OTS 210: Recognizing CVI in Your School-Based OT Practice
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Welcome to the show notes for Episode 210 of the OT Schoolhouse Podcast.
Many school-based occupational therapists are working with students who have cortical visual impairment (CVI) but don't recognize it. Unlike ocular visual impairments, CVI is a brain-based processing issue that affects functional vision in ways that fluctuate with environment, fatigue, and sensory complexity. In this episode, Lauren Andelin, OTD, OTR/L, BCP, assistant professor at Virginia Commonwealth University and assistive technology clinician at Children's Hospital, explains what CVI looks like in school settings and why it matters for OT practice.
This episode is for school-based OT practitioners who may be working with students with CVI without fully recognizing the signs, or who want practical strategies to support functional vision in the classroom. Lauren explains the difference between ocular and cortical visual impairments, shares the key behavioral signs to watch for, and offers immediately useful strategies like using preferred colors, managing visual complexity, and understanding visual fatigue.
Whether you suspect a student on your caseload might have CVI or you want to better support students with known diagnoses, this episode will give you actionable strategies you can use starting tomorrow.
Listen now to learn the following objectives:
Learners will describe why CVI is a brain-based visual processing difference and how environmental factors like clutter, lighting, fatigue, and sensory load can affect functional vision.
Learners will identify common behavioral signs and red flags that may indicate CVI in school settings.
Learners will recognize why CVI is often under-identified and misunderstood in schools.
Guest Bio
Lauren Andelin, OTD, OTR/L, BCP is a pediatric occupational therapist with 15+ years of clinical experience. Dr. Andelin is an assistant professor in the Department of Occupational Therapy at Virginia Commonwealth University. She also serves as the chairperson for AOTA's Sensory Integration and Processing Special Interest Section and has specialty training in sensory integration and assistive technology.
Quotes
"It's a brain-based visual issue. Somebody might have a normal eye exam, but really there may be a profound lack of functional vision."
— Lauren Andelin, OTD, OTR/L, BCP
"Because of neuroplasticity, we can really improve vision, but also improve the ability to use their vision functionally."
— Lauren Andelin, OTD, OTR/L, BCP
"We're not teachers for the visually impaired. We're not there to just work on improving vision. But the more that we're incorporating strategies to improve their use of vision, the more we're enhancing the visual processing."
—Lauren Andelin, OTD, OTR/L, BCP
“It’s really about functional vision across all environments.”
— Lauren Andelin, OTD, OTR/L, BCP
“I think a lot of us, we see a student who has difficulty with vision, but we don’t fully understand if it’s ocular-based or cortical-based.”
—Jayson Davies, M.A., OTR/L
Resources
👉Virginia Commonwealth University OT Program — Lauren's faculty page and contact information
Episode Transcript
Expand to view episode transcript
Jayson Davies
Hey everyone! Welcome to episode 210 of the OT Schoolhouse Podcast. I'm your host Jayson Davies, and today we are diving into a topic that I will be honest with you, I don't know a whole lot about. But I learned a lot during this episode, and I'm hearing a lot about this topic from so many of you. So I wanted to dive into it. We're talking about cortical visual impairments, aka CVI. And if you've ever had a student whose eye exam came back normal, but something still seemed a little bit off with the way that they were using their vision, this episode might just challenge the way that you look at your entire caseload. My guest today is Lauren Andelin, assistant professor and director of fieldwork at Virginia Commonwealth University, she's also a clinician at Children's Hospital, where she conducts assistive technology evaluations. In this episode, Lauren explains what CVI is, what it can look like in the classroom, and how we can distinguish brain-based visual challenges from more traditional ocular motor concerns. We'll also discuss visual fatigue, clutter, color preferences, positioning, accommodations, assistive technology, and collaboration across school and medical teams, so that you can begin to support your students better. Let's dive in with Lauren Andelin.
Amazing Narrator
Hello, and welcome to the OT Schoolhouse Podcast, your source for school-based occupational therapy tips, interviews, and professional development. Now, to get the conversation started, here is your host, Jayson Davies. Class is officially in session.
Jayson Davies
Lauren, welcome to the OT Schoolhouse Podcast. I'm excited to have you here. How are you doing today?
Lauren Andelin
I'm doing well. Thanks for having me, Jayson.
Jayson Davies
Absolutely. You know, this is a topic that we're going to be addressing today that I don't think has gotten the attention that it probably deserves. It's definitely something that I don't think I've ever taken a professional development course on or learned about in school. I'm sure there's other school-based OT practitioners who feel the same. So, thank you so much for for coming on to talk about CVI and kind of why it's so important to you, and and that's kind of where where I want to start is actually is just kind of understanding you know what what drew you into CVI when was it first really introduced to you and yeah we'll just kind of start with that
Lauren Andelin
yeah well I've been in practice since 2009 and one of my areas of interest and specialty is in assistive technology. So, in 2011, in my practice at an outpatient clinic that's part of a bigger medical system, I was asked to be part of our assistive technology team. I was one of two OTs that had been that did evaluations two to three times a week, and a lot of my evaluations were with with SLP. So we were often looking at children that needed augmentative and alternative communication, or AAC. And many of the children that I saw and continue to see are children that have complex bodies, or what we would call complex communicators. So children with diagnoses like cerebral palsy and other diagnoses that are brain-based. And I started around probably like two years in seeing a lot of children that had the diagnosis of cortical or cerebral visual impairment, and I honestly didn't know what it was or what it meant, I think probably many of us out there heard about maybe cortical blindness in OT school, so it sounded somewhat familiar. But I didn't feel like I had an understanding, and when I went to look in the literature, there wasn't a lot out there, so I just was kind of navigating it blindly-no Pun intended, and started looking at whatever I could. And I went to a, I think assistive technology industry association talk in probably 2012 or 2013 that was put on by I think Cincinnati Children's Hospital. There was an OT and speech group that was talking about cortical visual impairment, and that gave me kind of a framework to start learning about it. And so I started doing some reading, and I read Christine Roman's textbook. That there's now an updated version, but I read her original textbook, and that gave me kind of a framework to start working off of. And then the more I learned about it, the more I realized that it was so important to me as an OT and really to all of my colleagues to understand it more and realize like how powerful it was. The more that I learned about it, how powerful our role as OTs could be in helping these kids.
