cerebral visual impairment cvi -...

… when the perception is upside down

Cerebral Visual Impairment – CVI

Gerti Jaritz & Birgit Schloffer

Graz - Austria

ICEVI Europe 2013 - Istanbul Jaritz & Schloffer

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Insides from Graz



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Personally Background • Working in the educational field

• An increasing number of children have other symptoms than sensory visual impairment and blindness

• We felt a need to learn more about this topic

• We decided to attend the in-service course about CVI at the University of Dortmund, Germany.



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Working Background • Experts for CVI in Austria, but just on the first

mountain

• Decision to start a research project

• Supportive collaboration of Lea Hyvärinen, Fi and Marjolein Dik, NL – thanks a lot!



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Society Background • Assessment of visual impairment in children

in Austria quite good

• Satisfactory cooperation of ophthalmologists and the educators Problem: limited time of ophthalmologists

• Especially the assessment of children with CVI takes interdisciplinary experts and a lot of time with parents and teachers.



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What is CVI?

Cerebral Visual Impairment (CVI) is a condition where some of the special 'vision' parts of the brain and its connections are damaged. This causes visual impairment even though the eyes are normal. Often children with CVI actually have good visual acuity but can not 'make sense' of what they see. http://www.ssc.education.ed.ac.uk/resources/vi&multi/eyeconds/cereVI.html, 11.6.2013.



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http://www.ssc.education.ed.ac.uk/resources/vi&multi/eyeconds/cereVI.html

CVI - Processing of visual information

in the brain

Descriptions of visual processing problems (ICF b2102) also called Cerebral Visual Impairment (CVI) differ surprisingly much from each other. (Hyvärinen, 2011)



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CVI-Research project

RESEARCHERS:

G. Jaritz B. Schloffer

INTERNATIONAL EXPERTS & COOPERATIONS:

Prof. Dr. Lea Hyvärinen Drs. Marjolein Dik PH Steiermark, Odilien-Institut, TU Dortmund



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Research Questions

• “How can children with cerebral visual impairment see?”

• “How can we create better learning strategies for these children?”



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Phase 1: 2010/2011

Assessment of Functional Vision for Educational Purposes

with Dr. Hyvärinen

Sample: 21 children

Age: 5 - 15 years



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Assessment of Functional Vision by Prof. Dr. Lea Hyvärinen



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Results Phase 1

• Children all over Austria 9 boys, 12 girls

• Not the optimal visual correction: 7 ch.

• Problems in accomodation: a few

• Problems in face recogniton: 5

- in shape recognition: 3

- grating acuity: some

- in space & maths perception : many

Discussion about mobility training and processing route-based or map-based.



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Phase 2: 2011/2012 Interdisciplinary period

Drs. Dik Neuropsychological Assessment

Precondition: IQ Test

• 2nd Assessment of Functional Vision

Dr. Hyvärinen

• Educators and Parents

Sample: 13 children

Age: 6 – 15 years



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Neuropsychological Assement

• Develpmental Test of Visual Perception I + II

• Tea-CH Test of Every day attention of children

• Test Of Memory And Learning

• Beery

• Big Books



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Our neurospychological tests



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In-service Training



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Setting up a Local Network of experts


• Neuropsychologist

• Opthalmologist

• Orthoptist

• Occupational-therapist

• Educators

Getting to know each others professions Discussing the specific terms like:

- visual field or attention field - case discussion


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Phase 3: 2012 - 2014

“How can we create

better learning strategies for these

children?”



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Finding out daily needs & sharing strategies



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Results

Normal Visual Acuity:

in 4 children (but glasses have to be improved)

Visual Impairment:

in 4 children

Visual Processing Problems:

in 2 children

Subnormal Vision: in 7 children with specific field losses and visual processing problems



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Data about intelligence 7 out of 13 had lower Verbal IQs;

5 had mental retardation and

2 functioned below average

This was a surprise for some of the children´s teachers! Explained a lot about participants´ visual behaviour (simply on a younger developmental level)

The opposite happened as well : one young man with low vision and motor disability showed a nearly normal intelligence!



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Physical Impairments

Motor control and ergonomic adjustments are preconditions for seeing well. No wheelchair and/or not well adjusted supportive devices no visual task behaviour. Talk with occupational therapist.

Visual-motor-integration is impossible for the majority of this group: the functions can only be used in sequences: first look, make a plan, than move! “Driving” is usually without visual control (head down).



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Physical Impairments

In 2 of 7 children with cerebral palsy we found visual-motor-integration problems like Optic Ataxia.

1 in 13 had visual perception problems compared their cognitive functions.

2 in 13 had problems with visual attention.

All children with cerebral palsy had visual-motor-integration problems and 2 with Optic Ataxia.



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Our Research findings

• Austrian assessment has to be improved

• Local interdisciplinary networks for assessment and support have to be built

• Improving teaching methods according to the findings that the “label” is not important and relates to IQ and developmental age according to the ICF

• Concept „CVI“ has lost it´s mystic touch



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M.Dik CVRS 2011 Visio Huizen

My discrepancy working model

1.Ophthalmologist/Optometrist diagnoses

b210 Seeing functions Sensory functions visual acuity functions; visual field functions; quality of vision; functions of sensing light and colour, visual acuity of distant and near vision, monocular and binocular vision;etc.

b215 Functions of structures adjoining the eye (movement aspect)

Team: Can acuitivity and participation problems be explained by developmental level and these data?

