TSBVI Coffee Hour
CVI Scotland, Optimizing Support for Children with CVI, Part 2 CVI Clusters

>> while you are waiting set your chat from all panelists to "all panelists and attendees", that way everyone can see your questions and comments that you put in the chat box. Again, we're going to wait just a couple of minutes and while you're waiting, go ahead and set your chat from all panelists to "all panelists and attendees". We've got some folks here from Tennessee and from Arkansas, so far. Welcome. Oregon, Florida, New Mexico. Kansas, more Florida, Houston. Nova Scotia, Canada, Massachusetts, Pennsylvania, coming in so quick, more Canada, UK, Sarah glad you're here. Philadelphia. So glad you'll all here this morning. People from all over today. All right. Well, I'm going to go ahead and get us started with some announcements before I turn it over to our presenters today. If you have a question or a comment during the time that our presenters are speaking, please post that in the chat box. And make sure, again, that your chat is set to "all panelists and attendees". Your cameras and microphones are automatically muted so you don't need to worry about that. The handout for today's session will be shared in the chat for immediate viewing. And will also be available for later viewing, along with the recording of this and past Coffee Hour sessions shared there you a link on our Coffee Hour page, TSBVI.edu/Coffee Hour. Scroll down to under the list of sessions where it says visit the new TSBVI Coffee Hour archives. That's a link, it will take you to the recordings, handouts and chat information. To obtain your CEUs for today, you will respond to the evaluation emailed to you from our registration website, ESCworks. You will enter the code given at the end of today's session and the CEU certificate will automatically generate upon completion of that evaluation. There's no opening code, only a closing code and it will be given at the end of today's presentation. We will stop the presentation about 10:55 Central Time to give you your code and announcements. I'm happy to introduce today's presenters to you, professor Gordon Dutton and Helen St. Clair Tracy. 

>> Helen: All right. I'll start screen sharing. Okay. If people can't hear me, can someone just shout it out, please. Share. 

>> We can hear you fine. 

>> Helen: It's failing to -- just do this again. For some reason the screen share is not working now. It was working earlier, let me try again. Screen share. Have you got me now? 

>> Yep, we've got you now. 