Jayson Davies
Wow. Yeah, yeah. You know, you mentioned that right. Like cortical blindness is something we might have learned a little bit about in our OT program, but it's not something that like we really dive into, and you know that's common. Like CVI is not the only thing, right? That that that pops into. Like that's not the only thing we don't learn about in in school, and then have to figure it out when we get into into our real life. And then you mentioned like you just had to kind of. I mean, you didn't you didn't fake it till you made it. Like that's not what you did, but you kind of put two and two together. It had to do something with cortical blindness, put that together, and then you figured out you needed to learn more. And you just admitted to reading a textbook after school ended. I mean, that's important. Like that is something that not everyone is has the time to do, is willing to do, and that that shows a lot that you said. You know what? I need to learn more, and and you found a way to to do it. So awesome! Kudos to you for doing that. Since you do have, you know, have read a textbook about it, and and have a lot of experience. For people like myself who haven't done that, haven't had education in cortical visual impairments, and maybe we've even seen students that we've worked with that maybe had a CVI, and we didn't even know. Can you share with us a little bit about what that looks like, what the causes of a CVI might be, and and why we should should know about this?
Lauren Andelin
Yeah, and I mentioned that I started learning more about this around 2011, 2012. Since then, so in the past, like 15 years, there's been a huge increase in research and and understanding. And I think that probably people listening will have heard of CBI because I do think it's there's a lot more out there now. Like if I was in the same position that I was 15 years ago, now I would probably not have to read a textbook because I could look at lots of blog posts and there's literature out there, but it still continues to be a very like kind of nebulous area. Not a lot of consensus around language, but what I can say is that places like Perkins and other organizations are really putting out a lot more in terms of resources for it. So the biggest thing and why it's so important to SSOTs is that it's often associated with some kind of brain processing issue. So it's not strictly a it's not an ocular ocular issue. It's a brain-based visual issue. So somebody might have a normal or quote unquote normal eye exam, normal acuity, or not having significant acuity issues that explain the profound lack of functional vision. So, what we're seeing is that a lot of times children that have these other diagnoses also have visual issues, and parents are thinking that they can't see. But really, there may be an impact that we can do something with because of principles of neuroplasticity. So, with CVI, it's the way that the brain is processing the information that's coming in and making use of it. And as OTs, we can do a lot in the environment, and we can do a lot with understanding kind of how to work with the diagnosis instead of you looking at as a deficit and support either increase visual processing. So because of neuroplasticity, that's what I really like about it. We can really improve vision, but also improve the ability to use our their vision functionally with with what we know.
Jayson Davies
Interesting, because yeah, you mentioned both like the the accommodation side, like this is a technology, but then also the neuroplasticity side of it, where that implies right changing the structures of the brain a little bit over time. Of course, over time, through through therapy itself, is are both of those currently treatment strategies that are kind of in the research and kind of what is recommended at this point?
Lauren Andelin
Yeah, definitely. And I think what when I'm teaching, so now I teach students. I'm I'm faculty at VCU, and I think when we talk about CBI as a diagnosis, it's important to understand what it might look like in a child, and also, of course, like what we're going to do to intervene. And I think yes, accommodation. So knowing what you might see and how you might set up the environment or set up an activity to to promote the best use of their vision, but also understanding that the things we're doing on a daily basis, and then the collaboration we're doing with other caregivers, with teachers, with parents, with anybody else that's on the care team, other therapists can, and giving them that education about how to best set up the environment. If we are setting up a student for success to use their vision more functionally, there is a chance that we could also be helping improve those visual processing pathways, which you know it's helping set them up in the moment, but also helping to support that reforming of visual pathways.
Jayson Davies
Gotcha. Gotcha. Okay. And so now you've obviously have worked with a lot of individuals who have a CVI. You've done research into this. What are some of the common signs that make you wonder? Hey, is this an ocular motor thing, or is it more related to the eyes versus the brain and a CVI? What are some of the things that you look for and that you notice?
Lauren Andelin
I will say that often if a child has something has a diagnosis that's related to a brain that's related to their brain, so if they've had preemies, individuals that have have had ischemic events at birth or closely after birth, if they're coming to me and their one, if their chart says cortical blindness, I might say, is it really? Cortical blindness, or is it cerebral visual impairment, where where we we don't really know what the vision is, but they have you know they have potential.
Jayson Davies
Gotcha.
Lauren Andelin
Looking at if a child if a parent says or if a teacher says like you know it seems like sometimes they can see and sometimes they can't and their vision shuts down or you know I thought that they could identify this correctly and now it looks like they can't even see it. So, like that fluctuation in vision can also be a sign. But often, just looking at like the chart and kind of seeing what their history has been can help support doing some deeper dive into into kind of looking at that.
