University of Edinburgh

Lilli Nielsen

More on Cortical Visual Impairment

by Lilli Nielsen, Refsnaesskolen, Kalundborg, Denmark.
(This article was published in "Refsnaes-Nyt", No 39, 1994).

It can be extremely difficult to determine how much a child with cortical visual impairment is able to see. The results of assessments and tests that the ophthalmologists can make are often encumbered with great uncertainty. Even when an assessment is made successfully the tested ability to see can differ to a great extent from the child's ability to utilize sight.

When it seems that the child with CVI has fixated or visually followed an object, hand or person, it is still unknown what the child has seen, whether he has seen the whole object, hand or person or whether he has seen only a part or small parts thereof. It is also unknown whether the child is able to discriminate between two objects or persons, or whether what the child sees is blurred and without contours. Often the only possible assessment is that the child has reacted visually.

With this in mind we can still arrange the surroundings in various settings to enable the child to learn to see, that is, to utilize his residual sight while he: plays, experiments, combines visual experiences with other sensory experiences and compares visual experiences, and to do so whether he is in a supine or prone position, or is sitting, standing or walking.

Some children with CVI seem to be able to only see objects placed very near them, while others seems only to see objects and events that occur more than one meter away. The latter group of children have difficulties in combining visual with other sensory experiences - at least as long as they are still immobile and thus unable to move towards what they have seen.

The child must have the benefit of the doubt regarding the uncertainty of how much and what he can see. So it is necessary to observe the child. When it is noted that the child has been looking at something, the object should be analysed concerning its size, form and colour, and the colour of the background should also be noted. This can give valuable tips regarding how the environment should be organized in order to give the child optimal opportunity to utilize his ability to see.

Early in life the child without disablities starts to look at his hands. He turns his hands and later turns objects while looking at them. Still later he turns any object to see how it looks on the underneath. The extent to which the child with CVI will be able to combine visual experiences with movements depends on the level of his fine and gross motor development.

The child with CVI who is physically very passive must learn to move before he can utilize his ability to see. The child with CVI who is spastic must learn both to move and to counteract his spastic reactions before he can learn to combine movements with visual experiences.

When the child commences to look at something the adult ought to refrain from saying anything and preferably also reduce or eliminate other auditory affects from the surroundings. While the child experiments with looking, reaching for the seen object, making sounds with it, pushing it, or is active in other ways, auditory effects from the surroundings may distract the child's interest in utilizing his ability to see.

While the child is learning to fixate he has enough to do combining kinaesthetic and visual information - it would be difficult for him to concentrate on communication too. However, when the child has finished his activity it is appropriate to talk to him about what he has just been doing. If the child, while still active, turns towards the adult or in other ways shows that he wants to share his experience with somebody, a brief comment only will often encourage the child to return to the activity with renewed interest and concentration.

Some children with CVI have a limited visual field or need to hold an object very close to both eyes or to the one eye that is used for seeing. That means that it is necessary for such children to develop enough motor control so that they can grasp an object and bring it to the eyes or eye.

Motor skills are poorly developed in most of the children with CVI. Therefore, it may be necessary firstly to facilitate their learning to perform movements and to give them opportunities to combine movements with whatever sensory modality is functioning better than the visual sensory modality before expecting them to include visual information in their repertoire of experience of objects, persons and events.

An investigation of 20 congenitally blind infants (Nielsen, 1989) together with numerous observations of children with vision impairment and children who are developmentally at an early level show that children do not experiment with all sensory combinations at one time.

Some children start experimenting with combination of movements and sounds, and others with movements and vision. Only when the child has combined experiences from two sensory modalities will he include experiences from a third sensory modality.

When the child has looked at an object or a person he turns his head (and eyes) away from the object/person. 1-2 seconds later he will turn to look at the object. Thus he practices combining the movement with a visual experience as well as looking and not looking.

Later, when these skills are well established, the child reaches towards an object he has seen and so happens to touch the object - an action that will give the child a tactile and maybe an auditory experience, depending on the qualities of the object in question.

Since the child who is spastic often has a diminished ability to obtain tactile information it will probably facilitate his learning to ensure that the objects available for him have auditory qualities. If the child is at the level of using objects to play banging games, the development of eye-hand coordination may improve if his banging games have a visible result, for example, if the child has opportunities to bang with a crayon or a felt-pen on a piece of paper or cardboard.
If the child is at the level of pushing objects to and fro and is also able to hold a thick crayon or felt-pen the child may be interested in looking at the lines he makes. To reinforce the visual interest the paper could be placed on top of a piece of corrugated material or Braille print. While drawing on the paper the crayon will make various sounds that will encourage the child to look towards the sound and then to see the lines he has made.

A mother wanted to know how much more her child could see except for light.

"Do you think she can see pictures? She has commenced to name what is pictured in the children books that we read for her".

Since some children have an excellent ability to remember, the child's naming could be based on memory rather than on vision. It was suggested that an album be made containing photos of the members of the family with one person on each page and each of them photographed against a neutral background. Then the album was to be placed among the girl's toys so that she would find it without having had any previous information. It was pointed out that rather than looking at the photos the girl would probably commence with grasping and letting go the album, turning it around, maybe banging on it or banging it towards the floor, and only later begin to turn the pages. The result was that when the girl commenced to look at the pictures she only recognized the one of her grandmother. This photo was in black and white while the others were in color. One could be tempted to conclude that the girl was unable to see colours and maybe she actually was unable to distinguish faces in colours at that time. Nevertheless, later she became able to distinguish between colours, and among other things one day she named a picture of a half moon as a banana, and she preferred yellow toys. Still later she became very interested in all the primary colours.

Nielsen, L., 1993: Cortikal synsnedsættelse. Refsnæsnyt nr. 38. Refsnæsskolen, Kalundborg, Denmark.
Nielsen, L., 1989: Spatial Relations in Congenitally Blind Infants. Refsnæsskolen, Kalundborg, Denmark.
Nielsen, L., 1994: Early Learning - Step by Step. Sikon, Copenhagen, Denmark.

This article was printed in the journal "Information Exchange" March 1996.