>> Helen: The worst part is this bit here. My name is Helen St. Clair Tracy, I'm the parent founder of CVIs Scotland. Today's talk is optimizing support for children with CVI Part 2. I'm picking off where we left off last December, talking about half an hour, handing over to our advisor Gordon Dutton who will introduce himself. He's prepared to answer a number of questions that we've had in advance. First of all, a huge thank you for inviting us back, very nice to be asked back to Texas. Part 1 we looked at the individual CVIs from quite a long list, I focused on six, these six. We went through them in the session, explaining what they are, a bit about measurements and changes that can help children affected by them. We left Part 1 explaining that different CVIs have different approaches and looking at the same six, detail is not seeing clearly because of reduced visual acuity, increase contrast, whether it's a low visual field, use the part where the child has the best vision, where movement is not processed typically, from dyskinetopsia, slowing things down, agnostic vision, amongst other things, reduce the complexity and we are reaching for things accurately is impaired, called [indiscernible] taxia and keep things in the same place. It took me an age to learn the names of all of the different CVIs, I couldn't remember them, pronounce them, I couldn't begin to spell them. These six are important because they are commonly found in children, and many children are affected by several of them at the same time. They can, of course, be affected by others, but very quickly it can just become an overwhelming amount to learn. That's why I started with these six to begin with. And -- and some of the combinations of CVIs commonly found in children, we have used the term CVI cluster for them, that's just our name for them. As I wrote this talk, I got a bit stuck here. I need to explain multiple quite complex brain processes not working typically. Also processing inconsistently, creating a dynamic element, at the same time in the same child, allowing for the fact that every child is different. And it's something that has taken me the best part of five years to understand. I've got hall an hour today. So this is what I came up with, using simple icons, icons for each of the three of the visual impairments that I'm going to explain together. Here the reduced visual acuity, a magnifying glass with the letter A for acuity in the sensor, reduced contrast sensitivity we have a rainbow, this is not to show what contrast sensitivity looks like, but hopefully seeing the rainbow, it's easy to connect with the issues around how clearly shapes anding tones of color are seen. The dyskinetopsia, I have someone running, because it's about how we see things that are moving, especially when they are moving fast. Optic ataxia is a hand because it's about reaching for things. The gray area here is meant to represent the visual field area. The hole in the sensor is the window of vision. That's how simultanagnostic has been repeatedly described to us. Let me explain a bit about this in Part 1 with videos, I'm going to add to those explanations today. Finally, this is our visual field. I thought it easy to remember if it was an actual field. I have not added visual field impairments but I will as we go through. Here we have all of the icons, with the Cortical Visual Impairment, next to them a column with what is visually impaired because that is the bit that we need to know in relation to each child. Which areas of vision are not processing typically. So -- so the person running represents the visual impairment of how moving things are visually processed, meaning fast things are not seen so well. The reaching hand represents the visual impairment where reaching for things accurately is impaired. So on with the other CVIs. And so for explaining the clusters, hopefully the icons in simpler terms will make it easier when we put everything together. This is the first time that I have explained it like this. I'm really simplifying things. But the terms were all explained more clearly in Part 1. Before I start explaining some of the clusters, we need to remember that every child with CVI is different. Which CVIs are affected by -- it's just one part of what you need to know about them. They may have other conditions, different strengths, different likes, different abilities, based on multiple other factors, particularly their life's journey so far. So these are common combinations that we think will be helpful. Because if you see one of them you can check for evidence of the others. Ideally each child would have a comprehensive diagnostic assessment where the different CVIs affected the child's vision can be determined. Where do we get these clusters from? They have experts who have been diagnosis children with CVI for decades. There is research featuring these combinations when I'm presenting -- what I'm presenting is a simplified version today, but everything can be evidenced. This is the first culture, the bottom sliver is colored gray because it's a lower visual field impairment. It can vary from person-to-person, can mean a bit of a loss of clarity in the lowerrer most part of the visual field to no vision at all for the whole of the visual field this is a quick demonstration from Gordon here. [Captioned video]. So that bottom sliver is pretty important for walking. And not tripping. In clusters 1 the lower visual field impairment is typically mild. Just affecting the lower most sliver of vision. The tips of the chart [indiscernible] as they move forward in the very bottom of their visual field. So what issues might there be if vision was missing here or reduced? Well, they might trip over things low down, might not be so good at games like hockey or soccer and stepping on an escalator or going downstairs, especially if there's no rail it may be difficult for the child. If you complaint see where your feet -- if you can't see where your feet are going you might fall. A western a lower visual field impairment may have experienced falling downstairs and this can be a reason for their anxiety. So this is our oval icon showing the window of vision for simultanagnostic vision. How it's been described to us like a window of vision