Jayson Davies
Yeah, yeah. And now you're talking about this from your perspective and from your experience more in a medical model, and so I do want to kind of address this side because I think that there is this idea of like CVI that's like a DSM diagnosis. Like, how is this something that we should address in the schools? And we talked just a little bit about it a little bit ago about like accommodation with OT versus intervention, so not just OT practitioners, but like everyone in the school setting. There's like this, you know, separation of of medical versus school base. So I guess my question is like, why is this so important, or why should we think about this from a school education based perspective, as opposed to like saying, you know what, we're going to leave that for the clinic OT and the medical doctors to to focus on.
Lauren Andelin
Yeah, I think that that's and that's also going back to kind of what I'm teaching students is that this is not something that is static and it's dependent on environment. It's dependent on over time vision changing, but also kind of like how things are set up and kind of collaborating with the whole team about how to best support a student. So while I was, I see students in the clinic and I see them for evaluations to look at technology that's going to support either language or other access to the environment. I'm still if I'm seeing a CBI or if I'm working on going with a child with CBI, I'm focusing on how can we best support their visual function because it's really about functional vision across all environments. So not just helping to increase the odds of improved visual processing, but also to support if I'm doing something in a session that is going to help them be more independent with identifying items for their grooming routine. I might want that to carry over to their school environment where they're going to be able to independently gather their school supplies and using their vision. So the more that I can that we can collaborate across environments, the more likely that the strategies we're using in one are going to carry over to others, and it's it's not something that is just like a give. Let's let's do one thing and this will change
Jayson Davies
it. Yeah, yeah, and that's to be fair. I mean, that can be difficult. It can be difficult to collaborate. I mean, to be honest, it can be difficult to collaborate with the people who work on the same campus that we work on, and then you think about collaborating with the outside occupational therapists or the outside maybe it's the I don't know neurologist or something who is you know also supporting that student. That's that's tricky, but I think it is also an important piece that that we should be doing. And I think the system itself is not always set up to do that, but that the whole other conversation around how the systems are designed to kind of separate us and not put us in a place where we can do more of that, and we don't need to focus our time on that. But I guess I'm just trying to say, like, we do need to advocate every now and then for saying, "Hey, is it okay if I reach out to the outside OT? Is it okay if I reach out to whatever the medical doctor that submitted this report to the IEP team and and get more information. So yeah,
Lauren Andelin
for sure, for sure, yeah. And I think you know when I am looking at children or making recommendations on the medical side, I'm always if I can collaborating with with the school based OTs and other clinicians, but yes, not always a possibility.
Jayson Davies
It's not always easy. Yeah, I mean you can send in reports, and that is helpful, right? Like anytime we get a report, and from the IEP team's perspective, like yeah, it's important. Like to to ask a parent, hey, has the outside OT, has the outside whatever given you any reports that might be helpful to me, that I can review and and learn from. Like even if we don't have the ability to, or the time, or even just the what's that called when the the permission right to actually collaborate with an outside provider, that report can be helpful. Like if you don't even know that there's a diagnosis of CVI, then it's going to be really hard to to know which way to go. But if you have a report that even says there's a diagnosis and has some you know recommendations on there, much easier to to to move forward. So, all right. Well, we're going to take a quick break, and then when we jump back in. In just a moment, we're actually going to start to move toward the the part of this episode where we'll talk about what school-based OT practitioners can look for and do in their practice. So we'll be right back. All right, Lauren, we are back, and I want to start talking about a little bit about this. I don't want to necessarily call it an assessment piece, but like a screening piece, and then also the the moving forward with the intervention and accommodations for school based OT practitioners, and so I think to start there is the idea of you know what I think a lot of us we see a student who has difficulty with vision, but we don't fully understand if it's ocular based or cortical bays, and so what are I mean? Obviously, you mentioned earlier, like look for a diagnosis. But if we don't have that, what are some things that we might want to either you know an activity that we might be able to do or something that we should look into further?
Lauren Andelin
Yeah. So I mentioned when I first started learning about CBI, I read Christine Roman's book, and she has something called the CBI range. None of the tools right now that are out for actual assessment are validated to the point that I would say that it's something that can diagnose without having a neurologist or an ophthalmologist who is also on board giving that diagnosis, but I do think that particularly Dr. Roman's tool can help kind of frame the behaviors that you might see with a child with CBI, and even if you're not formally administering it, it has 10 different common behaviors or what she calls unique behavioral and visual characteristics that you would see in a child with cortical visual impairment, and knowing those behaviors can help kind of help you with your clinical observations. And so you can set things up and do things to kind of identify whether those behaviors exist and how you can use them to both give you more information and maybe like further determine. I think this is a child that would benefit from a further evaluation by a neurologist, and can also help support intervention because you might find things that support their vision and also things that don't. So I don't know if you want me to kind of go through some of those behaviors or
Jayson Davies
yeah, sure. That's I'm looking at them right now. I was able to to find a little bit about the CVI range, a little bit, and we'll link to that in the show notes. But yeah, I'd love to hear a little bit about the the behaviors.
Lauren Andelin
Yeah, so one that's really easy is that children with CVI often have a visual preference, and it's typically those highly saturated colors like red, orange, yellow. It's not. That's not 100% I mean, I've worked with children that blue is their preferred color, but typically that is where I will start. So, using some kind of highly saturated colored object, or I might put that in their line of vision, either on the right or the left side. So always on the periphery, and start to see with a lot of wait time if they'll start to look at that color in the absence of doing like some kind of performance-based thing like that, I might do more of an interview with caregivers, teachers, other people that are with the child a lot, and ask about what their preferences are. So just like we would do any kind of occupational profile, and we want to start with strengths and interests. You know what what is your what's their favorite clothing item? What what kinds of activities is your child like? What are their favorite toys? Their favorite TV shows or books? And a lot of times, even if a parent or a teacher doesn't know that a child has a color preference, you can start to see a pattern based on the things that they're choosing. So they might say like, "Oh, they really love this. They love Clifford. The Clifford and they're a dog, or they, you know, they really love. I don't know another thing that has like bluey. They really like bluey. Bluey has and and it might not be the color. It might be based on other things, but that's kind of a way that we can gather some some information. Do you want me to keep going with some of those? Yeah, go ahead. Because
Jayson Davies
you that was visual recognition, right?
