TETN 32954 - Functional Vision Assessment for VI Infants This video is posted online with the following chapter markers: Chapter 1. Intro & New Web Page - Introduction of TETN presenter Ann Rash, VI Infant Consultant for the Texas School for the Blind and Visually Impaired Outreach Program. Chapter 2. Functional Vision Checklist - Overview of Functional Vision Checklist Chapter 3. Vision in Infants - Overview of normal development of vision in infants. Chapter 4. FVA Kit - Lois Harrell, Pediatric Vision Specialist describes the function of various items in her Functional Vision Assessment Kit. Chapter 5. Parent Interaction - Lois Harrell, Pediatric Vision Specialist demonstrates positive interaction with a parent who may be anxious about their child's visual disability. Chapter 6. Functional Vision Assessment - Clips from two different Functional Vision Assessments conducted by Lois Harrell, Pediatric Vision Specialist. Chapter 7. Comparison of FVAs - Lois Harrell, Pediatric Vision Specialist discusses the difference between two different Functional Vision Assessments. Chapter 8. Final Comments - Questions from participants and final comments. TETN 32954 - Functional Vision Assessment for VI Infants Transcript Narrator: Texas School for the Blind and Visually Impaired Outreach Programs present TETN #32954 Functional Vision Assessment for VI Infants. October 21, 2014. Presented by Ann Rash, TVI for the Outreach Programs. Chapter 1. Intro & New Web Page Kate: Good Afternoon. Welcome to our second TETN broadcast of the year. I'm Kate Hurst, and I'm so pleased to welcome you and welcome our presenter today, Ann Rash. I want to show you guys something that is hot off of the presses, that Miss Ann created, [ Slide start: ] and this is a new page on our Outreach website. On the TSBVI website, and this is going to change soon, but you can still get to it this way, even when we make our new changes, if you go in to the Outreach tab, and you'll come to the Outreach homepage. [ Slide end: ] [ Slide start: ] If you go into the VI Outreach Program, from the Outreach homepage, you're going to see information about the infant and preschool services, [ Slide end: ] [ Slide start: ] and when you click on that tab, you're going to go to Ann's new page, that she's designed, and one of the things she has put together, and it's still somewhat in construction, but it's already got a lot of great resources on it, is the infant page. And it's actually the infant, toddlers and preschool's page. [ Slide end: ] [ Slide start: ] And the reason I am showing you this, in addition to a lot of articles and forms and information that you can find on that page, links to other great resources, the videos that we're going to see today, along with several others that you may not see ‑‑ will we see everything in its entirety today? Ann: Yes. Kate: We'll see it all today, but you'll want these to be able to go back and use as a resource in your training or working with others, mentoring. And it's also where the checklist is. You can go to this site and view the videos and get to the checklist right here. It is under Assessment on that infant page. So just wanted to make sure you knew where this was, and encourage to you checkout this page on our website. If you have ideas or suggestions for other information Ann should put up there, just let her know and we'll get it added up to the website very soon. [ Slide end: ] Chapter 2. Functional Vision Checklist We're so glad to have Ann today to share this wonderful presentation with you. I have already gotten a little preview and you are in for a delight. I will get out of the picture and turn it over to Ann. Thank you, Ann Ann: Thank you. I am excited that there are quite a few attending today. I am the Outreach VI Early Childhood, I took that position, I guess this is my third year. Stacy Shafer, I took her position, and one of the things that we are finding in Outreach is that people really want resources that they can check quickly or that they could get some kind of training. And another thing that happened, Region 13 here in Austin had a resource that they gave out to teachers every year. It was called the VI Infant Notebook. And as most of you who have tried to keep resources updated, that is quite a job. And because our, you know, education is changing every day. So I told them we would put that on our website. So you will see as you're looking on the infant page that some of those will say coming from Region 13. One of the things that was in their notebook, and those of you who have been doing Functional Visions for many years, probably recognized the Functional Vision Checklist, that it's part of your handout, and it's called the Functional Vision Evaluation Checklist for Preverbal and Nonverbal Children. And so this was in a book called First Look, some of you may still have that. But that book is out-of-date, out of publication, and so we started looking for getting permission to use that -- this checklist on our website. So when you're doing things for websites, you have to really be rigorous about getting permission. And so that was my first lesson in getting things on a website. And what happened is, Lois Harrell, who has been ‑‑ you will hear her say, she has been a teacher over 40 years, actually was attributed to that. So I started talking with her, and she was just so delightful. After we had several conversations, I said, "would you be willing to come and let us video you using this instrument with some of our babies," and she agreed. So that's how the whole video came to be. Chapter 3. Vision in Infants But for today, one of the things that when we think about infants, we really need infants, toddlers, we need to really think about, what is the developmental process of vision? Because we know that we don't come out of the womb seeing 20/20. So I wanted to start the handout with just sort of going back over that. And this is also important to remember that -- that sometimes when our kids have neurological disorders or maybe were born prematurely, that that will change because it's not always chronological. But what I have given you under What Does Baby See is the typical development. I attended a workshop this summer with pediatric