within the visual field. Meaning there is less to see. At its most severe level it's been described like seeing life looking through a drinking straw. With stress it can deteriorate to a state of functional blindness. So this CVI cluster is usually mild. So the window of vision is still pretty big. Not quite as big as typical, but probably be unaware their vision was different to anyone else's. This would almost certainly not be picked up in any sort of standardized test. Reduced visual attention due to simultanagnostic is not going to be a perfect oval. This diagram is illustrative. But this window of vision will depend on many things. If the brain is working typically, the whole of the visual field should be mapped. It's the case for all of us that we see most clearly in the center of our visual field and rereach for things accurately in the center of our visual field but the whole of the visual field is mapped. With this cluster, not all of the visual field is mapped. And this mapping process is important. The picture has been created but not all of the picture has been mapped. I think this is one of the most complicated areas of CVI to understand. We have dedicated level nine of our lessons just to explain this mapping process. In this image the area covered with gray represents the area that has not been mapped. Because there is a process visual attention follows on from the mapping process. If an area of the visual field is not mapped, there is nothing to add attention to. Visual attention is absent, you can't see. No map, no attention, then, of course, nothing to take to your library of memory to recognize. Compared to typical vision, though, it still seems like there's quite a lot to see. But from repeated accounts, vision attention is likely to be dynamic, somewhere open and clear. Vision may be almost typical. Somewhere busy or when the person is tired or stress the area of visual attention may reduce meaning that the same person can see better somewhere quiet, familiar, when they are seeing well and have reduced vision when they are tired or somewhere busy. So someone affected may seem less attentive when tired or somewhere busy. They may need breaks. This mapping process is going on all the time in all of us and it can be exhausting if it is not working typically. That's going to make staying focused in class for example difficult, so a child might find it hard to keep up and they might start to fall behind. Recognizing people puts a great demand on the brain. This can be tricky. Some with this type of vision as could be recognizing facial expressions which can lead to social difficulties. And the child may also have some mild recognition issues. They would be pretty difficult to separate from learning difficulties. As I was writing this I realized I iced the expression this type of vision. CVIs technically seen and measured as an impairment, a deviation from what is considered normal, less of something or low something. Maybe it's the parent in me, but I see [indiscernible] I marvel at the things my son can do. For me I think it's the clusters have really helped me understand CVI as a type of vision with a focus on what the child can do not what they can't do. But cluster 1 when they are reaching for things accurately, difficult to illustrate using pictures so I'm going to try to explain it. From our images, I'm just putting the hand on the field here and that's to show that the -- the reaching for accuracy issue is included in this cluster, I've only changed it white to make it clearer on the green grass. But this is our first cluster showing the lower visual field impairment, slightly reduced visual attention with the symbol of the hand showing inaccurate visual guidance of reach. The mild difficulties reaching for things accurately, this might make a person sometimes a bit clumsy, but what else? Think about putting your pen on a piece of paper to write. The pen held in your hand is visually guided through space to the point on the paper you are aiming for. That visual guidance is created in your mind. That is your visual map. As your mind has accurately mapped where everything is, your pen goes to the exact point that you want it to. What if it's a little bit off, not quite so accurately mapped. When you put your pen on the paper, it doesn't go quite where you expect it because where the paper is in the real world and where your mind has placed it is slightly different, even just a millimeter or two. What will your writing be like? Maybe a bit like this? Another thing requiring fine levels of accuracy may be difficult for a child, so they may seem a bit clumsy, they may struggle with handwriting and they may have difficulties with activity tees needing fine -- activities needing fine accuracy skills, for example needle work. Bringing everything together we have a mini profile of some of the challenges of a child with CVI cluster 1 might face. I know this is a lot to one side, but I have literally put the three slides together. This is a lot for one slide. What does this child need for support? The purpose of explaining the clusters in terms of individual CVIs is so that you can decide. What support is necessary. Because every child with CVI is different, including their home and school setup. For example you might have a child who doesn't like stairs and they have stairs between classes which are really busy and the children make a lot of noise, you could make a plan, they might go early, they might go late to teach them to stick to the right-hand side where there is a handrail and you need to work out what works for that child in their environment with the issues relative to them. Because the child with CVI is the most important resource on the child with CVI. You may have different test results, you may have different assessment results, brain scans, you may know different strategies and suggestions to deal with all sorts of different things that have worked with different children. This makes for a sort of CVI toolbox. A good toolkit is a great resource but only in the hands of someone who will put the child first. I have put a link to the CVI educator Amanda [indiscernible] about this. As far as CVI toolboxes go I think she may have one of the bers. She writes that it's so