over/between other heads and objects.
• Provide chair with arms to help child sit on the centre of the chair so they cannot fall off and can concentrate on 'looking' and 'listening'.
• Sit with teacher slightly to the right for left visual field or attentional impairment and vice versa.
• Provide a separate work station (can still be situated beside neighbour) or ensure large surface area on double desks to prevent distracting 'elbow bumping' and peripheral distraction caused by movement of a restless neighbour.
• Consider portable 'work screen' to minimise visual and auditory distraction.

Difficulty copying from blackboard and seeing computer screen

• Ensure that all written and pictorial material is within limits of acuity and contrast sensitivity.
• Give full hypermetropic correction, which has secondary effect of magnification and reduction of clutter.
• Position child face on within close proximity to minimise clutter and obtain magnification.
• Remove distracting wall coverings around blackboard.
• Consider 'white board' for different contrast.
• Provide material on handouts to reduce unnecessary copying.
• Ensure good lighting of the teacher and the board.
• Classroom assistant to help with scribing or keeping child's visual attention on target.
• Teacher not to talk and write on board at the same time to allow visual sense to be the maximum focus.
• Ask the teacher to use large well spaced script for the whole class.
• Provide a computer with a digital camera with a zoom facility to both view distant material and import it.
• Scan or Email work from the white board to the child's lap top computer to avoid copying.

Regularly loses school materials

• Use a portable screen to demarcate the desk area.
• Use coloured tape to mark placement zones, eg; jotter in red box, pencil placed on yellow rectangle to the right.
• Provide labelled storage tray with personal colours or pictures for child to store and return materials to.
• Encourage child to only have current items required on desk.
• Provide clear pencil case with a white cardboard insert, or a pencil case with individual sections for each item.
• Use coloured coded paper to cover school books or use a picture or clear symbol to assist visual recognition.
• For older children, have a coloured folder for each subject.
• Train in placing pencil in the same place, use Blu Tak or similar putty to hold pencil.
• Use a school bag with different compartments to help with organisation.

Becomes fatigued and overwhelmed by visual and sensory input. Behaviour deteriorates

• Allow child to place head on arms for 'time out' at desk.
• Change activity to less demanding one and return later when refreshed.
• Consider content of teaching day and do not do too many intensely visually focussed tasks in a row.
• Allow for some gross motor physical movements to 'calm down'.
• Let child move from desk to designated quiet area.
• Ensure time out zone is viewed positively and used by other children.
• Involve child with design of this zone, the colour choice and the position and seating.
• Encourage the use of a 'traffic light' system, eg; child can say I am feeling 'green' for go, 'amber' for tiring and 'red' for stop. This allows the child to express how they feel as a single word.

Difficulty accessing playground and playing
Inform classmates of child's poor vision and explain that an individual child in a group cannot be identified (explaining why affected children stand at the side of the playground or attach themselves to another child for security).

• Accompanying classroom assistant or 'play buddy'.
• Use bright colours to highlight changes in surface areas such as low steps.
• Highlight steps with bright colours.
• Handrails at steps, smooth pathways, clear boundary markings.
• Handrails for path guides or footprints to follow.
• Soft zone for safe play.
• Bright paint on railings, designated play zones.
• Push along toys available to walk with.
• Suitable activities accessible for CVI children. Team games may be difficult.
• Involve child in activities that they are able to do, enjoy and excel in.

Difficulty with sports
Visual field defects and impaired attention lead to considerable difficulties with team sports. Problems coping with the speed and vectors of balls also impair participation. Swimming, track field and aiming sports require singular focus and can prove popular.

Strategies for daily living

Difficulty finding clothes

• Lay out clothes the night before.
• Hanging vertical wardrobe pockets with the day’s clothes inside, stored from bottom up (lower visual field impairment inhibits downward search).
• Hang clothes in groups and colour matched in wardrobe to limit visual confusion
  Place a day’s outfit on the one coat hanger.
• Place clothes in accessible drawers, eg; tops in top, vests in next drawer, pants next etc (limit the amount in each drawer).
• Place shoes at eye level stored in upright position to help identification, or use a hanging shoe rack.
• Use best label type, eg; real pictures, drawings or colour coded or black and white symbols or numbers, eg; 1=pants, 2=vests.
• Dress part of child but let them finish rest (easiest articles first).
• Consider a new child-selected outfit to increase motivation when required.

Missing food on plate
This can be due to both visual field impairment, inattention on one side and visual crowding.

• Plain plates without pattern.
• Put plate on a rotating base.
• Use coloured place mat under plate to highlight location of plate.
• Teach child to turn the plate round.
• Keep portions of food separate and don't overlap them.
• Provide bright foodstuffs of different colours.

Difficulty completing homework independently

• Clear 'work zone' in bedroom and 'walls' around the computer if one is used.
• Use labelled shelves for storing schoolbooks or plastic storage boxes.
• Use spotlights.
• Ensure all school based equipment is also available at home, eg; Typoscope, sloping board, magnifying aids.
• Set laptop computer to the child's preferred font size and style, and screen colour.
• Cover books with coloured coded paper, symbols or pictures to speed up selection.
• Factor in breaks; choose optimum time of day where possible.
• The child may need a physical activity prior to settling down.
• Use a visual or auditory timer (eg; cooker or egg timer) to break work into short periods.