2. Yes: standard approach for sensory impairments

No:

Neuropsychologist chooses testmaterial taking into account all available diagnoses - also brainstruccture information (s110) from neurologist - to formulate hypotheses

b110 consciousness/b130 energy and drive functions

• b117 (verbal) Intellectual functions

• b122 Global psychosocial functions

• b7.. Movement related functions

• b144 non visual memory functions

• b140 non visual attentional functions

• B164 executive (higher cognitive) functions

• b1561 visual perception

• b1565 visuo-spatial perception

• B144 visual memory

• b140 visual attention

• … visual … integration

=

3. Find information about, measure and compare the following functions:

4. Team: Validate each visual problem: mild, moderate, severe, complete impairment

5. Team: Help is indicated by one complete/ severe, moderate and mild (taking other diagnoses into

account as well)

F. Premature born

in the 26. gestational week

1000 Gr. Hydrocephalus,

Cerebral hemorrhage

Visual acuity: 0,25

Refuses glasses +6

Age: 13



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F.s health condition

Disease / Disorder

Body function / structure

(Impairment)

Mental retardation

Optic Ataxia left sided

Language processing and

memory are weak.

Activities (Limitation)

Motoric restrictions.

Planning of complex

Activities (ADL)

Likes walking by

herself and playing

with smaller children.

Participation

(Restriction)

Needs very long time

to reply, restricted

self-initiative.

Very uncertain in new

situations

Environmental factors

Teachers and peers have

problems to wait for her

Activities.

Personal factors

One parent family

M. Premature born – twin in the 31. gestational week; 1.238 Gramm, PVL

Central Apnosesyndrom Cerebral Palsy

Hypermetropia levis

Near visual acuity : 0,03

Age: 16



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M. s Health condition

Disease / Disorder


(Impairment)

Nearly normal under

standing (verbal IQ)

Learning disabilities

(dyslexia, dyscalculia)

Problems in motor

functions and

visual-motor-integration.

Activities

(Limitation)

Very limited mobility in his

wheel chair.

Strength:

Listening to people and

retell stories

Participation

(Restriction)

School has not the right

computeradjustments

for his learning

possibilities


No fitting devices!

Misses fitting computer!

Personal factors

Very supportive family

S.


Hydrocephalus, subnormal vision

vision field loss, small vision field especially

in the lower part.

Intelligence level average

(K-ABC), behavior problems

Age: 8


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• S. s visual processing is on age level and relates to intelligence.

• S. s behaviour is influenced especially by his retardation in social-emotional areas. Therapy and play development support is needed in this area.

Jaritz & Schloffer ICEVI Europe 2013 – Turkey -

Istanbul


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S. s Health condition

Disease / Disorder


(Impairment)

Cognitive level average

Psycho-social below

Average.

Visual perception problems

(CVI)

Activities

(Limitation)

Impatient (out-bursting)

Needs quiet lay out and

sometimes enlargement.

Participation

(Restriction)

He is sometimes unable to

cope with the main stream

class because of behavior


Follows local psycho-

therapy with peers

Personal factors

Overprotection by his

parents

BALS, Irmgard: Zerebrale Sehstörung. Begleitung von Kindern mit zerebraler

Sehstörung in Kindergarten und Schule. Aus dem Niederländischen von Heinz

Graumann. Würzburg 2009.

DIK, Marjolein: Babys und Kleinkinder mit visuellem Funktionsverlust. Ratgeber für

Eltern von blinden und sehbeeinträchtigen Kleinkindern. Eemnes, Niederlanden 2006.

DUTTON, Gordon N. / BAX, Martin [Hrsg.]: Visual Impairment in Children Due to

Damage to the Brain. London 2010.

GOLDSTEIN, E. Bruce: Wahrnehmungspsychologie. Der Grundkurs. Deutsche

Ausgabe herausgegeben von Hans Irtel. Berlin. Heidelberg 7. Aufl. 2008.

GÜNTHER, Anja / JÄGER, Melanie: „Ich sehe den Wald vor lauter Bäumen nicht!“

Fördermöglichkeiten für den Alltag visuell wahrnehmungsgestörter Kinder. Dortmund

3., verbesserte Aufl. 2011.

GRUBER, Hildegard / HAMMER, Andrea: Ich sehe anders. Medizinische, psy-

chologische und pädagogische Grundlagen der Blindheit und Sehbehinderung bei

Kindern. Würzburg 2. erweiterte Aufl. 2002.

Literature

HYVÄRINEN, Lea / JACOB, Namita: WHAT and HOW Does This Child See?

Helsinki 2011.

KARNATH, Hans-Otto / THIER, Peter: Neuropsychologie. Tübingen. 2. Aufl.

2006.

MUNDHENK, Susanne: Die Schleswiger Seh-Kiste zur Beobachtung des funk-

tionalen Sehens von Kindern und Jugendlichen unter der Fragestellung von CVI

(Cerebral Visual Impairment). Eine Material- und Ideensammlung für den päda-

gogischen Alltag. Würzburg 2008.

VERBAND DER BLINDEN- UND SEHBEHINDERTENPÄDAGOGEN UND –

PÄDAGOGINNEN E.V. [Hrsg.]: Teilhabe gestalten. Kongressbericht. XXXIV.

Kongress vom 14. – 18. Juli 2008 in Hannover. Würzburg 2009.

ZIHL, Josef / MENDIUS, Katharina / SCHUETT, Susanne / PRIGLINGER,

Siegfried: Sehstörungen bei Kindern. Visuoperzeptive und visuokognitive Stö-

rungen bei Kindern mit CVI. Wien. New York. 2. Aufl. 2012.

VBS Conference 2016

in Graz



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