important for parents to trust what they have learned from their children and to communicate this to professionals. I have found that it is important to wipe the slate of my preconceptions utterly clean, although this is not easy to do. I have learned to watch as each child teaches me and others how he or she experiences the world. And each child is a universe. Each universe has its own rules, checks and balances. I love this quote. I use it a lot, each child has its own rules, checks and balances. Optimal support is targeted to the individual child. Here are just a few suggestions for support of what is an enormous list. But check for tiredness, plan breaks. Encourage friends and family to use words to express how they feel rather than rely on a fleeting facial expression. With handwriting, joined handwriting we have heard can be helpful for some. Also learning to touch type and paper with thick black lines. And encourage talking to learn from the child where life is difficult. Accounts parents, when a child finds something difficult, school work, not making friends, not being good at sports, so often they blame themselves, it must be me, something is missing, I am the problem. It's heart breaking when you hear this. Talk to children and open up conversations about their difficulties to find out the cause of them. And then you can look to what you can do to help. I talked about the CVI project in my last talk. How many children in mainstream schools have CVI. And they have now published their findings and across several mainstream primarily schools, that's age five to 11, the average age was 8, they said at least three [indiscernible] of the children had CVI related visual difficulties with my references I have included a link to the introduction to this paper or introduction explaining the figures and the issues they raise. One is that it is looking increasingly likely in addition to being the biggest cause of childhood visual impairments in developed countries, CVI might also be one of the biggest causes of learning difficulties in children. Of the children from CVI related difficulties, 80% were struggling in school in some level. I have included in my links another study in a mainstream school, it was small, but compared CVI and autism. CVI project finds CVI is more than three times more common than autism in mainstream schools. Next culture, culture 2, looks a lot like culture 1. We have the one addition here, the difficulty of seeing things that move clearly, particularly if they are moving fast. Everything else is CVI culture 1, a little bit more severe. The window of vision is smaller and the lower visual field impairment is slightly more severe and it might seem like there is still a lot of vision available to see there, but compared to typical vision, we can see that there is actually a considerable amount of visual loss across the visual field. These diagrams are just illustrative to explain the point. We have the other difficulty of how things that are moving are seen. So what might that be like for a child with CVI? We have stood on a train platform when a fast train is passing through, not stopping, you have to stand back behind a line. As it passes there's a sort of thud followed by the line of the clarity for the moving train. Imagine that, but it's not a fast approaching train, instead it's the same experience, but maybe from a car that's not actually driving that fast around the neighborhood or even a cyclist. Things everyone else can see clearly suddenly coming into view out of nowhere, but they can't be seen clearly then just as quickly disappearing. We can't know for sure what it's like. Certainly from my son's reactions to moving things, this is how I imagine it may be like. Thinking of our profile, what -- what difficulties might a child with this type of vision have, things maybe seeing inconsistently, sometimes seen clearly, sometimes not clearly, sometimes not at all. May be easily confused as things appear and disappear. Sometimes startled and frightened, dislike places with a lot of movement and feel safer in a car. The reason for cars -- also in wheelchairs we've heard, too, maybe preferred, there might be a learned understanding that they are protected, bit like in a protective shield and can switch off and relax rather than being frightened and startled. So let's look at the lower visual field impairment. It's a bit more severe. One of the added issues here is that things may be repeatedly tripped over and not learned. Same difficulty was sports, with the low ball, like, for example, soccer and hockey. Going downstairs and escalators, might not be just avoided but might be a cause of severe anxiety and stress. Several children that we know with this level of lower visual field impairment choose to watch television on the floor looking up towards the screen. If we imagine this is the full television screen seen with typical vision, with the visual impairment the child is positioned on-- if they are positioned with the center of the television eye level as with the image on the left, they may not be able to see the bottom half of the screen. They move their position down to maybe sit on the floor or kneel and look up, also moving down their lower visual field impairment and more of the television screen is available to be seen now. They have moved it into their visual field so the program will make more sense, be more enjoyable. And going down slide head first, why? Slides are fun, we all know that. But probably less scary if you can see where you are going. Which you can if you go head first with a lower visual field impairment. The thing about lower visual field impairments is that it is a very common CVI but also relatively easy to spot a measure if you know what you are looking for. If you think back to Gordon's demonstration where you can see the tip of your toe, not all children can follow an instruction to do this exercise. But fears like the slide, how they watch TV, regularly tripping over things or missing things, they are very good indicators. And the lower visual field impairment is quite consistent. Some of the CVIs are very dynamic. It's a very good indicator of specific other CVIs to look for. So looking at our window of vision for the CVI cluster 