ophthalmologists, and the phrase that kept coming up, that they use in their practice and in their workshops, is "vision drives development." And so I think that we need to keep that in mind, and that's why we do Functional Visions is to really sort of look at that. So let's think about it. Just from birth to three months, there is quite a change. And remember also that with babies, that focal point, or that distance, that you use in presenting materials to a baby is eight to ten inches. Think about when you're holding a child and feeding them, think about that distance from their face to your face. So when a baby -- a baby is in this world, they are really -- it is all about just within mom's arm reach, almost. And that tracking does not begin until three months. And then five to eight months is when you start seeing the baby's eyes working together, and even when they are able to see things in three-dimension. They don't have good color vision until around five months and then their better eye‑hand‑body starts working once they start scooting, crawling, moving. So think about those kids, because I don't know about you, but I am getting calls on babies -- I, in fact, just got one from a mom whose baby was three months and she said he's not tracking and he's supposed to be tracking at three months. So we're getting some referrals earlier and earlier and then we have the opposite problem that we are not getting them until they start school. So think about for that first year of life, they go from a focal distance of just within the arm's reach to being able to see perhaps a target and able to start throwing that. That's when that distance vision is starting to come in. [ Slide start: ] So from two to three years, you start seeing more eye-hand coordination, more interest in the environment, passed just their bodies and starting to notice what is going on in their environment, and where you will see that they start pointing at things they want and also scribbling. So I wanted to mention, before we go to the next section, which is What is Distance Vision for a Baby, [ Slide end: ] and the reason I put this in, is you know that it's part of a Functional Vision Evaluation, we are -- we are going to be testing in different environments, and we need to be able to address their near and distance vision and task. So, also at the end of our slide presentation, we do have the link to the bridge and this is where you would want to go to look at that, is the Region 18 legal framework, that, excuse me, lists out exactly what needs to be a part of that Functional. In the assessment videos, we do have a very few examples of distance. [ Slide start: ] So let's look at what is distance vision for a baby, and we sort of went over it in What a Typical Baby Sees. But he uses that distance vision by beginning to look for familiar people in his environment; mom, dad, you know, even the puppy dog that runs in and out. Or the things that he gets interested in. And he begins moving. When he starts moving in his environment, he has to use his distance vision, because he's looking for those things that he wants and then moves toward those. So what, as you're looking at this typical development, what you notice is, is that vision, movement, integration is very crucial to our infants and toddlers and preschoolers. [ Slide end: ] And that really is crucial to their development because that's what is motivating them. The -- so I want to tell you a little bit about the babies in the video. [ Slide start: ] We had a young ‑‑ one of the ways we got the babies, we asked in Region 13, because that's traveling distance for us, and our camera people, [ Slide end: ] for someone who would be interested in Lois Harrell doing a Functional Vision on their baby, and whose parents would sign the release for these videos to be up on our website. And we had several, and you know what, with babies, they get colds, other people in the family, different things happen. But we felt very fortunate flying in Lois and that we actually had two kids on that day. So that was something to celebrate. So the first little girl was born prematurely. She has a twin that you are going to see in the videos as well. The vision teacher felt that she probably had Cortical Visual Impairment based on her medical record, but the diagnosis on our report was Delayed Visual Maturation. And the baby boy, that's sort of how Lois talks about them, [ Slide start: ] has a diagnosis of ONH. Both of the students -- the vision teachers had questions and so think about these as you are watching the videos. [ Slide end: ] The little boy, the doctor pretty much did not feel like he had any vision, not even light perception. But the vision teacher was seeing some responses. So look and watch the video and sort of see what you think. The other thing I wanted to share with you is, we spent about -- so we have four hours total with these children. And so we just are catching a snapshot of the -- and all the videos were about 20 minutes. When we got to the homes, each one of them, the babies were very fussy and did not want to cooperate. But, one, I think Lois is a baby charmer. I think the parents were very motivated for this to work and so we just took little breaks and started all over. So think about that when you have gone into a home and the baby is so fussy, just try some intermittent things that you can work with. So looking at -- I hope you will pull out your checklist, [ Slide start: ] because we have four different videos, as you see on the slide and we are going to -- I want you to have the checklist to go over. This is also downloadable from that infant website. You should be able to put on it your iPads or whatever and then type in right as you are there. That's what we hope. I tried it and it worked. So Kate did that for us and I think that will be very helpful. [ Slide end: ] So the very first video that we're going to do, when I picked up Lois at the airport and I had told her, bring your Function Kit with you and she brought a little cardboard box that was about eight by eleven and two inches thick. And I said, "That is your Functional?" Because I thought about the suitcases I used to take out to do a Functional Vision Evaluation. But this first