TRANSCRIPT Ð Promising Practices - Considerations for the Accessibility of Sign Language for Individuals with CVI Ð 5/15/23
>>Marguerite: Thank you so much, Kaycee. I'm so happy to be here with all of you. This is a topic that I've been really interested in for the past few years and I've just really only begun socializing it this past year. So I see us at the very beginning of the journey and I welcome any questions, comments, and discussion along the way because I certainly don't have all the answers but I hope to be starting some deeper conversations to get us where we need to be. So my presentation today is titled Promising Practices: Considerations for the Accessibility of Sign Language for Individuals with CVI. Let's get going. So Promising Practices. What is that term and why does it relate to this presentation? So right now many current educational practices around CVI are considered Promising Practices, meaning that there's some research out there to support application but there's not a substantial amount of research to have it be a best practice. So we're hopefully on our way there but that's why we're using the term Promising Practices. The information in this presentation is based heavily on my own professional experiences as well as some shared quotes from individuals living with CVI. It's really important to me that as many perspectives be shared from those living with CVI so that as educators we really have insight as to what the day-to-day experiences are so that we can shape our practices around that. Also within this presentation the Promising Practices, so I'll give a lot of thought for discussion or questions that I want you to consider as you're working with your students. All of this is going to be linked to research to the greatest extent possible. So everything along the way the linked to research around CVI or what we know about visual perception in general. As I mentioned as I opened, the presentation goals are really to socialize an evolving concept. We're really at the beginning of having this conversation because a lot we know about CVI and there's a lot that we still need to know about CVI. So the goal of this isn't to say there's one right way, there's one wrong way. It's to encourage thoughtful, individualized, and methodical evaluation of sign language accessibility for students with CVI. So one tool that I I've loved in the past and I still love is the Adam LS that looks at oc par assessment and how to look at sign language accessibility for students with ocular impairment. So I hope to do the same around CVI. Because it's very important. I also want to emphasize along the way that there's no one size fits all for any student with CVI. There are different means of communication access, receptively and expressively, all which should be honored and encouraged. We have a very diverse population and we want to meet the needs of the student in front of us. And then my last goal is to highlight those experiences of those living with CVI. So as I go through this presentation, I'm primarily referring to some possible implications as it goes to in air sign. So hands in the air sign. And then tactile sign being the alternative. So I'm going to talk a little bit about them in a moment but just to clearly define what I'm referring to. So when I say "in air sign" I'm referring to when the receiver is watching the signs produced by their communication partner. For tactile sign, I'm referring to the receiver placing their hands on top of the hands of their communication partner. Why are we talking about this to begin with? Let's think about CVI and DeafBlindness. There are many shared risk factors with CVI and DeafBlindness. In the Deafblind program here at Perkins we have 56% of our Deafblind population as having a diagnosis of CVI. And some of the known risk factors that are shared between the two can include many hereditary syndromes, hydrocephaly, meningitis, and complications from prematurely. There's not enough research to look at the prevalence. At Perkins, 23% of our students also have charge syndrome. 7% have Cornelia deLang syndrome and 7% have Down syndrome. I don't think we can ever rule CVI out of a child with DeafBlindness so we really need to be thinking critically around every student that we serve because, again, the population is very unique and diverse. When it comes to DeafBlindness, we know, speaking about diversity, that learners who are Deafblind can have residual use of their vision or hearing. They may have no residual use of vision or hearing. They might have additional needs which can impact physical, cognitive development and communication. There's often less access and engagement and reduced incidental learning. The learning passively, from looking around and experiencing everyday experience. We learn so much that way and that can be significantly reduced for someone who is Deafblind. So when it comes to CVI and sign, what I have found in my own practice that if a child has any residual vision, in air sign tends to be implemented. It seems to be the first stop. I don't know if that resonates with any of you listening today but that's been my experience. When it comes to children with CVI, vision attention and visual recognition abilities can be deceiving and are often misunderstood. If a child is looking in a particular direction, it might be interpreted as visual recognition and understanding when in fact there might be a significant barrier to understanding what they're looking at. There may also be the prioritization in some cases of visual means of access being the focal point due to the focus on vision and the assumption that vision will improve. Others wait based on the recommendation of, well, we're going to wait and see. So we know with CVI that changes in vision is possible because of the neuroplasticity