2, again, as we culture 1 the child may be less attentive with child or busy, but slightly more severe, yes still need breaks but might become quickly overwhelmed or stressed or confused. Struggles socially, possibly leading to behavioral challenges. It can severely affect all aspects of learning, they might lose things and have difficulty finding things and they may be a little bit obsessive about things not being moved. This list is starting to look a lot like autism. Looking at reaching for this cluster, again as cluster 1 but a little bit more marked, more severe. They may seem very clumsy, they may struggle with writing, copying, drawing. They may have difficulties with accuracy -- activities needing accuracy of motor skills, for example, catching a ball or tying laces. And they may line things up. Why line things up? If reaching for things is difficult, by placing toys in a line or in a remembered order they are easier to find and therefore easier to see and if they are easier to see, they are easier to reach for. And, therefore, easier to play with. Looming, it was first described to me by a mother who described her son in the supermarket. He loved holding on to her shopping trollly, but he was regularly brace himself that something was about to hit him, even though there was nothing that he could see. His brain had not mapped his surroundings accurately. In the same way he couldn't reach for things accurately he couldn't tell how far things were from him as he was approaching him. He was in a supermarket, busy place, he kept bracing himself thinking that something was going to hit him became. The bin in this picture, took a photo of it for me, it caused the person with CVI to scream. From the firsthand account, it suddenly appeared in front of me and terrified me. I screamed, jumped and almost ran away. When it comes to using a pen or pencil, it must be frustratingly difficult for many children with more marked optic ataxia, reaching difficulties, same thing I explained with handwriting but so much harder. One thing to consider is breaking every task down into learning just one new thing at a time. If your child is learning a letter, maybe the letter S, copy it with their finger, maybe in a tray of sand or a lovely beach if you are lucky enough to be near one. Let them build up familiarity with that letter. What it looks like, how it's formed. You are creating a memory. And as they recreate over and over the visual Emory becomes stronger and forms a haptic memory. Connecting what is seen, felt and known and then when the child tries to form the letter S, with a crayon or pencil, they already have that letter. What it looks like and the movements needed to make it in their mind and from there they can start the incredibly difficult challenge of trying to copy it on to a piece of paper with the crayon or pencil. I explained last time I know, but I cannot stress enough, especially where learning is difficult with CVI, one step at a time. Only one new thing at a time. Starting with what the child already knows and in a way that the child can learn, which may be difficult to how other children learn and at their pace. They are bringing everything together from culture 2, we have another profile. This is just the other -- all brought together in one place. This is very general and what you need to do is make it specific to the child with CVI. That you support. Oops sorry. From the unique profile, create a program of targeted support for that child. Which, of course, needs to be organic and evolve with the child. Because if you get it right, that child is going to learn and develop. So that program of support is going to need to be reviewed and updated as they progress. This is something a parent or career can do or a teacher, but the best in my view is where the family and professionals all work together. As might be expected as the CVIs become both more severe and more in number, learning and other areas of development will be more severely affected. This is not the case for all we know both very severe CVI and very able children, very child CVI and profoundly learning disabled children, but broadly speaking as the CVIs become more severe, there are greater support needs. And you may find children with communication difficulties in this group. Supporting a child with language is a particular challenge. I have a link about understanding the needs of non-verbal children with CVI and [indiscernible] sections at the end. So this is our second culture. This is what it looks like. Here we have the first and the second culture next to each other. First culture is as culture 2, but everything is more severe again with the added elements of reduced visual acuity and reduced contrast sensitivity. The lower visual field impairment is more severe maybe covering the whole of the bottom half of the visual field and the window of vision is even smaller. This is the culture that I went through in Part 1 explaining my son's CVIs and we edited this photo of me simultaneousing his multiple CVIs and ended up with the image on the right as his vision compared to typical vig. We started with clear images using the program [indiscernible] edited them to show increasingly severe levels of reduced combined visual acuity and contrast sensitivity. I'm not going to go through this culture again in detail today as I have already covered, but if you didn't manage to see Part 1 it is available online. Just look at what's happening from typical vision there is a combination of the lower visual field impairment becoming more severe and the window of vision reducing. Rather than thinking of very fixed clusters 1, 2, 3, maybe think of this as a CVI spectrum and one that is found very commonly in children. As a greater area of the brain is affected, everything is more severe. And more CVIs are added because the area of the brain where they are processed are affected. So with culture 1, most of the processing is on-- comes from the back of the parietal lobes, with cluster 2, that extends to a part of the temporal lobes. Cluster three it extends furtherer to the occipital lobes. I thank you for your time, I really hope it made sense. I'm going to pass you over to the man who taught me all of this. Thank you very much. Gordon Dutton. 