one is, we're going to go through and look and she is going to talk about the different things that she has in a functional kit. You will notice as she goes through the kit that there are some very -- there are some high skills that you are not going see the kids doing in these videos. But of course, we are going to -- you are going to be testing kids who have different -- different skills. So she just, you know, it's a very nice video that I think any of you at the service center who wanted to do training, or if you wanted as a vision teacher to show the mom, these are some things that I am going to be using, and this is what we are looking for, so that moms kind of understand what you are doing beforehand. And this is the longest ‑‑ this is the longest video. Chapter 4. FVA Kit [ Video start: ] [ music ] Lois Harrell: Hi, I'm Lois Harrell. I'm a Pediatric Vision Specialist. I started out about 40 years ago as a counselor with Blind Babies Foundation, and worked with them for several years; and then moved to University of California Davis, Department of Ophthalmology, Project Director of Children's Vision Center. When I retired from that job, I realized that nobody was doing it, so I remain a free agent and see about 30 families a month in about 5 counties in California. Many years ago I developed the Functional Vision Assessment Kit primarily because it was becoming recognized that early diagnosis and early intervention with children with vision problems can make a difference. But functional use of vision is more than following a light from a babies perspective; as in, 'I've looked at that light, now what do you want me to do with it? You won't let me have it!' So, I decided to make a kit that was interesting, that would capture many of the qualities that we're looking for. So the first item is the Pen Light. One is for looking at the eyes to see if there are any differences or to see if the pupils are different, to see if the pupils respond. It can then be used -- to have some interesting little objects put on it -- help the child to activate his visual curiosity as he does track. Just a variety interesting little objects. Because, again, we're talking about children. This bounces! And we things that they may not have seen before. So that they can be curious about it. If we use their familiar rattles, if use their things, like spoons and things they've had in the house... It's like, 'Ahh, I already know what that is! Why should I look.' They can just be brought up -- brought to the side and... just sometimes... we made need to touch the item to the child's hand to bring it into his attention space. And then invite him to even try to reach for it. We can bring around an object from the back to the front, and at what point does he -- while focusing on this -- get attracted to that object coming in from the side; which gives us information on Peripheral Vision. Faces are great! Because there's a genetic predisposition to facial attraction. But they also -- other pictures -- simple pictures. It's fun to take another identical book, or pages and skip through them. 'What are we looking for? We're looking for...? No... that's not it. That's not it.' And the triangle. And it's kind of interesting, how many kids start recognizing this -- and the goal is to establish Comparative Looking. We also want to assess... um... Alternating Gaze. And this one's gonna be a little challenge here, because what I use, often, is a ball that I let the child track and follow, and then I say, 'Oops, watch!' And it falls apart! And they look from one side to the other and reach for it. There they go. Two bubbles. Bunk! And... many time kids watch at first, and they're very curious, and it's like, 'What is that?' And then pretty soon you start seeing them reaching their hand up and then they start -- they start following and -- so bubbles are really exciting for children that have some vision going for them. And they're also very indicative if the vision isn't that good. Cars. Balls. Little things that will role are good to get Tracking. And... also following Moving Objects. Now the challenge here is that... it's not gonna necessarily go someplace -- but you get it in the loop and you let it go. Like that! And often it will scoot on a little bit farther. And sometimes the kids don't know where to look when they're going. So the count of, '1... 2... 3...' And the first time they're, 'What's happening?' But then the second time, you do, '1... 2... 3...' And then they really watch to see where it goes. The string can be a pretty valuable piece of equipment. Once they've kind of looked at it, we bring it around, slowly! But remember, if we're wanting the child to track across -- if we go straight, we're asking him to converge and to follow. So it has to be in a loop, going out. And going up and over. And we want to look for how they eyes are tracking -- if they're both tracking together. If they -- the other thing we're looking for is -- as we're going across, does the child kind of follow and then disengage at mid-line? Sometimes that can be an indicator of some neurological problems, other CNS, central nervous system problems. Just a sock, but all you need is some stripped material. And you bring it across in front of the child, and as he tracks -- Does he skip? So are his eyes -- and it's called Saccadic Movement, but are his eyes skipping on the lines? That means he's getting some visual input of the pattern. Kids like to see their faces. So... So is he looking at the face? And when he brings it up, does he smile? Is there an indication that he's got eye contact with himself? This is a glow stick. When you bend them, sometimes they light up, and the kid gets interested in the light and follows the light. You can bring it across this way and this way, and then they can grab it and... and hold it... and it's... rather safe. An interesting thing. Just recently I was with an ophthalmologist, and she said, 'Lois, this is the first time I've done this!' And she's been doing it for 20 years! 