of the brain. The brain can adapt and change. But there is no research that can predict the rate or extent of visual improvement for all children. So it's really important that we understand what that child in front of us needs right now in order to access learning. I wanted to share this portion of a blog written by an adult with CVI and APD. The blog is the CVI perspective and I have a link on the handout. I really encourage you to read it in full. It is incredibly powerful. So the author writes the following: The first time I met another adult with CVI we spent eight hours straight -- yes. Eight consecutive hours swapping techniques that we had both used to pass as sighted. Not tips on how to see things better. We both agreed that even during our strongest visual years, trying to use our eyesight had always been exhausting, confusing, frightening, and straight-up traumatic. We swapped tips on how we used our other senses so we could fool people into thinking we were seeing things. This blog is incredibly, incredibly powerful and how this individual felt so pigeon holed into using their vision when at times it was really difficult. I want us to think about how we can be in the mindset of an individual living with CVI and think about autonomy and serving them so that there's accessibility without shame. And as we think about accessibility, we also have to think about how the neural network of the CVI brain is fundamentally different. And that's a quote taken by Dr. Merabet. The science is showing that the brain is wired differently. Information is processed differently so we have to think of it from a visual processing lens, not just ocular impairment. When we're starting to think about accessibility, the first question is if learning is not happening, what do we need to think about? Is the information perceivable? So if the input is not perceivable, a memory cannot be formed that can then be used for future recognition. So the brain needs to be able to receive information, no matter what form that might be: Visual, auditorily, tactual. Information must come in for the brain to make sense of it. And then if the information is perceivable, we also have to think about is it sustainable. Is it the most efficient means of input? So perhaps a child is perceiving some sign but maybe it's not sustainable. That's kind of what I'm thinking about. How do we look at these isolated events and also holistically supporting that child across everyday experiences. So this is a really complex topic and so I just wanted to share a bit about what this flow is going to look like as I dive into this a bit deeper. Again, this is a conversation starter and along the way I'm really trying to provide some considerations around the assessment process. So we're going to start with a brief overview of visual processing areas of the brain. Very, very high level. Brief overview of related implications. CVI implications in regards to sign language where I'm going to invent some probing questions that you can put together when working with your students. Some guidelines as to what you can think about. And then I'm going to conclude with some very brief examples from case studies. This case study is typically longer in nature but due to time constraints I've had to just share a portion of it. All right. So we're going to start off with the visual brain. So when information first enters the brain, the starting point is the primary visual cortex. It's located in the occipital lobe. If you touch the back of your head, that's where that occipital is located. It's responsible for the early visual processing. Dr. Marabet mentions it's like not having all the meal. I'm going to call out some areas where they play a part because you're going to hear some of these words mentioned as I go through this presentation. So complex patterns, object owners, form, orientation, motion, and depth perception. Understanding color, motion, and spatial vision, and understanding motion. This is happening in those early stations of visual processing and then we're going to get to some of the higher-level implications as well. If you heard about CVI before, you have probably heard of the terms dorsal stream and ventral stream. These are highly simplified definitions. The dorsal stream of vision extends from the occipital lobe to the parietal lobe. This is known as the where and how visual stream. Where are things and how do I respond to these things. It supports the behavioral goals of action control and the understanding of spatial relationships. The ventral stream is the who and what system. And this goes from the occipital lobe to the ventral lobe, which is right above your ear. And this is where we process information in the recognition of objects and faces. So these systems, while described in isolation, actually work together. There's high level of interconnectivity. The whole brain is working to process information coming in through the sensory channels and responding outwards. We described them in this way because it's easy to show what they do but that interconnectivity is significant. There's a constant interplay. So before we go into implications, I want to touch on visual spatial processing. I mentioned this in relation to the dorsal stream. Visual-spatial processing relies on the integration of many areas and systems in the brain. Again, the whole brain is often involved in many of these processes. Spatial perception and visually guided actions are equally represented in the dorsal stream. Developing relations to several areas of the cortex such as the frontal, temporal, and limbic lobes. We know visual-spatial abilities is going to pop up pretty often when we talk about sign language. We're going to get a little bit deep in that in a moment. As for the ventral extreme, I want to touch on this as it