>> Gordon: Hello. Am I on now? I think I am. Thank you so much for being invited and inviting me to give this talk. I thought that I would tell you a little bit about myself first. My name is Gordon Dutton, I'm a pediatric ophthalmologist who got started working on this subject in the late 1980s when I set up a special clinic. In that clinic, I thought that I would look to see as many children with neurological disorders affecting vision. And the thing that I saw the most common was Cerebral Visual Impairment. My first paper, our first paper, a group of us wrote it, was in 1995, when we called it Cortical Visual Impairment until the term changed in Europe because the word cerebral felt that it embraced a larger part of the brain. And I would like to give you some personal perspectives on our medical approach to the education of affected children. But let me first think about you. In this strange time, we are -- I am in over 300 homes. What an amazing thing to happen. And as I'm in your home, I'm with you one to one. In order to teach you, ideally, I need to know what you know. How can I know that? I have already found out that the vast majority of you are trained teachers of visual impairment. So I'm trying to use a language matched to your knowledge. I've already found out that -- that you are the enthusiasts in the audience and therefore probably have a considerable amount of knowledge on the subject. So I've done a bit of homework to the best of my ability. So my job is to be personally with you trying to imagine your circumstances and your needs and that's a challenge. Anyway, Helen has given me a good start. I'm going to follow on from her outline where she's outlined the limitations to work with. What does everyone need to do? Well, the first thing to recognize is that I am normal. You, sitting in your rooms watching this, are normal. And so are all of the children that we look after. Because "Normal" is what we know to be ourselves. They may not be typical. In a sense I would like to redefine normal as being us, me, myself, you, yourself. As being normal. Because for those who have cerebral vimplet from a very young age, are little, have yet to learn about their vision, they know that their visual experience is normal. I always remember a little boy who I asked about his vision, he had very low vision, he had optic nerve hypoplasia. As I did the normal test that I did for everybody, the facial expression recognition distance, getting very close and then further away and then further away and then further away, with either a smile or a cross look or a sad look, I would then say, what am I doing now? And I would have said this is a smile. This is me looking cross, and this is my looking sad. And he said smile. Cross. Sad. And I went a bit further back and he said don't know. I said don't know, what do I look like? Two black holes in your head, of course, was the language that he used, of course, two black holes in your head, of course, because he knew that his vision was normal and I should know that as well. So that leads on to trying to imagine these circumstances, to imagine what Helen's outline means within the sight of the child. Imagine being the other. Because as a doctor, I would see hundreds and hundreds of children with low-vision of different types, I always felt it would be entirely appropriate to first of all identify their visual limits. What are their limits? And then to explain what these limits are. And then to explain how to always work within them. Just as I'm trying to work within your limits. I'm trying to communicate using language which I assume everyone in the audience knows rather than using my language and my limits within my specialty. Because if I do, I'm betraying you, I'm letting you down, I'm not letting you learn because I'm using myself as the reference for your normality. And, of course, that's not correct. I have my own subspecialty knowledge. I have my own experiences. And so if I use that as my frame of reference to teach you, then, of course, you can't learn. So what do we need to learn? We need to learn about -- about the three key elements, the three key elements being to learn information, whether it's a tree or whether it's a leaf or whether it's a chair or a word. Each element has a meaning. And if it's not there, it cannot be learned from. So we need to make it there, either by feeling it, touching it, making it bigger, put it in the right part of the visual field, making the field open up by being relaxed in an open landscape. Whatever it is. We need to understand what is and is not seen. So that that information can be conveyed. If we use words describing our experiences, then we are betraying that child, aren't we? We are saying to them I think that you should see as I do. So if they don't return the smile to you, you might say well they haven't got theory of mind, maybe they are autistic. But who may not have that theory of mind, is it -- is it the child? Or is it me? Is it me blaming them for not recognizing my face? For not recognizing my facial expression, for not realizing that they can't see my facial expression, for not realizing what I should be doing all of the time -- excuse me -- is to label their emotion. So when he feel sad, ah, John is sad. Sad. When he's happy, oh, John is happy. Then they to say daddy is happy, daddy is sad. Then teach through language as a way of learning. So -- excuse me. So there's two elements of understanding their normal and then always working within that normal is the thing that we must always be doing to the best of our ability. Let me move on then to the three questions that I've been asked. The first is: How is hearing affected? Cerebral visual impairment? Here I'm going to answer from my experience. I apologize, I seem to have a ticklely cough. I'm going to