'But I had a kid that would not cooperate at all! So I had some glasses, and they were 2.5 glasses -- and I knew he had a vision problem, but I was having trouble. I put the glasses on the child and he all of a sudden woke up! And just looked and looked...' These are curious little objects. They're actually small erasers... with happy faces. So we need to be cautious with them to make sure that the child doesn't grab it and put it in his mouth first. But what I do with these... is I present them to the child, and I say... 'Watch!' And I take one. 'On!'... 'On!'... 'On!' And I'm always amazed at after they've had the demonstration, they often try, 'On!' And many times I've had kids get up to six, that were very challenged! Are they using their fingers to hold as they go to the next one? Is there Depth Perception or Depth Conception? Depth Perception means that both eyes focus on the target together; so I can just drop it right on the target. And Depth Conception is I'm conceptualizing the space and by putting it this way, I can guide it with my fingers. Just take pipe cleaners. Ok! And these little beads. Now you could use blocks with holes in them, too. But what I found is -- kids that I didn't expect to be able to be interested in this -- they can feel the hole! And I demonstrate one. And then I demonstrate, two. And then I go, 'Hey! Look! It can go off.' And I let the child take one off, or see me take it off -- let him take the other one off. They like the monitoring -- or the modeling. This is just one of those things for Depth Perception, Eye-Hand Coordination, and something that's just kind of unique, that they're not going to find in their in their little toy box. The other thing that's useful... is... just paper. And then take a pen -- I have black right here, but red and green -- and just, 'Da, da, da.' And then give him the pen and see if he wants to do it. Has he seen the lines? And then, does he kind of imitate with it? You can even draw a face... with the eyes and with the mouth. And have the child point to the eyes. And we want the child to do this -- the same things with those small hard board -- hard books. Put a glue dot on the nose of the dogs -- on each page. So he can point to the nose of the dog and he can feel it, he'll get touch feedback. So just a little glue dot, or a pin from the underside of a page gives touch feedback. Because if we can get the child to point, we'll start to learn to understand his detail vision and how he's doing comparative looking, too. I have dots and dots. And I want to take that line and I want to make it so that it's raised. The child has touch input to go across from one side to the other. And the touch input, sometimes, invites more detailed looking or processing. There are lots and lots of fun objects with which to do Functional Vision Screening. We're looking for so many characteristics, the Peripheral Vision, the Central Vision, the ability to Track. What kind of Detail Vision he may have. [background music] And giving us an opportunity to provide suggestions for adaptation. These things give us information on how to provide intervention that will make a difference. [ music ] [ Video end: ] Ann: Okay. Anyone have any comments or questions about the materials used? Most of those look like you could get them at the dollar store. So it is fairly economical. And then you will be seeing her use these same materials in the videos. Participant: By any chance, she mentioned or maybe I didn't catch it or maybe it wasn't mentioned. What age level? You're not going to have an infant stringing beads, but was there somewhere a discussion about the activities and age that it might and appropriate for? Ann: And remember, we are -- the babies in our videos really are babies. But by the age of two, kids are putting puzzles together. So think about that really this kind of -- this -- when we talk about infants, it's up to three. So some of those kids will be doing that. Also this is for nonverbal children as well. I used to use this Functional Vision Evaluation with all ages when I had students who couldn't talk or perhaps were at a developmental level that they could not explain what they were seeing. So that's why we wanted to show the whole kit and the whole checklist. Are we still having ‑‑ still showing the checklist because you would be using this with kids of all ages or definitely up to three years of age. Again, remember you might have some low vision kids who would be able to imitate and that will tell you something developmentally as well. Chapter 6. Parent Interaction So not only was Lois a baby whisperer, she was very effective in talking with the parents. And so we asked her to do this sort of -- give her advice about what happens when a parent might ask hard questions, because remember we may be one of the first people who come in who are actually talking about the child's vision, other than the doctor saying, "Oh, well." You know, sometimes it's very hard because parents do not -- when you get bad news at the doctor, you really don't hear every detail. So, this is a very short little interaction with her talking about how as vision teachers, we can respond to the family's questions. [ Video start: ] [ Music ] Lois Harrell: Vision teachers often get questions asked of the parents, sometimes the parents don't understand what the ophthalmologist said, or sometimes they feel that they just didn't get any answers whatsoever. And so there's some cautions here; we should answer their questions, but we should respect the ophthalmologist's position and let the family know that the ophthalmologist is looking at the visual system, the physical visual system, and now what we do is take that information and help the child to develop his functional vision, if we can. Parent: But our ophthalmologist said it was the worst case he's ever seen [inaudible]. Harrell: So where does that take us? Parent: Nowhere! [laughing] Harrell: It does. Parent: It does? Harrell: It gives us lots of information. Yeah? Harrell: Okay? 