relates to incidental access. There can be barriers to passively learning, observing, and understanding. So the ventral stream processing complex objects. For example, body parts, patterns, places, objects, words, and faces. Even when their position, angle, or size changes. This ability is called form constancy. Individuals with CVI might not recognize something for a few reasons. It can be because it's not seen well. So it's not perceived. It's not known because the child has never experienced it, therefore they cannot know it. Or it's both unclear and there's no prior experience. Here I think about that global impact of limited incidental learning. We learn so much from just passively learning and engaging with the world around us and our brain creates these rules that it abides by to get us information. So I mentioned form constancy. Here's an example how I think about it in relation to sign language. So on the slide here on the left-hand side, I have four photographs of somebody producing the sign for "more." You can see the sign from front on, from the sides, from the top down. And on the right-hand side, I have an image of a little girl and you can tell that it's still the same little girl, although now you see her from the side. The picture is smaller in one instance and in another picture the lighting has changed. So if you don't have CVI, you have typically-developing sight your whole life, you can look at these images and know they are the same signs, the same images, the same meaning. That it's the same child, despite all these changes. That's because your brain has, again, had these enate rules that it follows. It's developed form constancy and you can put all that together flawlessly. And we know some of our students with CVI, if they're not perceiving things or experiencing things, this could be challenging, to say the least. So what goes wrong? So for dorsal and ventral streams, let's talk about what some areas of dysfunction could look like. For the dorsal stream dysfunction, it could result in impacted spatial perception, impaired motion perception, impacted visually-guided reach, trouble walking around obstacles, challenges with visual clutter. For the ventral stream, it can result in difficulty identifying and interpreting objects and faces. Result in impaired depth perception or have challenges with route finding. Just a few examples of possible implications. Let's keep all this in mind and now talk about what sign language is. Sign language is a visual, iconic language. Signs often look like the words that they represent. It's primarily a visual spatial language, being produced manually and perceived visually rather than being produced orally and being perceived auditorially. And it relies heavily on the analysis of hand motion. In the last few sides I touched on a few difficulties here. Incidental learning and access, visual-spatial challenges, motion perception challenges. So that's kind of setting the baseline to some of my thoughts around access. So now we're going to dive into this a little bit more deep where we're going to look at sign language and the implications of CVI paired together. So when I'm talking about this, and I've mentioned before it's about the assessment process. Assessments at Perkins, we're using the Perkins CVI Protocol. It's our new assessment tool where we have 16 areas of assessment as well as 17 areas of compensatory skills. I'm not going to go into all of these areas in detail for this presentation but I'm going to list them off briefly. So we look at visual attention, visual recognition. Response interval. Appearance of the eyes and movement of the eyes. Visual curiosity, form accessibility, visual fields. We look at visual guidance of the upper and lower limbs. Impact of motion and motion perception. Sensory integration and the impact that it has on vision. Impact of color. Impact of light. Impact of clutter and access to people. And if you're interested in knowing any more about these categories or if you want to see the research that we gather through the validation process, all of this is available on CVInow.org. When we're going through the assessment process, I always like to remind people that the answers are only as good as the questions asked. So we need to know exactly which questions to ask to get the information we need to be accurate in our approach that follows assessment. So as we're going through the assessment process, and certainly after the assessment process, we need to understand the student's communicative intents and reliable responses. This is absolutely essential. We need to understand what that child is doing to let us know they've understood something or that they need our support. Because, otherwise, we really can only make assumptions. Part of this is really building partnerships with the student, certainly their family, and team members. Everyone should be communicating and collaborating. When we dive into the assessment, we want to be really sure of what we're looking for in assessment and we also want to know how we're going to analyze the findings. We could gather all the information and not know what to do with it and we don't really have a path forward. During our assessment process it's highly comprehensive, similar to many other FVE processes that exist out there. There's a file review where we look at the vision care reports, the FVE, LMA, we look at education documents. We complete interviews with multiple team members and the parents. We have observations across environments, tasks, and people. And direct assessment which occurs one-to-one with the student. Through this process we're looking at how CVI impacts them globally and then we can make some links to sign language accessibility as it relates to the holistic assessment process. When we're thinking about sign language, the first stop always is that visual care report. So right off the bat we want to know about the student's visual field, acuity, contrast sensitivity, ocular motility, alignment, and their general ocular health. We want to know if the children can fixate and follow, scan, are there degenerative conditions? We want to know if there's a concern for a diagnosis with CVI so we can better understand where they are in the process of diagnosis or if we should be looking out for any red flags. Coexisting ocular impairments are very common in children with CVI. Sometimes children just have CVI. More often than not, there is another factor that we need to consider. In the Perkins Deafblind program, as it relates to our students diagnosed with CVI, 23% have reduced contrast sensitivity. We have to be thinking about contrast. 