Lauren Andelin
Yeah, that was look thinking about like color, like thinking about color preferences.
Jayson Davies
Okay.
Lauren Andelin
Another thing that we know about children with CVI is that they are tend to be attracted to light, so they can see light better than other things. So using like a spotlight to help support their visual attention to something might get their attention better, and then they might show more visual focus on that. So, using a light that I'm putting over something that has a color preference, and maybe moving it a little bit, because we also know that movement is something that children with CVI are more likely to see or be distracted by. So, either that can be a help or hindrance, but using those strategies to help support visual attention and then to see if they can then process that better.
Jayson Davies
Yeah, yeah, and then I saw also like the impact of of clutter and crowding.
Lauren Andelin
So that's a big one, and that's something that when we think about like. Sensory and visual complexity in the environment, and that would be for any for a lot of our kids that might get overwhelmed by lots of visual stimuli, and particular particularly in a classroom or in a any kind of environment in the school setting. There's a lot of visual stuff going on, but visual complexity if by decreasing visual complexity, so that might mean just putting a black background on top of a table that has a lot of stuff going on, and then putting one item on top of it, that can really give us a sense of if if a child can see something when all of that complexity is gone. When we think about sensory complexity, we're also thinking about the environment of not just vision but sound, movement, texture, things, other things that are going on in the environment can really impact the ability to use their vision. So, just like a person that has needs a little bit longer to process auditory, if they have auditory processing challenges, they might need a little bit more time. A child with visual processing things like CVI are going to need more time to process that, and the more distractions they have from other sensory input is going to decrease their ability to use their vision. So the more that we can kind of like decrease all that extra stuff, it's going to make a difference.
Jayson Davies
Yeah, given how, I mean, this is somewhat complex, right? Anytime we start talking about the brain, it gets really complex, and I'm trying to think like as a school-based OT, without going into some really, you know, going down a rabbit hole and really seeking out professional development. This is going to be, it's it's not going to be easy for for your average school-based OT to to really be able to discern these. I mean, is that an accurate description? Do you think?
Lauren Andelin
I think it's not something that an OT in general is expected to diagnose, and so I think it's important to remember that whether or not a child has officially has a CVI, which in and you know, we can be using some of the strategies that I'm talking about with a lot of children that have that might have a visual difficulty. So I think that once you start thinking about it, kind of using this idea of maybe these behaviors are things that would be prevalent in a child that has CVI, and maybe I can use these under this understanding to help support what I'm doing in my intervention. If it's helping to support their functional vision, then you might already be like halfway there. A lot of the children that I work with that have a suspected CVI, we might not know for sure that they're diagnosed with it, but using some of these strategies is supporting them in their functional vision, and it's also things that you might be able to do with a child that just has a visual impairment that's not a CVI, and it could support them as well.
Jayson Davies
Yeah, I've got two follow-up questions. We'll start with this one, and that is, what are some things that you listen to? You you mentioned like the occupational profile earlier and talking to the parents and stuff. What are some things that you really listen to from someone like a parent or a teacher? What are you listening for, or what might you hear from those individuals when they're talking about their child or their student who has a CVI that kind of cue you into things.
Lauren Andelin
I think a lot of times thinking about when you hear like their vision changes throughout the day because really it's not that their vision or their visual their functional vision is their vision is different, but just that it's environmentally dependent. So it seems like they maybe can't see something that they could see in the morning that they saw yesterday afternoon, and turns out it's actually that the way the environment was set up, or the impact of other factors like fatigue or hunger, are impacting that visual function. So I think that when you hear that vision is changing, that's for sure something.
Jayson Davies
Okay.
Lauren Andelin
Again, when a child has a history of something that would point to a brain-based vision issue, that can clue you in to start trying some of these strategies. When there's a visual shutdown, that can often happen when a child with CVI is, you know because they're working so hard to use their vision and an environment may be too much, so they'll just have that shutdown. That could be something you see. So all of those things would kind of point to versus like if like closing their I mean closing their eyes meaning like visual shutdown like that.
Jayson Davies
Gotcha, gotcha. Okay, and then the second follow-up question I wanted to ask, because I think we all know, right? OTs, we are not like diagnosticians, especially not when it comes to something like this. And but you have worked with teams who it sounds like have done diagnosing and whatnot. And so I'm interested to hear, a who is typically the expert that would. Diagnosis CVI and B, what does that assessment, if it is an assessment, look like? What are they actually looking at when they're trying to determine whether or not a child or a person has a CVI?
Lauren Andelin
Yeah, so medically, a neurologist or an ophthalmologist or an optometrist that has specialty training and understanding would be able to diagnose this, and they typically would do imaging and see. You know, they would pair that with some of these behaviors that are the visual behaviors that are can't can't be explained by an eye exam alone. So a lot of these kids might have visual, like they might have ocular issues, they may have ocular motor things, they might have nystagmus or amblyopia or other visual behaviors that or visual things in their eyes that would give would point to some vision issues, but the profound lack of functional vision cannot be explained just by that. Or they might have acuity issues. They might have myopia or need glasses, corrective lenses for something, but that is not enough to explain this profound lack of functional vision. There are special educators and OTs and speech therapists and other professionals that are trained on some of these tools, like the CBI range that I mentioned. The Perkins, the Perkins Institute now has a tool that they are roll. They have rolled out that is available. It's about $200, I think, to be trained on it. And both of those tools, they're different, but but similar enough in that they're but they're looking at these these behaviors, these visual behaviors, and saying how much that those behaviors are apparent in a child, and based on those behaviors, making the diagnosis.