have one more cough. Sorry. My experience is that the way the hearing works with respect to higher levels of processing is very, very similar to that of cerebral visual impairment. For a child that has a difficulty in knowing where things are surrounding them because they have got this simultanagnostic vision, the vast majority of the parents say they don't seem to know where my voice is coming from. They cannot map my voice. And in that circumstance, I've met a number of children whose Cerebral Visual Impairment has been aided considerably by using a Roger focus hearing aid. A hearing aid? Yes. Because what happened was by using this directional hearing aid, they were able to cut out all of the surrounding sound and then direct the hearing and their teacher having their own microphone so that the child could actually learn from the teacher because that was the sound they heard in their ear phones and not the noise from anywhere else. And their vision was directed at the teacher so they knew where the sound was coming from and the peripheral sound was got rid of and that improved their vision. It probably decreased their simultanagnostic vision. These are personal experiences I'm sharing with you, not literature. The next is to think of sound in terms of timing. With a number of people, I learned that if I were to teach them about timing of sound, it made a difference. Let me explain. When -- when a child came into the clinic who had profound disability and I learned that they had no language, or no spoken language or didn't understand language, then the test I always did was to do this. I would talk to mom or dad, whoever was with the child in a normal kind of way, explain the time of day, say hello to the child but in a slow voice. Then I would gradually slow my voice down in such a way that I gradually went slower [Slowing down] and the point at which they turned and gave me attention, I then sped up again and they would lose attention. Then they would turn and give attention and then as I sped up, they would lose attention. And it was quite clear that there is a temporal element with respect to children who have got profound difficulties as well as Cerebral Visual Impairment that they have a temporal processing problem, too. So that if we prolong the words [Speaking slowly] making them separate, then they may well hear and start to learn. And if they have -- see only one thing at once as Helen was explaining, if we only put one word to that one thing over and again, because that is all that they are experiencing, then in many, many families I've helped, that has been the beginning of their learning the language and it's very exciting. Again, this is not in literature. This is personal experience. But I've had a number of really good feedbacks, in fact I even had one yesterday from a lady in the Czech republic whose 18 month old had not learned any language due to Cerebral Visual Impairment and auditory difficulties, she has written back a year later that this child understands almost all of her words and is speaking about 20, which is phenomenal. So exciting. So to understand that in Cerebral Visual Impairment, it's not vision to think about, it's modes, the mode of sound, the mode of sight. They are all linked together. They are all mapped together and they are all interpreted together to create that holistic understanding of what we appreciate. So having that approach is one in which, for those more profoundly affected children, in which we understand that their sound processing and their sight processing is going to be slow, recognizing that when a visual evoked potential is measured, the electrical signals from the brain -- produced in the brain from the eyes, they can be slow in arriving instead of being a 10th of a second, 100 milliseconds, instead of being a 10th of a second, they arrive at 120 milliseconds. It's slow. So clearly that brain is slow. So clearly when using YouTube, you need to go in and slow the video down for the child you are looking after to match their speed of processing. Even the sound slows down then. And you need to slow the voice. And if they are simultanagnostic, you need to give a singularity. So by making sure that we match to the child, we are ensuring that they are learning because we have rendered everything that we are doing accessible. Then, of course a language -- a language, of course, in terms of person. We have done timing, we have done place, where the sound is coming from, we now do person, think of language and sight in terms of what is already known. Using what they know to communicate normally. But what they do not know to introduce singly. And then once you have built each element up, it's so exciting, as language develops. And knowledge develops. And that's -- that development of language leads to development of vision because the three are the same. If you look at me and I reach to my side and I pick up something and I open it and I start to eat it, as you can see, I'm eating a banana, and I put it down, what happened to you? You could smell it. You could feel it. You could imagine it. You could even hold it. You could appreciate banananess. And if I had said banana at the same time, you would have got the language. So my use of that word banana is vision because it is stimulating the visual system. The whole lot is integrated, we need to stop breaking things down into the component senses because that's not how the brain works. We need to start building things up through the multiple senses and using those senses that work best to add to the knowledge acquired by that child so that they feel the banana, they hold the banana, they smell it. They have that tactile and haptic appreciation of the banana, they know where to put it and how to use it, eat it, appreciate it, and gain total banananess. 