11% have nystagmus, that's rapid eye movement. Refractive errors, 30%. Strabismus, 30%, and 8% have colobomas. There's always more to think about with CVI. In the general goals, as it comes to sign language, the goal is to look at what signs are being perceived receptively. We want to know which factors are supporting these abilities and which factors are causing difficulties. We also want to look at what signs are being produced expressively with the understanding that what goes in is going to influence what goes out. We think about how that child is perceiving information and then replicating it. When we're thinking about expressive signs, we want to see if they're traditional, are they approximated, modified. Are the signs having increased body to body contact? Do motor impairments explain any difficulties with expressive sign development? And just in general, what are the trends? We're always looking for trends through data collection. The first stop when we're thinking about CVI and possible indications is often visual attention. This is what we know about visual attention and CVI. Damage along the occipital parietal frontal pathway can cause difficulty with sustained attention, selective attention, and visual search. It's not just about where to look but also where not to look. Another quote by Dr. Merabet, it's about knowing what is where. I want to share some quotes again from an adult living with CVI, Dr. Nicola McDowel. She is also a researcher in the field of CVI. Her blog is available on CVI Scotland. This is where these quotes came from. Dr. McDowel shares that when she's shopping she noted the following: People also have a tendency to dress in bright, bold colors that would draw my attention like a moth to a flame and distract me from focusing on navigating safely through the minefield ahead. She also describes looking through a clutterrered fridge. I had no systematic search technique as I felt I couldn't control my eyes. They had a mind of their own and would decide to look at whatever they wanted to and because of the abundance of food to look at, I seemed to have no control over their movements at all. I thought this blog post was incredibly interesting because it showed how little control there was for Nicola in these circumstances. I think about our students and the situations we put them in and how critical it is that we think about how to optimize access if they could be so easily drawn to bright colors in the wrong setting or not have a strategy to get the information that they need. So visual attention first and foremost it's preceded by awareness. We have to first know something is there so we know it is important for us to look at it. Visual attention is an important prerequisite for recognition. You have to be able to look and attend and pick up details to put all the pieces together to make sense of information. When you're working with your students, here are some ways to think about their visual attention. Is their visual attention extremely brief or is it maintained? Is there an ocular reason for the decreased visual attention? Can they scan? Is the student with CVI able to visually attend under many circumstances? Or is visual attention only established under very contrived situations? And does the student establish attention in non-visual form? Do they prefer to tactually engage? All the things we want to be thinking about as we're setting the stage for being able to access sign. On the screen here I have an image of two adults signing to one another. And so if you think about how much visual attention it takes just to look at this static image where you want to look at the individual's facial expressions, the sign that she's presenting. Can we assume that our students with CVI are focusing on the same elements or are they drawn to the bright colorful pink T-shirt that she's wearing or perhaps a decoration in the background. Then we add in the complexity of movement. I'm going to break this down in a bit. That would add on another layer of complexity outside of just having this photo image, for example. You have to look at what's important and disregard everything else. And we know that our students with CVI have a lot of difficulty with this. So now I'm going to break this down with the five basic elements of sign language. So I'm going to talk about handshape, movement, palm orientation, location, non-manual markers. Users are constantly manipulating and perceiving signs created in space to communicate complex concepts. It's not just these elements in isolation, it's how all of these elements come together to convey very rich, meaningful information. So we're going to start off with handshape. This simply refers to the configuration of the hands. On the slide here I just have a graphic that gives some examples of different handshapes. There's a number of them that exceeds the examples I have on these slides. A hand, for example, open A. B, open B. The handshape takes on different position and so on. The