Jayson Davies
Gotcha. Yeah, it's it's always fascinating to hear like how diagnoses are actually formulated because obviously as OT practitioners, like we just we don't we make treatment diagnoses, right? Like we like to know what's going on and and how to move forward. But the whole idea of being a diagnostician of some kind always has kind of excited me. Like I don't know, in another world, maybe right, like doing something like that. But it's always interesting to hear how the how the professionals who do do that actually make those decisions. So yeah, okay. So bringing it back down to like the school based OT level, we've talked a little bit about what CVI is, what it can look like. We even talked a little bit about the actual intervention versus accommodations, and I do want to dive a little bit more into that because you explicitly actually said that the way that you got into all this was originally kind of being part of an AT team. So I would love to. Maybe we should start there with this such a technology and accommodations piece. What are some common things that you have actually seen used by either yourself or others when it comes to accommodations and assistive technology?
Lauren Andelin
Yeah, I mean, I think I started exploring more because I felt like knowing when parents. I had one family in particular that I can think of, and they would they talked about how their child had CVI, and they obviously knew a lot about it. And I felt like there was there were certain things that they were doing that they were telling me that they were doing that were because of the CVI to support the functional vision. And so I kind of explored further to see what I could do. So one, we know that, like I was saying, with visual complexity, like if there is a a cluttered field when you're thinking about an AAC system. So with lots of different cells, lots of pictures next to each other, that's going to be harder than if you space things apart. So knowing that a child needs to have maybe like a pull off, if you're using a low tech board of pulling off a picture and bringing it to them to bring it away from the other pictures, like that might be a strategy you use, and that might be if you're if you're doing an assessment like a like a an assessment in the classroom of which word you know are you looking for. You might have these things that you can pull off and and bring it to the child one by one instead of having it all together on a worksheet.
Jayson Davies
Gotcha.
Lauren Andelin
Thinking about the impact of color. So if I know that a child's colored preference is red and that they can see red really well, and that's going to draw their attention, I can use that as an anchor when I am setting up a dynamic display system. Use it for for speech. I might have if I'm if we're tar if the speech therapist is targeting certain words on a device and we want them to better access them visually and motor-wise. I might highlight them in red, and those might be the ones that we're working on because it's going to draw their attention. Or I'll use something like a pipe cleaner wand that is the color of preference to help get their visual attention, and then bring it to the item that I want them to look at. And I might also move the pipe cleaner because that element of movement is going to help draw that person's attention, knowing that movement can be something that individuals with CVI can better see.
Jayson Davies
Yeah, is is more high tech technology a common accommodation used with with people? Who have a CVI, or is it just one option that that's a possibility?
Lauren Andelin
I think it's just I would say it's just one option because every every child with CVI is different, and they might have different abilities and you know challenges. And so, if somebody is able to you know use a high tech system, we would, and and they need that, and it works. Then we would go there. But yeah, I think it it kind of depends. I definitely have heard families that get frustrated when their child just gets a light box. Like a light box is often used for individuals with visual impairment, and because we know individuals with CVI tend to see light more and get drawn to light. That that's kind of like the catch-all thing that we'll use, and that's not necessarily the only. You know, that's just one activity or one thing that we can put there. But using principles of light, like highlighting, so using like a really high lumen flashlight, 300 lumens or more, to have the brightness that you need to spotlight either pictures or things in your environment, or like for reading, that can help support the ability to better see something.
Jayson Davies
Yeah, that's a very yeah very familiar with lightboards. But yeah, the idea of it's kind of flipping that around and rather lighting up an entire eight and a half by 11 space or whatever size it is can narrow that down with with a flashlight or something and just kind of highlight a very specific point. Yeah. One thing I know with with the light boards, and I wonder if this is something that you've ever done is you can have a light board on, but then use like a visual shield or whatever to really narrow down where the light is actually coming from. For example, you know, using black paper over a light board that has a small hole in it or something, and so that way it draws the focus to wherever it's kind of like the reverse highlighter. Yeah, yeah, yeah. In a degree or yeah, yeah. So just just creative ideas.
Lauren Andelin
Yeah, and also similar. Oh, sorry. No, I was gonna say like similarly using like a black a tent and putting a child in like a an enclosed space and then lighting up the space where they're in with the area that you want, or dimming the lights the external lights and just focusing in one small area. So like a similar way to use light. Yeah.
Jayson Davies
Okay. You know, I'm thinking, and and this is not specific to this diagnosis or anything, but we're talking about some of these accommodations, and sometimes they're easier said than done, and so I'm curious as to you know with the with the individuals that you've worked with, what are some ways that have allowed them to expand the carryover of a strategy beyond the physical space that you know we're introducing the strategy to them. You know how are they like? What has made it so that they can take it home and use these strategies? What has made it so that they can go to school and use these strategies? Have you found something? Obviously, every strategy is different, but how have you assisted with that carryover?
