The Bridge School’s CVI Integrated Program
Introduction
By Sarah Blackstone, Board Member of The Bridge School
The Bridge School is excited to announce the AAC-CVI Framework, adapted from work at Penn State University described in “An Evidence-Based Approach to Augmentative and Alternative Communication Design for Individuals with Cortical Visual Impairment” by Wilkinson et al. (2023).
The Bridge Schools AAC-CVI Framework incorporates the staff’s 13 years of experience working with children who have cortical/cerebral visual impairment (CVI), extensive physical and speech disabilities, and use augmentative and alternative communication (AAC). It also reflects the personal experiences and insights gained from our colleagues at CATIC in Mexico who work with a more diverse population.
Working with children with CVI who use AAC
An adapted version of the AAC-CVI Framework
Background
By Gabriela Berlanga, The Bridge School, Executive Director
After many years of working with children with Cortical/Cerebral Visual Impairment (CVI) who use Augmentative and Alternative Communication (AAC) under the guidance of Dr. Christine Roman-Lantzy regarding CVI, we realized the unimagined possibilities for these students.
Inspired by these insights, we began sharing our findings, focusing on the new information related to CVI that we discovered. Our belief was that all professionals in the field of AAC would greatly benefit from this information.
Through collaboration with interprofessional teams, including those led by Teachers of the Visually Impaired (TVIs), we recognized the importance of sharing the full comprehensive approach we were using, as for example, TVIs who knew about CVI were more interested in learning how we were taking into account our student´s expressive and receptive language and merging that information with the rest of the areas for decision making.
Another factor that pushed us to share this comprehensive approach, was that while supporting teams beyond The Bridge School’s educational program, we noticed the negative impact of professionals working in silos. We witnessed how focusing solely on a child’s language needs without considering their functional vision, seating and positioning, or sensory needs can be detrimental. Conversely, decisions based only on functional vision, disregarding language skills and needs, are equally problematic.
As we were putting together webinars, conference presentations and research publications that highlighted the importance of interprofessional collaboration, one of our board members participated in a single-case study that proposed the AAC-CVI framework we are referencing here.
We believe this framework, offers a comprehensive and systematic way of considering all areas as part of assessment and intervention. And while we wait for the second part of the study, in which more cases will be considered, we are pleased to share our adapted version of the AAC-CVI framework, which incorporates 13 years of experience integrating CVI information at The Bridge School. This framework also reflects personal experiences and insights from 11 years of working with a more heterogeneous population at CATIC in Mexico.
We hope this adapted version will be useful for you. We will continue to update this page as new information from the ongoing research at Penn State University becomes available.
AAC-CVI Framework
*Blue text indicates adaptations to the original.
Domain: Skills brought by the Individual
| Characteristics | Diagnostic questions to consider | Assessment information needed | Possible considerations for intervention |
|---|---|---|---|
| Physical and emotional wellbeing | What is impacting the individual’s ability to engage/interact/use vision at time of assessment/intervention? | Medical status, medications, Attention levels & variations in alertness Preferences and interests Sensory needs | Incorporating sensory preferences and regulation Alternate input methods |
| Language comprehension and expression | Experience using symbols for language representation, where in the continuum is the person? Can communication needs be met by a visually accessible AAC tool, if not, can visually accessible communication tools be created as supplementary options? | AAC and Language Assessment Tools (E.g.: McArthur, C-BiLLT, Forms and Functions, Communication Matrix, AAC Profile, etc.) | Selection of Representation Mode(s) that considers language, cognitive and visual needs. Identify supports needed to transition to abstract representation modes. |
| Auditory function | What auditory/partner-assisted strategies are currently in use, and how might exploration of voice output from aided AAC or partners assist with learning of the AAC layout? | Auditory/hearing function, receptive language, use of scanning, use of exploration activities of voice output | Direct selection with support of auditory cues, PAAS, PAVAS Determine when auditory supports are needed (always, only for complex environments or fatigue?) |
| Level of functional vision | What functional vision does the individual have and how was it assessed? When was it assessed? What co-occurring ocular motor conditions exist? Based on results, is vision a possibility of primary input mode for AAC tools? Supplementary tools? Teaching materials? What idiosyncratic skills, if any, have the individuals developed to aid them in visual engagement (e.g., rocking, pushing away, resetting the screen, leaning towards AAC)? | CVI Range Score (based on interview with parents, observation and direct assessment), ophthalmologist report, parent input, teacher of the visually impaired input, 2D image assessment, learning media assessment, complexity of AAC layout assessment | Characteristics of visually accessible symbols (3D and/or 2D). Learning Media used for AAC tools (primary, supplementary, etc.). Consider information regarding tactile information Learning Media used for teaching materials. |