next element is palm orientation. Now this refers to the direction that the palm faces. That could be up, down, left, right, outward, inward. Signs can have the same handshape but different palm orientation. And this will change the meaning. So, for example, the sign for yours or mine. The handshape is the same but the direction changes, which changes the meaning. Yours versus mine. So let's think about this in terms of CVI. Handshape and palm orientation together. We talked about ventral stream challenges and spatial challenges. So we want to look at our students' ability to consistently demonstrate hand position and fine detail rockings. Are they accurately picking up the details of that handshape and palm orientation or is there confusion? Are they able to identify fine details due to impaired contrast sensitivity? We want to look at their ability to recognize signs from different viewing perspectives , which I linked in form constancy here. Is it always the same and recognized or do they have to be positioned very particularly in front of the student? Is there a dependency on compensatory strategies? Is it true recognition or is the child recognizing it by auditory cues, context, or other visual cues not related to the sign. Does the student have a tendency to demonstrate confusion between similar handshapes? On the screen here I just put the examples for the sign for letter S and letter T where the palm orientation is the same but the handshape changes slightly with the thumb positioning. Is the child constantly confusing handshapes that are very similar in visual presentation. And then there's the element of movement when it comes to sign. Movement refers to the changing of location in the physical space during sign production. It impacts the meaning of signs as well. So the sign -- some science can signs can have the same orientation but have a different movement. Signs can change based on the direction as well such as "in" versus out. On the slide here I have a few images again. I have that letter S. I have that letter T. And we know that if we add some movement to the letter T, it's no longer T, it's restroom. So that slight movement changes the meaning of that sign. Here's what we know about movement and motion in CVI. This is taken right out of the research, so the jargon and terminology is pretty heavy. On average, individuals with CVI require nearly three times the motion coherence signals in order to reliably detect the direction of movement of the optic flow stimulus. So what does this mean simply? It means they need motion to be three times as obvious for the individual with CVI to get the same information about its direction that an individual that does not have CVI would get. Three times more obvious. Another quote from the literature: Children with CVI may manifest motion perception deficits attributed to dorsal stream dysfunction, including abnormalities in detection of optic flow and global or bilogically vel vant motion as well as integration deficits leading to optic ataxia. That's interpret movement and planning a response to that movement. Individuals with CVI may experience diskinetopsia. How could that impact their ability to receptively take in information and understand it? Furthermore around the impact of motion CVI, many children with CVI can have difficulty judging direction of motion, speed, and an objects relation to themselves. Individuals with CVI may be more likely to alert to movement and there may be an inability to visually disengage. I think back to what Dr. McDowel shared earlier around being drawn to bright color. Individuals with CVI can be drawn to movement. It's involuntary, to a degree. So a child might be looking at you signing but are they looking to gain information or are they drawn to the motion that you're producing in near distance, perhaps? We also know that not all students with CVI need or prefer movement. Some children with CVI are completely adverse to movement. So here are some example things that you should be thinking about during assessment. Does the student rely on motion over fine detail for recognition? So are they attuned to global motion but not necessarily the details of that sign? Are signs that are replicated only produced with gross motion approximations? Are they missing those fine details but instead imitating big movements? Does the child's attention and recognition change based on the speed at which the sign is being presented? Is there reliance on compensatory cues? For example, does the child actually know the sign for bathroom and can they understand that out of context? Or do they need to be standing right outside the bathroom while you're pointing to the bathroom, saying bathroom, showing them their symbol, and presenting the sign? We want to be really careful to understand which compensatory strategies are being employed, not because they're a bad thing. They are an incredible skill and we want to encourage compensatory skills but we want to differentiate between visual recognition and compensatory strategies so we are always giving them the supports they actually need to access learning. This brings us next to the signing area. So signing occurs in front of the body from the top of the head down to the waist, shoulder to shoulder. Signs may have the same handshape, same palm orientation and movement, but vary in location. This changes the meaning. So, for example, mother versus father. Open palm, thumb on the chin movement for mother. And the same for father up top. So it's changed now in the child's visual field. Which brings us to the signing area and visual field and implications of CVI. Many children with CVI have visual field challenges, not all but most. So the effects of visual field deficits can include impaired visual motor coordination. It may impact social interaction, and