Lauren Andelin
So a really easy and you know something that I I talk about a lot is just thinking about like again that color preference and using things like ribbon. So if if orange or red is the color preference, having red or orange ribbon that's tied around an item that they're using every day, or using in a in a regular in a regular capacity. So, like when I think about in the home environment, maybe just tying a red ribbon around their toothbrush. If they could have a red toothbrush, that would be even better because it's going to be something that they can see better. But thinking about something like that that you can put on lots of items that are important to the child, the knowledge and advocacy about what behaviors the child or what visual things the child tends to do is kind of like that education piece for the caregivers, so that they understand here are ways that I can maximize the environmental space. But a lot of low tech things, colored tape, like I said, ribbons, small flashlights, things that can help support in the moment occupations are things that I try to do the most when I'm kind of thinking about carryover.
Jayson Davies
Yeah, yeah, because you know a light board is not the simplest thing to carry around with you. Yeah, but something like a a small flashlight is much easier to carry around with you as is like you you were mentioning. I love the idea of like the little ribbon, and you can carry around something to just tie to something, and and really easily use that.
Lauren Andelin
Or just have like another idea is just having like a black tablecloth from the Dollar Tree that you have that they have in their bag that you can just like throw over if an environment is really cluttered, so they could put that as the backdrop, or in an environment where you just want to hang it up to like block all the other things. Obviously, you can't do that in every classroom, but if that was a way to just like isolate the environment for the child, another thing is a lot of the kids that I see have clear boards, like clear. What I'm forgetting, like
Jayson Davies
whiteboard type of thing, or
Lauren Andelin
like on their chair, their tray. They have clear trays. Oh, okay. Like plastic. They're made out of that material that I plexigla. Yes, yes, plexiglas trays, and that can be really great because they can see through them. But they can also be really hard to place things on top of. So either having like a piece of of black, and I and I go to black because black contact paper or something like a sticker that can cover it. Black can be kind of universal because even though you might think like I want to have the color that they can see as that background, that's going to be what they draw their attention to. So if you can use black, it's going to help with that contrast, so then when you're placing things like an item for their classwork or if they're eating, so that they can better see that. So things like that can be really helpful.
Jayson Davies
That makes sense, and yeah, $1 Tree, you know, black
Lauren Andelin
tablecloth
Jayson Davies
place, not placement, tablecloth. There we go. Not something we talk about every day. is really easy to tie over one of those you know classroom desks really easily and like that that simple. Or even if you don't have the ability to run to $1 Tree right now, is something that you can black construction paper is readily available on a campus that you can, you know, just at least try with that. Start there. I actually know of a handwriting program that is coming to my mind as we talk about right now, and they are specifically using the high contrast. Now they use black and white. It's called Black Back Handwriting Program, and they really rely on contrast. It's actually black paper with right or right with white visual, and so that's like kind of where my head's going. But you could easily do something like that with the other colors, the colors that are more friendly to that particular person. Yeah. What about visual overlays? Is that a common use? Is it something that you've seen?
Lauren Andelin
You mean like to block out, like to have like a cutout, like visual overlays like that. Well, I'm thinking you like the yellow. Okay,
Jayson Davies
I'm thinking like the yellow, like the red see-through plastic, right? That you can put over something. Is that something that
Lauren Andelin
I wouldn't say that that would be CVI friendly necessarily? Just because I think that that the color itself might draw their attention, but you want to think about like is that gonna highlight out those specific things that you're trying to do versus like if you have a dark background and then you put something that's bright on top of it and you want them to look at the isolated thing.
Jayson Davies
Yeah, I was just trying to think like it's really hard to get like red paper all like for the teacher to print out all their worksheets or whatever we're working on on red paper, but instead maybe the the student could have a red overlay or whatever color overlay to then place over the white colored paper. The problem with that though then is that you can't interact with the worksheet if you've got an overlay on top of the paper, so
Lauren Andelin
and and then yeah, love
Jayson Davies
occupational therapy. Yeah, no, and then
Lauren Andelin
differentiating out like what's on the actual worksheet. But I think you could just use highlighter, like you could have a white paper with, and then highlight in the color if you want them to focus on a specific area, like actual, like I mean, a highlighter marker. But
Jayson Davies
yeah,
Lauren Andelin
yeah, I think every situation is different, but
Jayson Davies
but that's what what's great about OT is like we see the educational side. We also understand to the best of our ability, or we or we made the the effort to go understand the diagnosis and the difficulty, and then we kind of pair this together. Yeah, like to be fair, yes, we have a caseload of 55 kids or more or less, but the teacher is very focused on supporting 31 kids all at the same exact time, versus we have the ability to go learn specifically about this one student's diagnosis and bring that knowledge and pair it with the educational knowledge that we understand about the classroom to bring the strategies that will work in the classroom. And I mean, I don't know. It makes OT very unique and very special, and I love it because very holistic. So yeah. Okay, we talked a little bit about accommodations here now, and you have mentioned more of the the others, not the other side, but complementary the neuro the neuroplasticity and the actual treatment and intervention that we can support these students. And you said something that was very important earlier about how you kind of, you know, put these two together, right? Like when you are trying to incorporate an accommodation, you're also using strategies to support the student, you know, potential neuroplasticity growth within. But I want to lean more on that treatment intervention side. What are some things that that come to mind when we talk about the actual treatment itself outside of the accommodations?