>> Dr. Dutton, we just have about five minutes -- 

>> Gordon: My apologies. 

>> Sara: Just wanted to let you know. 

>> Gordon: My apologies. My watch was -- I thought that I was finishing on the hour, but I'm obviously wrong. So let's move on to the 17-year-old teenager with Cerebral Visual Impairment I've been asked about in Phase III, range nine to 10. I have to admit I had to go to the book to let it up to find out what it meant. Because I find it really difficult to use codes. I have never used codes. I can't even remember birthdays. For me I can't use codes easily. Anyway, I found that it is markedly limited vision in a 17-year-old. Where do we go from there? Well, in essence, the same kind of approaches. To identify what motivates. To identify and know what all of the skills and abilities are and so always work within them. To be thinking of time, place and person in the same way. Identify likes and dislikes. Like this with additional knowledge to match our behavior and approaches to match the needs of that individual to continue to build skills, knowledge, excitement and give happiness within that young man's normality. The third question relates to eye gaze technology. And how best to use it. And for this the user nee to be motivated and they need to understand. Of course, eye gaze technology can be used for many purposes, to switch switches and used for communication. But how can somebody learn. Again, this all relates back to Helen's tutorial. Which part of the visual field is the image that needs to be looked at going to be presented. How well do the eyes move from one place to another. Will they move to that element? Is it seeable? Has it been rendered visible? Does it match the measured capacity to see? Is it too cluttered, is it single? Do we need to use Cascades of three, because if you have three points or two points and you cascade in two, left or right, if it's left, means something, up can come the next thing, two more things, then two. Four times two to the power of four is of course 16 options within four moves. So when it comes to using screens, the key thing for using screens is to make sure that the targets are visible, accessible and can easily be motivational so that they get the result that the user wants as soon as possible so that they are motivated to move forward and then develop further. And you will find with that kind of approach, you've got an ongoing developmental approach matched to the needs of the individual. So, sorry. I've got one and a half minutes left. And I'll hand you over in case there is an additional question. There's so much to say and so little time to say it. Thank you. 

>> Kaycee: Thank you so much. Let's see. We've got like one to two minutes. Sarah and Lynne, do you have a question from the chat that you would like for him to answer really quickly? I see lots of requests for Part 3 coming in, in the chat right now. 

>> Lynne: There was a question about diagnosis CVI clusters. Someone wondered would that be done by a neurologist? 

>> Gordon: No, it's not a diagnosis. A diagnosis of Cerebral Visual Impairment has been made. No, everybody in this audience can identify these clusters, every single one of us. As soon as we start to understand what Helen is putting across, what we are trying to do is to say that's not diagnosis, this is not medical, this is habilitational. This is outside medicine. Once a doctor has made the diagnosis, it's up to us to identify all of these elements. It's up to us to understand them, to identify them and utilize them to the best of our ability. 

>> Bennett: Phenomenal, thank you guys, so, so much. So much wonderful feedback coming in the chat. Before I give the code and the rest of the announcements, I want to encourage all of you that are putting in your ideas for future sessions to please put those in your evaluations, we look at those as we plan for future sessions and we want to know what you guys think. Thank you so, so much, professor Dutton and Helen for coming today. Everybody is raving about the presentation in the chat right now. I'm going to move over really quickly and give the code in case somebody needs to jump to their next meeting. On Thursday, that's April 29th, we have a collaboration with -- for a two-hour session titled through native eyes, serving Native American families in tribal communities. With Kathi [indiscernible] and Gregory and Wendy Proust. On May third early numeracy with Debra, Renee and Kathi Garza and May 6th we have exploring chrome box on your Chromebooks with Cecilia Robinson and [indiscernible] check for the upcoming registration information. To obtain your CEUs for today, you will respond to the evaluation that will be emailed to you from our registration website, esc works, you will enter the code and the CEU certificate will automatically generate upon completion of that evaluation. Also the handouts and recordings from this and past sessions are available through our link on our Coffee Hour page, TSBVI.edu/coffeehour. You will scroll down to under the list of sessions where it says visit the new TSBVI outreach Coffee Hour archives. That's a link and it will take you to the recordings, handouts, transcripts and chat information. On the evaluation that you receive from ESCworks two boxes that say additional comments that you would like to share with the presenters and additional comments that you would like to share with the event planning committee. Please let us know if the dates and times of Coffee Hour that are being offered typically are working for your schedule, or if you have other suggestions, particularly thinking about next school year. Also we would love to hear your ideas for topics on future Coffee Hours and all of those things that you put in the chat would be super wonderful. We do read all of these and use them for planning.