there may be focal deficits, blind spots in vision, for example. Visuospatial neglect or visual inattention. And then visual fields can additionally be impacted by contrast sensitivity challenges, ocular motor challenges, visual motor difficulties, visual clutter, competing sensory stimuli, visual fatigue, and motion in the environment. So there are a lot of factors that need tor considered around visual field. It's not just about having one available field and then unavailable remaining fields. There's a lot of factors that weigh into this and I'm going to share some very powerful examples. So, again, Dr. McDowell from CVI Scotland within her blog talked about simultan agnosia. She said I can see multiple things at one time so I can't possibly have it. In this new unfamiliar environment that is exactly what is happening. Every time I leave the house I am only seeing one interesting thing in the environment at a time. One day a familiar name on a road sign. Another day a cool-looking house. You see how this is going. But because I am only seeing these things in isolation, I couldn't possibly tell you where they are in relation to each other. So Nicola McDowell talks about how impacted she is in this unfamiliar environment and that is where it is most profound. Only seeing one thing at a time. And if she's only seeing one thing at a time, she has difficulty putting all those things together to make sense of where they are in space. Because they're just popping up in isolation. And so I think about this in relation to sign and the visual field accessibility. If you're only seeing one thing at a time do you really know where they are in relation to the other signs that are being produced? Another impact on visual field: Fatigue and clutter. Here's another quote from an adult living with CVI. The full blog writeup is available on CVInow.org. When I'm rested and happy, I see clearly, except for the visual field loss. My acuity is fine but when I have visual fatigue it's like looking through a straw. I have an extremely limited visual field. It gets all fuzzy. Usually when I'm not fatigued it's like looking through an empty toilet paper roll. They talk about how this visual fatigue and exhaustion is physically impacting her visual field. While it's larger when she's feeling okay, it shrinks significantly when she's feeling fatigued. As does the clarity of what she's seeing. And so on the slide here I have two images because I wanted to think about this as it relates to the day-to-day goings on of our students in the classroom and in different environments. I have a photograph on the top of a young child signing with an adult. The environment is very bare. There's no decorations. It's one-to-one conversation. Below that is an image of three children signing to one another in a visually-busy classroom is is it possible that a child could have better receptive signing skills in a controlled environment where there's one communication partner, where they're feeling happy and calm and energized? And then go into a busy classroom and experience something such as Dagbjort where this visual field becomes reduced. This is when I originally opened up this presentation and talked about sustainability, we have to think about sustainability of access because just because a child can access sign in one environment doesn't necessarily mean they're going to access it just as well in another environment. On a slide here now I have blocked out everything on that image of the classroom so that you can only see one child's hand, just to provide a simulation of what I mean by the visual field narrowing out. And if we're thinking about visual fields and simultagnosia, it's not just single-handed signs. The sign for king. There's two-handed symmetrical signs. They have the same movement together. And two-handed non-symmetrical signs where each has a different hand position put together to form one word, such as the sign for "help." Many combinations of different types of signs. And then there's also signs that have contact points. So signs can make physical contact with the body so there can be points on the hands, the face, torso, the arms. And they can also occur without physical contact with other points on the body out in open air. For example, I have two images on the screen here. The sign for "more" would have a contact point because the fingertips are touching each other. The sign for "wait" is out in front of you. No contact with the body. Very different. I bring this up because of some of the known challenges around spatial skills and CVI and sign. What could this mean for sign language? So just to start, spatial skills is an umbrella term that includes spatial visualization, spatial orientation, and mental row indication. So when learning sign language the learner is seeing the sign, flipping the sign up 180 degrees in order to properly produce it with their own hands. So they're mentally rotating. The signer must consider the signer's perspective, rotate the movements and map them on to their own body. This takes a significant amount of internal process. So here's an area of implication when it comes to CVI. People with CVI often have visual impairment associated with dysfunction of the parietal lobe. So that's part of the dorsal stream that we had talked about. And this may potentially impact an individual's ability to perform mental rotation as this occurs bilaterally in the parietal cortex. It can impact their ability to evaluate the relative spatial positions of objects in a visual scene. Impact the ability to differentiate the right and left side space, referred to as right left confusion. These are possibilities. It's not a rule. Here are some considerations when it comes to this area. Does the child confuse handshape, position, and relative motion of signs? Is