Lauren Andelin
Um, I think that in my you know most of the kids that I'm working with were looking at how we can adapt their assistive technology so. They can best use it, but with that we might be fading off. So, like I said, using some of these things we know about them, like color preference, visual field preference, movement, light, I might use that as kind of an anchor to help draw their attention. But the idea is that the more that they are seeing the same thing and their visual pathways are improving. The more we can fade out some of those accommodations. So, if I'm starting with an a system, a computer-based system that has the words that they're learning with a red highlight around them, we hopefully will be able to because the more that they look at look because of the red, the more that their visual processing will improve, the more that they'll be able to interpret those things. We can start to fade out those accommodations. So then, for the next, then when we're teaching the new words, we can use those anchors again, and then they can start to attend to those. And with the knowledge that the other ones have been built, I don't think that there's like a clear. Again, we're not we're not we're not teachers for the visually impaired. We're not there to just work on improving vision. But I think that the more that we're incorporating some of these strategies to improve their use of vision, the more that we're enhancing their visual processing, and then that's because of neuroplasticity, hopefully improving their vision.
Jayson Davies
Yeah, it's a similar. It's scaffolding. It's it's a form of scaffolding, right? Correct. Yeah, yeah. Okay. Another term that you mentioned earlier, and I wanted to come back to it, was advocacy. And I'm interested to hear from your perspective how advocacy plays into all of this when we're working with these clients, because just as important as it is to help them implement a specific strategy that we've talked about on this podcast, I think it's also super important to help them advocate for their own abilities and for their own access. And so, I'm interested to hear what you what your thoughts on that are.
Lauren Andelin
Yeah, I mean, advocacy to me is always like our biggest, probably like the first thing we need to be thinking about working with well with all individuals, but especially with kids, as young as like as young as possible, so that they can start to understand their own needs. And I think that one again, that education around like what it might look like if a child has CVI, so that they understand and they can say it might take me a little bit more time. One of the things we haven't talked about is visual latency. So often these children need longer to process. That just means, like, just like again with auditory, when we think of auditory processing challenges, a child might need a little bit of a wait time between giving them them a command and interpreting what you said or processing that auditory input. Same thing with the vision. You might it might seem like a child is not seeing something, but if you wait 30 seconds, sometimes longer, and don't say anything else, then they might be able to attend to it. So if a child or an individual knows that about themselves, saying, you know, I need more time, so in whatever way that they can communicate that, the more that they can explain that, sometimes they have to look and then look away and then look again, and maybe they are not coordinating their reach, their motor with their vision, and that's how their body works better. So, being able to somehow advocate that to, or be able to communicate that to others, I think thinking about ways that we can have like, I don't know, like a fact sheet that they carry around with them if they can't, you know, maybe communicate all of that right now. If their care team is helping them to create something like that, so that it can be passed along to different caregivers, I think a lot of it is just like education and understanding. So presuming competence, being able to give them that language in whatever way that they can to to tell others what they're working with.
Jayson Davies
Yeah, yeah. Okay, so you mentioned earlier when deciding or when understanding when you needed to look at a student, it kind of defined whether or not it's a CVI versus maybe some other sort of visual impairment. A neurological disorder might be kind of like a red flag for you, right? If you see something, but we didn't go a little bit more into in depth into that, and so I did want to ask: like, are there certain diagnoses that maybe might kind of make you more strongly look into a CVI, or is it just pretty general? Anything neurological? I know you're in a different position where a lot of I think students or a lot of children are coming to you. They already already got that diagnosis. Sometimes, but are there others? Yeah,
Lauren Andelin
no. I mean, I would say definitely CP prematurity. Some, I mean, retinopathy of prematurity is not that is a separate visual diagnosis. But if a child has that, typically that means that they were premature and then they had some delayed visual maturity, and that might indicate that there could have been an event. Sometimes children are having visual issues, and they haven't been diagnosed specifically with like a CP with CP, but you do know that their history indicates that they may have had some, you know, some things that have happened. Epilepsy or different kinds of seizure disorders, non-traumatic or non-accidental trauma, head trauma. There's been a lot of there's been a much bigger incidence. They're realizing children with Down syndrome and autism are having more likelihood of there's more of them have that come out later with having CBI. So it's not as apparent, but anything where there's yes, like brain base. So if there was like a hypoxic event, or if you see and you know see that in the chart, PVC, periventricular leukomalacia, HIE, hypoxic ischemic encephalopathy, meningitis, anything like that where there may have been something like brain swelling. Yeah.
Jayson Davies
Wow. All right. Yeah, I, I, I had no idea, so I had to ask. So thank you for sharing that. That's more than honestly more than I was expecting. But that just kind of goes to show, you know, that if you just hear one diagnosis, you can't look at that. Like you can't just think CVI from one diagnosis. It really is kind of all-encompassing to a degree, any sort of neurological thing going on. So, all right,
Lauren Andelin
yeah.
Jayson Davies
I do want to take this back to the classroom here as we start to wrap up here, because obviously, school-based OT practitioners were in the classroom a lot. You mentioned the black tablecloth idea. If an OT practitioner was going to say, "Okay, I want all of my teachers to know like one or two things that they might be able to support a student who has a CVI, and they're doing like a professional development at the beginning of the year. What are just you know the the key points that you would want an OT to be able to share with a teacher to to maybe look that or to maybe support a student that is not so commonly known.
