Cerebral visual impairment (CVI) is a complex condition, affecting the way children use their vision. For children with CVI, it can be difficult to function in a classroom or school environment, due to their unique perception of their visual surroundings. 

For example, a child with dorsal stream dysfunction may not find their way around in the classroom or school, especially if it is busy and cluttered, as this impairs their ability to map their surroundings. If items are moved within the classroom, this can be disorientating and exhausting for a child, as they need all their energy to deal with this challenge. As a result, their behaviour may change. 

Some children take longer to process visual and/or auditive information and cannot keep up with the pace of learning, compared to their peers. Other children may have difficulties knowing who their friends are and where to find them during play-time, leading to social embarrassment and isolation. For children with CVI, a typical school day can include many challenges in terms of accessing learning material, navigating independently and forming social relationships.

This article discusses the role of vision in learning and perspectives from teachers and families concerning vision and learning as well as the impact of vision on functioning in the school environment. When completing the survey in the next step, please screenshot your answers before submitting in case of any technical issues.

The role of vision in learning

Vision and motivation play an important role in learning and development.1,2 If vision cannot be used effectively, as can be the case in children with CVI, one needs to find alternative ways to access learning material. Oakland et al3 found that children with a visual impairment more often preferred a practical learning style, rather than an imaginative style compared to their sighted peers. They were also more likely to use thinking, rather than feeling to learn new concepts. Preferred learning styles vary between children, and therefore teachers offer different strategies to their pupils to promote inclusion. 

For children with a visual impairment, or CVI, specific barriers for learning need to be overcome and educational materials need to be adapted to suit the needs of these children. Learning strategies need to be specific as CVI is an umbrella term and each child has a unique combination of visual dysfunctions and behaviours, which affect their learning. These include bumping into things, difficulties staying on task or switching between the board and the iPad or workbook and difficulties finding things in a cluttered scene.4

Children may also find it more difficult to see small details or low contrasting items, or they may not see the board or teacher from where they are sitting in the classroom. Children with reading difficulties need to be assessed for potential dorsal stream dysfunction, as it has been shown that the dorsal stream network plays an important role in reading.5-9

The specific visual dysfunctions for individual children need to be understood to allow teachers of these children to modify their teaching approach in order to enhance their development and learning, matching the strategies to the child’s limitations and abilities.10

Parents’ perspective

Discussion forums and CVI websites provide valuable insight into patient and parent experiences of CVI, how it was diagnosed, how it was managed and what strategies worked well. Themes that emerge from these sources are that many parents waited a long time for a diagnosis and often feel that their problem is poorly understood by medical and educational professionals. 

Once a diagnosis is made and parents learn more about their child’s condition through self-education or support from professionals, they feel empowered to change the environment for their children and to offer strategies to improve their learning, development and well-being.11-16

In a study by Jackel et al,17 more than half of the parents of children with CVI stated that they were given no information about CVI at the time of diagnosis and access to services was very patchy. Early trends from a follow-up study show that information sharing at the point of diagnosis remains insufficient nearly a decade later.18 

McDowell19 highlights the importance of giving parents information about CVI early on as this empowers them to become better advocates for their children, to develop more positive relationships with healthcare and educational professionals and to ensure appropriate support for their children. A number of studies showed the importance of a good relationship between healthcare professionals and parents of children with disabilities and/or other health issues, whereby healthcare professionals share information, show an interest in the child, collaborate with the family and communicate well.20, 21 

Goodenough et al22 sought views from affected families through semi-structured interviews, which included similar themes. In this study, parents of children with CVI shared their experiences of effective strategies. For example, one parent shared that the introduction of a quiet space, a tent over the bed and tactile toys had made a significant difference in the child’s ability to engage. Parents also reported that de-cluttering in the home and school environment helped their child’s learning. Giving children time-outs, carefully positioning them in the classroom and creating a quiet work space were all strategies that parents recommended. 

Some children reported that they found it easier to learn through audio-books, rather than having to learn by sight. Strategies that work well for one child may not work for another child, due to the heterogeneity of this condition, and therefore approaches need to be tailored to individual children’s needs, in the home and in the school environment. Goodenough22 highlighted the importance of educating teachers and learning assistants about CVI, in order for them to offer appropriate learning strategies.