there a difference in accuracy between the body contact points and those without? Is there adaptation of signs to increase body contact? Body contact gives you a data point, really, of where your body is in space. So it can be somewhat grounding if you are having difficulty with this visual-spatial aspect. We also want to look at if there are different levels of accuracy with one-handed signs. Two-handed, asymmetrical, or symmetrical signs. You are looking at all possibilities to see what trends you are identifying over a period of time to help inform your instruction. And now this brings us to the last element, which is non-manual markers, so we're going to talk about facial expressions and body language. Expressions and signals from the face, which can include eye browse, the nose, eyes, lips, shoulders. Raising the shoulders. Head movements. That can be tilts, nods, or shaking. And body tilting. All convey meaning in addition to the use of the hands. Yes, the hands are formulating these signs but it's everything that goes along with it from this non-manual standpoint that shares meaning. Facial expressions represent tone, emotion, and intent in a visual form. And the body is used to convey past, present, and future. Varying speed and incorporation of facial expressions are also employed to convey meaning. A lot of complexity to this. Here's what we know about CVI as it relates to access to people. [ Reading slide ] Some of our students may not be able to recognize you by your phase. It results  [ Reading slide ] There are individuals without the evidence of brain injury as well. Another part of the brain, the STS is responsible for processing changeable aspects of faces. So facial expressions, direction of eyegaze, expression, lip movements, or lipreading. If you're impacted in this area, what can that means in terms of accessibility? I mentioned biological motion and we talked about the impaired perception of faces. Impaired perception of faces can be accompanied by impaired biological motion perception. Biological motion perception is the ability to perceive the movement of a living creature. It refers to our ability to make inferences about identity and actions of another human being based on visual perception. It's really about recognizing stereotypical movement. You can imagine someone walking. You know that pattern. You're picking up on the data points that tell you about the action that's happening. Biological motion can involve the hands, eyes, lip, whole body movement which constitutes social cognition and interaction. You can think there's many different areas where this could be impactful for some of our students with CVI if they are impacted -- if their biological motion abilities are impacted. So here's some considerations around this in terms of access to people. Does the child respond to motion and the motion of others atypically? Can they recognize themselves or others? Is there a dependency on compensatory cues? Do they rely on context, voice, smell, or touch? Do they make eye contact or attend to facial expressions? Do they just glance or are they able to sustain attention to your facial expressions to gain meaning? Do they respond to facial expressions and make inference? Do they startle when approached? Can they anticipate you're coming and respond appropriately and can they make inference about body movement as well. Okay. So that brings us to some really briefcase study examples of things I have looked at with a few students . I'm going to introduce Jenny again. I shortened this for the sake of time. Jenny is 17 years old, has a diagnosis of CVI, also has optic atrophy resulting in decreased contrast sensitivity. And Jenny is Deaf. So the whole CVI assessment -- so interview, observations, direct assessment, and file review found the following: Jenny has significant eccentric viewing. Relying heavily on peripheral vision for information. In our peripheral vision we don't get fine detail vision. It's really gross color and shape. Not fine details. She requires very close viewing. Clutter interfered with access. Impaired motion perception, especially fast motion. Impacted visual fields, specifically the inferior, superior, and right visual fields. Increased response interval. Longer time to attend, recognize, and respond. Impacted facial recognition relied heavily on compensatory strategies for recognition. And then generally reliant on compensatory cues for most pieces of information. Most pieces of visual information was supplemented by non-visual information. In relation to Jenny's sign language observations, she was heavily reliant on context, gestures, and prompting. She rarely responded to a single sign directive. There needed to be multiple occurring for comprehension. She was not observed to fixate and shift visual attention to fast-moving sign. It was the look through behavior. Less responsive to signs that moved into her lower visual field. She was reliant on peripheral movement. So really attentive to multiple prompts alongside gesture cues. Big movements for fine detail signs. For expressive signs, they were primarily gross approximations and produced with general movement. In a conversation with OT, the OT reported that the fine motor abilities of Jenny did not fully explain the deficits. So I want to share one piece of testing that I did with Jenny and, again, this was part of a larger testing procedure and I just pulled out a few examples for you. I met with the teacher and said what concepts does Jenny understand and gave her a list of the nouns I wanted Jenny to find. On one part of the assessment I had a picture of grass, which I have here on the screen and a picture of a bird. I said where is the grass? And she pointed to it. She was okay with this task. And then I asked her why is the frog and where is the pig? So I