Lauren Andelin
I think, like, just thinking about that impact of clutter in the environment. So, really decreasing the complexity of the visual environment, having things that are easy, like light activities that you can focus their attention, having different color activities. So, kind of thinking if like a child is not interested in one, maybe they'll be interested in another color. Thinking about the impact of positioning. So, if we, if you know, if you know that a child has a CBI and they can see better on the right side, knowing to present things on that side. I mean, things that we don't always think about, but that are that that seem pretty simple to us, but might not be something that another individual who's not an OT and thinking about the environment would think about. Putting things we often want to like put things face on with children, like one, you know, we want to be eye to eye and central vision can be really hard for these kids. So thinking about the importance of presenting things on again that preferred side, or even just trying the right or the left side positioning of yourself versus the item, and thinking about also like if you as an individual have a very busy shirt, or have a lot going on on your body, or your you know on your person, and you're presenting things to a child that becomes part of the visual background. So thinking about again like that, being able to decrease clutter when we are presenting things if we want a child to use their vision, and I think the other piece that we haven't talked about, and this goes back to kind of that accommodations and kind of a strength based approach is that a child that has CVI is struggling to use their vision, like it's still something that's hard for them. So if they are doing an activity that they want to rely on their sense of hearing or their like, I can give the example of AAC. If we're doing a scanning system, auditory scanning might work a lot more efficiently for a child that has CBI, and that is something that I would probably want to use if I can. If they're very efficient with that, and it doesn't mean that I have to just focus on them getting better with their scanning, but I don't abandon the fact that we know that their vision can improve and we can use their vision,
Jayson Davies
yeah,
Lauren Andelin
in other ways. So deciding kind of like where we're going to harness the things that are easier and where we're going to work on kind of improving that visual processing for function because we goes back to function yeah
Jayson Davies
and and it's something that we said on the podcast a lot like using using the strengths almost to accommodate the difficulties but not replace replace that skill that they're still working on, you kind of went actually exactly where I wanted to go for this final, you know, question here, and that was about visual fatigue. It was something that we had kind of on our notes here, and you kind of like that's kind of the reasoning for using that audio system as opposed to forcing the student to always use their vision system using that AAC device, I would imagine, is kind of that visual fatigue piece, and is that right? And and just want to let you kind of speak to that really quickly before we start to wrap up.
Lauren Andelin
Yeah, I mean, one thing that we can see with these children is decreased blink to threat and decreased blinking in general, and they're working really hard to use their vision. And so, if we are deciding that in an OT intervention session that we're going to work on improving visual reach, so using their vision and their motor at the same time, we might want to decide like when are we going to do that? Is it going to be at the beginning of the day when they're the most rested before they've had a lot of other demands, or do we want to think about you know resting later, later doing something later in the day that's working on their motor and not allowing them or expecting them to rely as much on their vision. So yes, they have visual fatigue just like any of us, but it's going to fatigue faster in in environments that are novel or activities that are novel visually are going to be a lot more challenging and are not going to be something that we want to do when a child is already been taxed using their vision. So, kind of like thoughtfully knowing when to make those visual challenges or interests of visual challenges.
Jayson Davies
Yeah, so much to think about, Lauren. Where can someone go if they're like, "Hey, I need to know more about this and how to support my students. I I I can already think of like five students who I need to work with more on this. Where are some good resources for them to go to? Whether it be a course, a book, a talk on YouTube, like whatever it might be.
Lauren Andelin
Yeah, yeah, yeah. So I wrote. So there's a ton of ton of there's a lot out there. Like I said, like it's very different than when I tried to find things in 2012. But CVI now the Perkins Institute they have a ton a ton of stuff that's free some paid things but a lot of like free videos resources things about the assessment that I was talking about Christine Roman has her own webpage Dr Christine Roman it's just called cviresources.com I think and that has a lot of that has things about the CVI range, which is that assessment tool that goes through the 10 behaviors. She has also the second edition of her book now is out. It's Christine Roman, and I think it's just called cortical visual impairment. There's also the Pediatric Cortical Visual Impairment Society, that is another organization that has free resources. Those would probably be like the three places that I would start with. Just starting for you, and yeah, and then you know, with that, you can probably find a lot of links that go to other things. Another person that does a lot of I went to a workshop of hers years ago. Her name is Diane Sheeline. She has a book called Strategy to See, and she has written some things that that I think are on Perkins as well. But she has a lot of do-it-yourself kind of like fun OT type things that you can do to help support your students. So that might be another person you might want to look at.
Jayson Davies
Awesome, perfect. Well, thank you for all those. We'll be sure to link to all of those resources in the show notes for this episode, as well as Lauren's page over at the university that she's working with. And that way, if you want to learn more about Lauren and more about CVI, you have all those access or all of those resources available to you. So, Lauren, thank you so much. Really appreciate you kind of introducing us to CVI and kind of just you know some things to get started with. And as you mentioned, there's a lot more resources to learn more. So thank you, we really appreciate it.
Lauren Andelin
Thanks, thanks for having me.
Jayson Davies
All right, and that is a wrap on episode 210. Thank you so much for listening, and thank you to Lauren for taking the time to join us and share your expertise on cortical visual impairment. Whether you're just hearing about CVI for the first time, or maybe you've had a hunch about a student on your caseload for a while and wanted to learn more, I hope this conversation gave you just what you needed to see everything in a new lens. Yes, pun intended. And I hope that this episode really does help you. The work that Lauren is putting out there into the world through through what she does at the university level, as well as all the works that she's putting out at AOTA and and all that good stuff, are really helping people like us to better understand CVI and to better support our students. If you want to keep learning and growing as a school-based OT practitioner, we would love to have you join the OT Schoolhouse Collaborative. This is where I hang out with other school-based OT practitioners just like you, sharing resources, sharing professional development, and providing real mentorship. We have a monthly theme every month. Right now, it is on neurodiversity, and you can learn all about the OT Schoolhouse Collaborative over at otschoolhouse.com/collab. I hope to see you there soon. Thanks so much for listening, and I'll catch you in the next episode.
Amazing Narrator
Thank you for listening to the OT Schoolhouse podcast. For more ways to help you and your students succeed right now, head on over to otschoolhouse.com. Until next time, class is dismissed.
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