'Cause I've seen hundreds of kids with optic nerve hypoplasia. I've been in practice for over 40 years... and what it says is... sometimes, sometimes kids with vision differences, their vision improves as they, as they get [inaudible]. But it says, function and touch. You know, he focuses on touch, so that he can do organized scanning. And I'm quite an advocate of pre-braille... but there are ways to expose him to the braille early, okay? If you don't mind, I'll address that. Isn't that great? [music] Parent: Yes. Harrell: As you're working with the child to demystify the experience for the parents, let them know what you're looking for. The parents don't see that the child actually turned toward the pen light. So it's helping the parent to see what you're looking at, or to question some of the things that are different, and then address those issues in a way that says, "But there's things that can be done, and this is what we can start with." There are activities and experiences that allow the baby to be part of the action and then realize that he has a role in his activities, then my mind is actively involved with the process. [ Music ] [ Video end: ] Ann: That is just sort of a short snippet to give us maybe a little boost or a little pep talk if we feel like we're going to -- because these are hard questions for a parent. You could see how nervous she was about hearing that her child had the worst case, that he had ever seen. Chapter 6. Functional Vision Assessment Now, you get to see our two little cuties and Lois, and she's going to talk about -- she's going to be going back and forth between the form and the Functional. But as many of you know, the things that happen when you start going in with the checklist, the baby for some reason does not follow along the checklist with us. So other things happen and it looks like, oh, she's just jumping all over the place, but it is really because that is the way the baby responded. So if you are new to doing Functional Vision Evaluations, just know that that is the way it happens, and that if you watch this as she goes over it, you will learn to pick up on that and know that you can fill in the form afterwards. Let's watch Lois in action. [ Video start: ] [ Music ] Lois Harrell: Our next focus is, what do I do with the information from the functional vision assessment? And the first question we have, "What is this child's diagnosis of visual acuity?" And a question that' always asked is, "My child is nonverbal, how can that ophthalmologist assess his acuity?" With some ophthalmoscopes or magnifiers,they measure the distance of the eye and they can get some visual acuity. And if the visual acuity is not, is really out of normal then that child may be prescribed glasses. The appearance of the eyes, are they normal? Some eyes can be smaller than others, some eyes can have what's called ptosis where the eyelids are down, and they have a limit on the visual field. Some eyes can have what's referred to as colobomis or little dips in their irises, their irises are different; and when a child is light-sensitive they may shut their eyes when the light's too bright, that means they're getting fragmented input because they're only looking when the light is not bright, and that, they have to fill in the gaps, and that takes a developmental aspect too. [ Music ] In the functional vision assessment checklist we went to the section on Observations of Functional Vision. We saw two beautiful babies, I used the pen light for light perception. This baby was able to grab onto the light perception, not an even flow, but she was aware of the vision in her field. She was motivated by the light perception, especially when she was pulled in a blanket and pulled around past the window, [ background music ] you could see her open up her eyes and look at the light. [ Music ] The second child has very severe underdeveloped optic nerves, and he did not reflect awareness of the light except just very minimally. He does have enough light perception to make it functionally useful for moving about, and sometimes even for reaching for objects. With the little girl we used the light to follow. She was intermittent in following, but she was aware of it. We touched the object to her hand, letting her know that it was in her space, and therefore she was more motivated to follow it. And then when I brought it across to touch the other hand, and then back, and had a pattern, invited her to recognize that she could sometimes lock in, at least peripherally, on the object that was in her space. Able to fix and follow on an object. Fix and follow is often detail vision. The light is something you can fix on briefly and kind of follow it. Fix and follow gets a little bit more sophisticated sometimes when we're going for an object of interest rather than a light and they're kind of curious, "Ooh, what are the details of that object?" With the little boy that had very poor vision he did see some of the light, and then he had his cup of water, and it was not in contact with him and he reached directly for it. And then a second time, I had a card with a pattern with a broken corrugated line that he could feel, and he traced it once. And then I took it away. But then I put it in front of his other hand and he reached for it -- no noise, and then he reached for it again. So that child is cranking up his vision when he's aware of an object [ background music ] or he's internalized it in some way -- he went for it. He starts to crank up his vision to anticipate when the object is coming in his space. And now what we do is take that information and help the child to develop his functional vision, if we can, and if he doesn't have functional vision, help him to make adaptations that will help him to interact with others in his environment and his world. [ Video end: ] Ann: [ Inaudible ] it went really fast and so what I want to do now is just show some snippets that do not have audio, but that we can watch so that you can pick up some things that Lois was talking about in the video. So the first one is we're really looking at light perception. [ Video start: ] [ silence ] Ann: So I wanted you to see that one again because this is the little boy who the doctor had said he did not have light perception [ Video end: ] and in fact had told them because he did not blink at a threat and his pupils did not respond to light, that that would be an indication that he was not seeing anything. So that, I think, is important for the mom to know that, yes, we are seeing some things, and in watching, and the vision teacher also said, "Yes, that is what I've been seeing when you present objects in his lower