Difficulty selecting and playing independently with toys

• Keep background plain, eg; bedspread, carpets and store toys in clear boxes.
• Only put a few toys out at one time (rotate them).
• Try clear boxes or labelled toy cupboard with grouped toys on shelves.
• Put pictures or numbers on boxes.
• For younger children, select simple non-complex.
• Avoid toys which over stimulate or are too 'busy' or 'noisy'.

Difficulty reading for pleasure

• Ensure optimum print size and font with optimum spacing between words and between lines, not exceeding the amount of text the child can cope with.
• Photocopy and enlarge material. (Maintaining high contrast of print.)
• Select clear pictures with not too much detail or clutter.
• Photocopy a few pages at a time and encourage the child to increase the amount to read to provide sense of achievement and increased concentration.
• Compile a tailor-made book' for the child, which matches both the child's perceptual abilities and intellect.
• Occlude text with a Typoscope, or with a card which covers the text which has just been read.
• Use stories on CD or tape.

Strategies for leisure time and travelling

Difficulty with team sports and ball games leading to lack of leisure pursuits

• Try Riding for the Disabled with expert tuition for all levels of ability.
• Look for special needs riding class, with 1:1 lessons or go at a quiet time of day
  (Child can experience moving safely through their visual environment.)
• Swimming; enhances body awareness and can help with visual spatial skills when completing under water obstacle courses.
• Ballet and Tae Kwon Do enhance balance, core stability and visually guidance of movement through space, and stamina.
• Practise ball skills with balloons which move slowly.
• Use large bright pain coloured balls to practice throwing and catching.
• Consider using balls which are lit or make sound.

Difficulty in busy environments such as discos and birthday parties

• Explain the child's needs to the organisers.
• Take child in advance to explore and discover venue when empty.
• Arrive early and introduce to people as they arrive, plan to leave early if too busy.
• Talk child through stages of activity, use ongoing verbal prompts to reassure.
• Limit time spent to suit child.
• Prepare for loud noises and flashing lights or ensure child will not be part of the event but can simply observe.

Difficulty attending cinema/ theatre

• Check content of films to avoid those which are distressing on account of over-stimulation.
• Sit at front for full attention and no heads to look over, or choose back for quick exit.
• Try ballet or mime show rather than fast paced pantomimes.
• Arrive early with lights up so child knows where they are going, or arrange for back seats at door and arrive in darkness as main feature begins to prevent over excitement.

Difficulty recognising facial expressions

• Ask child to concentrate on tone of voice, use words to verbalise what you are feeling.
• Inform other parents/ group leaders and ask them to be aware of this and assist your child.

Difficulty walking outside

• Hold onto elbow of partner (not hand) or pocket of jacket or belt.
• Take a scooter or pram to push.
• Try hiking stick or hockey stick to feel the height of the ground ahead.
• Get the child to make his own 'hiking stick' to use on country walks.
• Use verbal prompts or physical cues such as tapping the shoulder for potential obstacles.

Difficulty finding the way

• Use digital camera to make route map of familiar sights, or ask child to draw a map with pictures they recognise.
• Let child lead the way and use their own verbal or visual cues.
• Use mnemonics or rhymes.
• Present pictures sequentially to child at each stage or compile into map.
• Look out for the sequence of shop symbols instead.
• Make up 'treasure hunts' for practice.
• Train older children in techniques for navigation.

Difficulty in busy environments

• Ask child to pick their own route through the supermarket.
• Sit inside shopping trolley.
• Provide verbal encouragement and prompts 'what are we looking for?'
• Bring comfort toy or involve them with selecting a treat if panic starts.
• Consider best time of day when shop is quiet (early or late).
• Try small corner shop.
• Use a motivating shop to encourage participation, eg; Games store.
• Slowly build up of exposure time on successive visits.
• Child may feel safer with their own small shopping trolley.
• Consider using distraction such as an I-pod or similar.

Travelling in car causes distress

• Take music player with headphones or possibly a portable DVD player to create distraction (only if this does not cause travel sickness).
• Give child dark tinted glasses to wear.

It is essential build up and maintain self esteem and confidence in all children. As those with cerebral visual impairment develop, they can become painfully aware that they are unable to interact socially as well as others and to perform a wide range of tasks with the same competence as their contemporaries. It takes considerable skill on the part of the parents, carers, teachers and friends to integrate children in such a way that they build up the self confidence that they need for long term secure integration into the community.

The establishment of long-term friendships with school friends who support and understand is fundamental to achieving this goal and the skill with which the primary teachers include and integrate the child into the class environment without stigmatisation is critical.

In conclusion, the above descriptions comprise the results of our preliminary approaches to a complex topic. Further refinements will need to include defining the best strategies for each age group and ensuring that recommendations are not generic but are matched to the specific visual difficulties of each child.

• Devising strategies