Apart from the direct effect of CVI on learning, it can also have an effect on social interactions. When a child feels isolated or anxious in social situations, this can inadvertently affect their function in a school environment.23 A good example of this is when children have impaired recognition of faces or facial expressions. 

Dalrymple et al24 interviewed parents of children with developmental prosopagnosia and realised that, while the children were aware of their face recognition impairment, the parents were largely unaware and wished they had known about it earlier, so they could understand their child’s difficulties and offer support. Children often felt isolated and struggled in social interactions. Some children developed helpful compensation strategies for recognition, while others avoided social situations. 

In recent years, it appears that schools are more proactive in supporting children with neuro-diversity. For example, the University of Edinburgh25 offers training courses and resources for schools and parents to help children with their educational, as well as their social development. Labels, such as ASD, ADHD, dyslexia and dyspraxia are often used as examples in these resources, while CVI does not tend to be specifically included.

Teachers’ perspective

In a study by Black et al,26 children in special education settings received an ocular and visual function assessment to identify unmet visual needs. They also used questionnaires to assess the difference in behaviour and performance once the visual needs were addressed. While the greatest ‘significant visual deficit’ was refractive error, they identified CVI in 23% (n=43) of children. The majority of children with CVI (98%, n=42) had ‘unmet visual needs’. 

After intervention, this number reduced to 12 children (6%). The interventions for visual processing dysfunction were based on recommendations from Dutton et al (Philip and Dutton 2014; McKillop and Dutton 2008).4, 27 

They demonstrated a teacher-perceived improvement in classroom performance when visual needs were addressed. Teachers appreciated the ‘Vision Report’, in which the visual needs of children were described along with suitable interventions as this allowed them to implement targeted interventions and effective strategies for these pupils. 

Pease et al28 interviewed teaching staff working with children with additional support needs at a primary school to gauge how teachers and school staff appreciated input from health care professionals. Their study revealed that school staff were keen to expand their knowledge about conditions through external training and to receive specific advice about strategies for the children in the school, including the rationale behind the strategies. They preferred a report with individual strategies for each child, rather than a generic list of potential interventions. 

Team working was seen as an essential element to facilitate putting advice about strategies into action and continual feedback helped to adapt the strategies when needed. Davies29 stressed the importance of information sharing from qualified teachers for the visually impaired (QTVIs) and other professionals with teaching staff within the child’s school. In his study in Wales, eye care within special schools was patchy and training for school staff in special education about how to support pupils with sight loss was desirable. 

McDowell and Budd30 looked at the effect of decluttering a classroom on visual problems and behavioural difficulties in children in a special school. Any glass panels and open shelving were covered with plain sheets or paper. Unnecessary furniture and other items were removed and information from walls or windows, or hanging from ceilings was removed. ‘Black hubs’ (panels covered in black paper) were introduced as a clutter-free space and the teachers reported improved focus and concentration in these ‘black hubs’. 

The teachers also noticed that the decluttered classrooms resulted in less sensory overload and frustration. However, children were still distracted from noise and movement, and therefore, further improvement in concentration and behaviour can be expected if these distractions are also removed.

In summary, teachers and parents observed that the impact of CVI on education, cognitive and social development is significant. However, it is possible for children to minimise the negative effects of CVI and to reach their full (learning) potential when they receive appropriate support.

Although optometrists are not expected to diagnose and manage CVI, they can still play an important role within the interdisciplinary team by providing the children and their carers and other relevant parties with information from the sight test and visual assessment. 

A report could include information about refractive error and visual acuity (near and distance) with an explanation about when glasses need to be worn and what a child is expected to be able to see. Binocular vision issues and ocular motility and the effect on the child’s functional vision can be explained. If a child would benefit from enlarged print or specific classroom positions, advice can be included. 

The next article explores approaches in terms of supporting these children in more detail. 

  • Cirta Tooth is a specialist low vision optometrist, working in both private practice and the hospital eye service.

References

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