field." So let's look at the next snippet. [ Video start: ] [ silence ] Ann: And this is the one where you see the card. I don't know if you can see it that well. But if you watch it several times, you will notice that this arm comes out without anyone giving him a clue. Okay. Let's look at the next one. [ Video end: ] [ Video start: ] [ silence ] Ann: And the reason a lot of times when we are doing Functional Vision Evaluations, we are told not to make any noise, and I wanted to show this little snippet [ Video end: ] because part of what Lois was explaining to the parents was that, yes, she of course did not use noise making items in the beginning, but once the children knew that there was something within that 18 to 24 inches, and she made a noise, she was trying to show and explain to the parents, we want them reaching out for those objects, because so many times kids with very limited vision, they need those kind of cues and clues that, yes, there is something out here. Let's go ahead and reach for it. So, that's why I wanted to pull that little snippet out. Is that the last one or is there one more? Chapter 7. Comparison of FVAs Okay. So next, we're going to go to -- and in your handout you will see it says Comparison, the twins. And because we had two children that were born at the same time that were in the same environment, we wanted to show what that typical development, what that would look like if you did a Functional with them. And this child -- they were just about to turn one and yet they were three months premature. We use an adjusted age, but -- so, we're going to look at the difference between the young boy, the twin, who we went through the functional routine. So here we go. Kate: [ Inaudible ] Ann: Yes. That child has not been diagnosed with any kind of visual impairment. [ Video start: ] [ Music ] Lois Harrell: First was a little girl with some challenges. And the first section was light perception, which she had. She was able to briefly look in on it and follow it, especially after it touched her hand and promoted awareness that it was in her space. At the same time, she has a twin brother whose vision has not presented with problems to his pediatrician. He was able to demonstrate light perception immediately, the ability to track it in all directions; up, down, across, and remember we go across around. The little girl skipped at mid-line, when she went across. He just went right straight across, went down, up, was visually curious enough to stick out his hand and reach. The little girl kind of opened her hand when she knew it was in her space, contacting her hand. He was able to visually do comparative looking with the objective. When it was placed on the table he reached for it. Was able to converge or follow the object end towards his nose, and he was able to follow the object when it was highlighted by the pen light or just present in his space. And the little girl kind of stopped at the point of tracking, just because, "Hmm, this is in my space," but she wasn't seeking information from the object. And, again, the sighted boy goes from left to right, right to left, from up to bottom, from... from all directions. And the little girl was primarily only able to go from across and a little bit up. And unfortunately her head would bop down when things went too long. The little boy alternated gaze between two visual targets. When one was presented he looked, and he initially looked when the noise was made, but he also looked when it was silent. But the noise was because he's a little boy that's interested in things that make noises. The little girl's functional use of vision was seen to fluctuate. His was consistent, and we could count on him being visually curious. Adaptive positioning -- have the feet on a surface because this aligns to a sense of security. In the little girl's case I wish I had positioned her more so that her head was really back on her mother. But she was also interested in falling forward, so it was a challenge. And the mother also indicated that she preferred looking to the right. But her mother was on her left while we were doing this, and she did turn her head to that direction. So she was giving us some information on visual curiosity, or seeking visual security with that. So that was interesting. The little boy didn't seem to bring things close to look for details. He just had a normal space for it. His sister wasn't able to grab. The little boy did not squint when he looked at things. He did not have a light preference for having to have something highlighted to address it. And he just seemed to have normal vision. If the child wears glasses -- which he doesn't and she doesn't, and we didn't use them -- but sometimes putting glasses on a child that has a refractive error or measurement of the eyes that says glasses would make a difference, boy, it's worth every action for the parents to get a pattern going. [ Music ] [ Video end: ] [ silence ] [ Video start: ] Ann: So, the twins and the bubbles, of course with the little girl, we couldn't use the bubbles because she would have never picked them up. But with the little boy, then he just tracked those across and looked at them disappearing, which is what you would expect. Positioning -- this is something that is very important, even for the little boy. He was sort of leaning over to one side and had one foot back and she had to reach in and get him. And he did respond much better and of course the little girl was unable to sit. She didn't have head control that would allow her to work independently. So mom was -- she really had to keep her supported as we were trying to do those. But we did try different ways to position her, and I think you going into a home are going to have to practice or look at what the best position is. [ Video end: ] The brother was able to get around, and you saw him in the filming that we did put him on the floor and he got interested in some other things. But in the beginning, he wouldn't pay any attention to Lois, and that's why we started looking for something that he could be stabilized in and then because she got interacted with him and got interested in her, then we could take him out and do that. So, just remember that the visual