have these two photographs up on the screen. And this is where Jenny struggled. She didn't know what I was asking her to find and guessed, even though the teacher said she knows what a pig is. She knows what a frog is. She's very familiar with animals and has done it before. Here is one of my theories. Why did she have trouble with this in direct assessment? With the signs for frog and pig, they have the same palm orientation, the same location, and the same movement. And the only difference is the hand shape. For the bird versus the grass, the only similarity is location. There was a different handshape, different movement, and palm orientation. One thought I had for Jenny was when there were so many shared similarities and that sign being produced and the task being taken completely out of context, she lacked the cues necessary to be successful. So we weren't at a farm where we could point to pigs and locate them. She was sitting on a desk being asked questions with no additional cues. And so I believe it really to be her limited ability to visually attend on detail. And just to emphasize this here a little bit and to share a little bit of a simulation, our peripheral fields can only handle so much information. So if Jenny struggled so significantly with me in a completely plain room with no noise, no movement, no distractions, how would her access to sign be impacted in generally-occurring environment situations? I invite you now to look at this red dot I have on the screen. I'm going to put up other images on the screen but don't divert your eyes to them. Keep your eyes on the dot. While you're looking at this dot, I put an image up on the screen and it's going to be really hard for you to be able to identify which handshape is located centrally amongst that mess on the right. But if I put up one on the left without all the visual distractions, it's quite easy to see the handshape for L. This is because our peripheral field cannot handle all this information. It's a crowding effect. So Jenny might be able to locate singular signs under certain situations but then lose that ability completely when presented with other environment conditions and situations. Again, always thinking very flexibly. Mark was 8 years old, has CVI, no light perception in the right eye. For hearing, unilateral hearing loss, severe to profound in one ear. Again, the end result of the CVI assessment found reduced visual attention, impacted right periphery but that was primarily ocular. And a reduced inferior visual field. Clutter impacted attention and recognition. Found to have impaired motion perception. Poor visuospatial abilities. Impacted hand-eye coordination, fluctuations in vision. So part of this assessment process included the review of Mark's sign language dictionary. So the team created a video dictionary of Mark signing so everyone on the team understood what Mark was expressing. It was a really beautiful tool that they made. I reviewed 40 signs -- and this is some of the trends that I found. Again, this was part of a larger assessment process. The traditional signs that Mark used all had open palm handshape or contact with the body. So bye, please, thank you, mom and dad and happy. All of these signs have open handshapes and/or contact with the body. All the modified signs that Mark completed were primarily the ones that were produced in air. So Mark actually modified some in the air signs to have contact. So, for example, for the sign for "all done" he put his right hand over his left wrist and pulled. That's typically done without contact. For "want" there was the open right palm with the thumb to the chest. There was a contact point made on the chest instead of open air want. For music, instead of swinging motion over the wrist, Mark would put his palm down on the wrist and move it back and forth to indicate music. Another trend in the modifications was increased gross motor movement production but limited fine detail. So, for example, the sign for "bathroom" he would just move his wrist but not put the T handshape into place. Yes would look like an O or E handshape. The sign for "help" was two C hands locked on the thumb's upper movement. I found it really interesting, given his motion perception challenges, visuospatial difficulties that he made these modifications in a way that likely gave him another physical point of contact and some additional information. So I know that's a lot of information but in closing this is really, again, evolving concept. I want to keep the conversation going. I planned on going a lot more work in this area so I can have something really up and running and get to the meat of this. In the meantime, while our understanding of CVI continues to involve, the issue of accessibility is well understood. We're learning more and more about CVI every day but we know when there's inaccessibility so we need to provide accessible learning right now. We also have to continue to acknowledge that there's no one size fits all approach but instead an umbrella of approaches for comprehensive, individualized assessment. And to be careful observers who ask the right questions and who put personal bias aside to the best of our ability so that access to learning is maintained. Always acknowledging our strengths as educators but more importantly looking at the needs of the child and having that prioritized. I have quite a few works cited that you're welcome to peruse in the handout. That's it. Thank you so much. 

>>Kaycee: Thank you so much, Marguerite. I know fitting those case studies into this short amount of time was difficult but I'm so glad that you did. I think that, at least for me just brought it all home when you think about how it impacts real kids. That's what we're doing. That was so well done. Thank you so, so much. 

>>Marguerite: My pleasure.