| Fine and gross motor, Visuomotor integration | How well does the individual use their vision to guide their reach? | GMFCS Seating and Positioning Visual field deficits, fine/gross motor abilities, observation of sequential vs. simultaneous visually guided reach | Accommodations for seating and positioning Access method: direct selection vs. eye-gaze, use of keyguards or touch-guides, consistent location of high-frequency vocabulary. |
Domain: Responsibilities of the Communication Partner
| Partner’s response to individual CVI characteristics | Diagnostic questions to consider | Assessment information needed | Possible considerations |
|---|---|---|---|
| Manage linguistic complexity | |||
| Manage environmental complexity | What is the impact of multisensory environmental factors on visual function (e.g. overhead lights, decorated walls, ceiling fans, teacher clothing, sound/noise level, and movement of people/things in the visual field? | Engineer the environment to promote visual engagement, participation, independence: Manage distractions created by IAs or teachers moving, talking, and assisting. Alternate layouts or access methods for busy environments that are part of the child’s life (e.g. recess time, grocery shopping, etc.) “Make communication possible in all environments” | |
| Consider placement in visual field | How does the location in which the stimulus appears in the visual field influence visual engagement? What are the student’s preferences? | ……stimuli are presented in different visual fields, including left/right, upper/lower quadrants, and periphery | Present stimuli on easier fields when other goals are present, time is limited, etc. Present stimuli on harder fields when time is available and other supports are in place (use of color, light, etc.) Decide location of communication partner depending on their role (e.g. a partner within an interaction on an easier side, if only supporting, locate where they would be least distracting). |
| Consider distance from individual | What is the optimal distance of the stimulus from the individual to maximize visual engagement (inclusive of any coexisting ocular needs such as nearsightedness). | … the distance of presentation of the individual is varied | Present stimulus at optimal distance. Use camera’s on tablet, video recording for stimulus presented at a distance. |
| Use movement to present stimuli | What is the effect of adding movement cues during stimulus presentation on visual engagement? | … the stimulus tracks from one side to the other of the side (left to right, right to left), or the stimulus grows/recedes in size upon presentation. … the stimulus is enhanced with shiny materials (processed in the brain as movement). | Use movement (actual movement or shiny materials) to attract and engage visual attention) |
| Provide wait time to assist with visual latency | How long should the partner quietly wait after presenting a stimulus to support the individual engagement? | … presenting stimuli of different complexity, contrast, lighting, etc. given the different design considerations in the rest of the table. | |
| Provide visual breaks to accommodate visual fatigue | Sensory balanced schedule | ||
| Consider individual’s preferences – do not presume competence-potential benefit |
Domain: Features of the AAC system
| Characteristics | Diagnostic questions to consider | Assessment information needed | Possible considerations |
|---|---|---|---|
| Design feature in response to individual CVI Characteristic | Aided AAC consideration (all ages/language level/ CVI Range phases) | Measure latency and duration of visual engagement when | |
| Representation Modalities | What is the student’s primary learning modality? Secondary? | All assessments previously mentioned. | Based on language needs, language comprehension, auditory processing and CVI characteristics, decide on representation modalities of AAC tools. (Be mindful that visual access can increase over time) Auditory only Tactile only Visual + auditory and/or tactile Visual |
| For tools using visual modalities: | |||
| Internal symbol complexity | What level of complexity within the symbol can the individual engage with / recognize? | ..simple vs complex stimuli are presented. Consider colors and patterns within the symbol and varying representations (object, photograph, realistic illustrations, abstract illustrations, etc..) Assess symbol complexity (2D Image Assessment) | Consider that selecting text as a representation mode involves the consideration of a whole set of aspects. |
| Number of symbols presented on the array | How is visual engagement/accuracy affected for large arrays vs small ones (one or two symbols)? | ..symbols are presented one by one, in pairs, larger arrays. Assess: complexity of array | Alternate layouts or access methods for complex environments, visual fatigue or when needed |
| Familiarity of symbols | What is the impact of familiar vs. novel symbols on visual engagement? | …stimuli of familiar vs. unfamiliar partners, settings, objects are presented. | Provide longer wait time with novel symbols, pages. Symbol pre-teaching |
| Symbol background and foreground | How do characteristics of the symbol impact visual engagement? | …symbols with complex background, background removed, black background, symbols that are overlapping, | Remove symbol background or use simpler background when appropriate. Alternate presentations of symbols that have overlapping components. |
| Color | What impact do color cues have for promoting visual processing? | … | |
Adapted by The Bridge School from: Wilkinson, K. et al., 2023. “An Evidence-Based Approach to Augmentative and Alternative Communication Design for Individuals with Cortical Visual Impairment. AJSLP