system, and with the body, the body has to be positioned so that the child feels comfortable for the vision period. [ silence ] [ Video start: ] Ann: And this is really very quick because of course the other little ones did not do ‑‑ have convergence, but we do see that he looks at things, brings it close to him. He even, you know, tries to do the little marking and when he brings it in, he almost eats it because he had a little bit of a bringing that to him. [ silence ] Kate: It's so subtle, Ann. Even with him, it's so subtle. Ann: Right. And so that's why we want you to have these videos to really watch a couple of times and then you can see how the babies are reacting. [ silence ] [ Video start: ] This video, or this little snippet, and I know that you may have wondered what are we doing here, but it is sometimes important for our kids who have neurological impairments to get those hands in midline and to get the head in midline and really look at, "Does that change the visual response?" So again, it's getting that body in alignment and see. And of course it's a little bit harder because she doesn't have the head control but it's taking like four hands to get, to get this. [ Video end: ] And so it really is important to get mom's help and to explain what it is that you are looking for. So that is ‑‑ those are the videos. One of the things that I did want to talk about is in the first -- or in the observation, you see that we take the little girl and we move her around the room. [ Video start: ] And one of the times that you really see her eyes, or where she notices the light, is when she goes around the window. [ Video end: ] Ann: For those kids that -- that really are not able to move themselves, they're not rolling, they're not scooting, they're not doing any of those things, that you might try some of these activities like putting her in a sheet, going by the window to get that natural light and see if there is a difference. Also for -- maybe discuss with your O&M whether this type of activity would also show the child sort of the area of the room, how big the room is. She seemed to -- that was one of the times that she was the most happy and didn't have to have her pacifier in her mouth during the testing, so that might be something that the O&M and the VI teacher could work on as far as combining those VI, really looking at those functional skills and the O&M skills because, we know that O&Ms are going to be going in and doing evaluations. Also I wanted to let -- sort of talk about the fact that this video -- we are representing seeing a baby for the first time, because this basically was all of our first times to see this child. So it would have been, using this checklist, going in to determine eligibility, because Lois -- we had very limited information, and some of the things that were discussed during the video, you might say, "Well, but for a child with Cortical Visual Impairment, that wouldn't be appropriate." So think about the mirror and looking -- that children are attracted to faces. We know that kids with CVI, faces are the last things that resolves. So this basically, this checklist is for those students that you're going in, or if you know that the child has a Cortical Visual Impairment, you might look through this and see, okay, will these be the items that I am going to use? Because it's a very general this -- you know, we're just seeing if all of the things that we see in typical developing children -- will the students be able to do that? So that -- as you look over the checklist, a lot of -- there are a couple of things on -- under observation, functional vision -- under number five, tracks from left-to-right, right-to-left, from top-to-bottom, from bottom-to-top, tracks after object has come in physical contact, or tracks only familiar objects. And we know with those students with Cortical Visual Impairment, they are more interested in their familiar objects, and sometimes will not look, or attend, to something else. So, you might want to make some notes on this form that helps you know, when you're looking -- if you -- what would go with the diagnosis of the child. So, did we have -- I would love to hear either through the chat or through the comments what you think about the videos. Also, if you feel like the videos will be helpful? I see some of you are practicing tracking right now. So are there any comments? Kate: Well,I have one question. [ Inaudible ] You know, so as a new vision teacher coming in and I've got this baby and I've never done these things before. The clock is ticking on eligibility. You know, I'm going to go in and will I attempt to try to get it in one shot or am I going to think about multiple shots when it comes to the Functional Vision Evaluation? Ann: One of the things, when that time clock is ticking and you're trying to get this child -- by doing this, this would provide eligibility in a one shot thing. If you can get the baby to cooperate at all. [ Laughter ] And of course we know that that's the big question, because you are -- it is a ticking clock by this time. So what I usually advise is you -- by going through this checklist, you are going to know if there is a vision problem. And so that way, from -- after you get them eligible until the next time, then if you keep a running data collection, then you are going to have a much more -- you will have a richer Functional and one that really explains and really pinpoints that child's vision. Because until you work with them on different days at different times of the day, then you will know, really, what effects their vision and if they are -- what they need in order to see the best. Because the child doesn't know you and if they will not have anything to do with you, then you have to build that relationship. One of the things, too, is that this is -- we again did not look at that much distance in the -- looking at distance in our videos. But we did have the little boy do -- at that time he was starting to walk, and he -- but he would only trail the wall with one hand and he was just cemented to his mother with the other hand, and so, again, he was not using distance vision even though he was trailing the wall because he was still -- and he has very limited vision and he is very hesitant. He was unable to walk without the wall and his mom with him. So I think those are important things to know and to know that you do include that. I think we do have the legal framework up, and Kate, if you could show them how to go -- for those who have not been to the legal framework to where they can go to that portion that goes that over what the Functional Vision Evaluation requires. [ Slide start: ] Kate: Well, I have gone to the link and I'm on the legal framework and I'm going to go scroll down, the Functional Vision Evaluation. [ Inaudible ] And we're going to go -- Ann: Well, what I was thinking, if you have not been to the legal framework, you basically just google Region 18 legal framework and this is what the page is going to look like and then you can just go to the A to Z listing and go to "Vision" and then just go to the "Vision" and it goes right down to evaluation. So that's important and then also -- it is also under eligibility, it's another place that VI eligibility is there. And so sometimes those are the types of questions we have about Functional Vision Evaluations. [ Slide end: ] So when you are testing a child who has more vision than these two students that we just saw, it is important to -- that may be a time that even if the clock is ticking, that you might want to come out for a second time or you really want to check those additional environments. And I think the O&M, if the O&M and VI teacher go in together on those cases, I think that is going to be the most helpful, because we are looking at it from different perspectives. It's important that -- if, you know, on one day, you know, you're expecting better vision based on the acuity or on the paperwork and you are not seeing it, yes, you can then try to come another time. Find out from mom, is this a usual day or an unusual day? So it really is important to talk with the parents to schedule that. Kate: Well, and I like the fact that form is set up and you can put it in electronic format on your iPad, or whatever, and get your initial stuff in and work through that form. Maybe even a number of times [ Inaudible ] Ann: Right. Right. Right. Because we really -- we really do need to know what that child's functional vision is but sometimes eligibility speeds us up. Kate: Right. Ann: So and that -- that the next time around you will have much more information. Chapter 8. Final Comments Kate: Do we have some questions out there or comments? Either about the content or the videos themselves? [ silence ] Now Ann, I know you said that there is a approximately four hours of video, and what we have processed so far to go up on the web is nowhere near that. Ann: It's about 22 minutes. Kate: So do you have any plans to include some future snippets of this? Ann: Absolutely. Absolutely. Kate: Great. Great. Great. That would be really helpful [ Inaudible ] Ann: Is this something that you feel like you will use or -- that is helpful? Participant: Helpful. Ann: Who is that? Oh, I can't see you who you are. Participant: Oh, I am sorry, from Cuero, ISD. Ann: Okay. Now, I see you. Thanks. I'm glad. I'm glad that it will be -- that it's something that will be helpful, and that's really what I would love to hear, comments through e-mail of what else you would like, what videos or handouts that would really make it easier for you in serving infants. Kate: And even questions you might have, too. You know, I think that that's like, "I'm not sure what, you know, what I am actually looking for?" Ann: Right. Kate: So that we can know how to add more information and detail to accompany the videos to help you with either seeing what you need to see, or being able to share what people should be looking at; like if you are sharing this with a parent or another teacher, who maybe has never done an assessment with a baby before. We'd like this to be something that could be a real individual learning tool that you don't have to have somebody right there with you to get something out of it. Participant: Ann, one of questions that came from one of our remote sites, and this may not be time to address now but maybe can be addressed on the website, but addressing expanded core for infants. I know it is not [ multiple voices ] Ann: Right, And in fact when you -- I am glad you brought that up. In fact, Twinkle, the way -- part of what the website, the sort of the subcategories, one of them will be intervention strategies and those are going to be listed by the expanded core. So there will be strategies and resources under each one. Participant: Awesome. Thank you. Ann: Uh‑huh. Participant: Ann, this is Region 4. Ann: Yes. Participant: Any ideas? We had a question about possibly having an LMA portion. Ann: Oh well, I would love that. And I think now that we sort of have some things up, and we have a full media department now, who can come out and film, while we get to play with the babies, so I love that idea. Kate: If any of you would like the volunteer yourself, and or babies, for us to come out and be able to work on doing an LMA for the baby, that would be terrific. Ann: And we really could do an LMA from the videos we have. But if you have a baby that maybe has more vision or that you are really wondering about the LMA section, that would be great. Kate: Yes, please let us know if we can work with you to capture more video. Because you know, the more examples you have of any process, the better. So let us know if you are at all interested, and it is not something we are going to make you do, like, tomorrow but we could begin a conversation and see what might be possible. Let us know. Ann, thank you so much for sharing this. I know it was real quick and we had some technical difficulties. For those of you who were frustrated with the audio quality, we do have all of these videos up on the infant page so you can see all of the videos, and we will do our best to kind of cleanup the audio quality of the broadcast today before it goes up on our distant site in the archived version. So don't despair. We are continuing to try to figure out why we have so many problems and repair them. But in the meantime, I am glad you joined us today. Don't forget your evaluation and we will see you next month at the TETN.