TRANSCRIPT - TSBVI Coffee Hour: Cortical Visual Impairment: Considerations for Augmentative & Alternative Communication Development Ð 01-10-21

>>Jen: Awesome. So welcome, everybody. My name is Jennifer Willis, I'm from the Maryland Deafblind Project and I'm sure you are all familiar with my counterpart here, Chris Russell from the New York Deafblind collaborative. We are excited to be talking about augmentative and alternative communication or AAC and cortical visual impairment, CVI. We have created this document to guide you guys in trying to blend both of those assessments to try and create a balanced communication system for a student who has CVI. So what are we seeing out there? We've created this document because what we're seeing is that sometimes that there might be a mismatch in a system that's created for a student with a CVI. So maybe it is accessible for their communication level, let's say that they are a strong formal language user that needs AAC for communication but they might have a system that's not visually accessible for them given their cortical visual or a system that is visually accessible to them but in terms of their communication level isn't appropriate where they are expressively. So, for example, a student who is in phase one using a complex eye gaze system, that might be great. They might be able to handle all of those icons and words that are on there but visually it's just not going to be accessible to them. Or a student who is in phase three, who visually is able to access a complex 2D iPad system with a large array but communicatively they're at that pre-symbolic level and so they don't have that ability to access that level of vocabulary or express themselves in that manner. So our goal in what we created was to develop a more balanced communication plan. So something that is going to balance a child's sensory access. So given where they are on the matrix, their phase and their preferred learning channel. Are they a visual channel, do they need more auditory information, tactile, and balance that with their communication level access. So are they a child who is using formal language or are they still at that prelinguistic level and if they're still at the prelinguistic level do they have access to symbolism or are they still at that pre-symbolic level and that's going to help us determine what type of AAC we're using but how we structure it, how complex it is and, again, we are always incorporating multisensory access, universal design and our biggest thing is to always remember that we want to provide our students with a robust AAC program receptively. What does that mean? It's constantly providing them with access, with meaningful access to receptive information, be that spoken language, be that American Sign Language, if they're Deaf or hard of hearing, we are not limiting with what we are providing them with receptively. And, yes, we can send out a copy of these slides minus any pictures of students or videos. We're happy to share that. Hopefully our people can share that out with you all. So this is the American speech language association's definition of A AC. It includes all forms of communication other than oral speech that are used to express thoughts, needs, wants, and ideas. And so that's a point of controversy for some of us because you know in the Deaf and hard of hearing world we would say that American Sign Language is also a full and complete language, so isn't considered AAC but under ASHA's definition it's all forms of communication other than oral speech but the thing to point out is that we all use AAC, using facial expressions, gestures, symbols, pictures, or writing. So when we think AAC, when we're talking about AAC, we want to think more than just, say, maybe a speech-generating device or an iPad or certain forms of technology. So and students use multiple modes of communication, either simultaneously or at different times for different purposes. What do we mean by that, if my thing would click. So a student may shift modes throughout the course of the day, maybe fatigue-wise. A student may be able to start out using a visual mode of communication, maybe ASL or, you know, a complex device. But as they fatigue throughout the day they might need to shift to more of a tactile mode of communication, be it tactile language or using more auditory information. They may just use multiple modes within the same setting. They might use one mode expressively and one receptively. Different modes with different communication partners. One mode at, you know, at home with their parents versus one at school. Chris, do you have something? 

>>Chris: This is Chris. Yes, absolutely. Thanks, Jen. Just wanted to chime in to say that something that's really important to consider, which Jen started to mention there, is that one thing that's very unique about kids with CVI is that they may actually be able to access modalities that are more visually complex at certain times of day and at other times of day may need modalities that are less complex. The most kind of classic example of this is a child who is in late Phase 2, mid to late Phase 2 of CVI and who is ready for a two dimensional, you know, photo or icon-based communication system when they're kind of at their visual best. But as they get visually fatigued, based on the impact of multisensory complexity, positioning, and just general fatigue throughout the day, they may actually revert to needing three dimensional systems. So a back up or low-tech communication system for a child with CVI might not just be from high-tech to low tech. It might be from 2D to 3D. From two dimensional photos back to using objects as a backup system. Back to you. 

>>Jen: that can also be from environment to environment, a student in a quiet classroom or a, you know, quiet room even where they're able to access that information, might go into the cafeteria and use a completely different mode because the multisensory complexity is too overwhelming. So having a variety of systems available to that child, given what they're able to do in a certain situation. 

>>Chris: This is Chris. One more thing is, Jen, you just reminded me that one of the ways that -- one of the tools that we have available for planning that type of programming, which can sound kind of overwhelming is the CVI schedule. If you're not familiar, the CVI schedule is a way of looking at the school day, all of the various activities and environments, the way that CVI impacts those environments and the child's access to vision throughout the day and what adaptations you might need in order to ensure the child's participation visually or that they meet their visual goals. So you can almost add to that a separate column that's what communication modalities need to be available and part of the program to be considered throughout different times of the day. 

>>Jen: Awesome. Helps determine sometimes why behaviors happen at certain times of the day, help determine why could this child do something yesterday that now they can't or why this morning they were able to communicate in this manner and now they're not able to. It's looking at all that additional information that's happening. So this slide includes a couple of photos of different modes of communication, just as examples for you. Some aided, unaided, no technology, light or high-technology. Since we're kind of on a time crunch with getting all this information in, maybe you guys want to use the chat box to throw in some examples that you have seen or that you've used with students of different modes of communication. So we want to disclose that we are not talking today about what a student is capable of or what he or she may understand receptively. We always want to presume confidence in our students. That being said, as a teacher of the Deaf, I will say as long as it is an accessible means of communication, we need to look at what our students are physically able to access and then what are they able to process and interpret. In regards to receptive information, but really today we are looking at the current levels of a student's expressive mode of communication, which is the results that you get from the communication matrix. And so just a brief overview that the communication matrix, for anybody not familiar with it, it can be found at communicationmatrix.org. It's an online version you can complete, either a professional or a parent can complete. I suggest using both because you will get different information potentially sometimes from families versus what a child can do in a school system. And it covers seven levels of communication. It really is that one of the greatest tools that we have found for assessing expressive communication in children who are prelinguistic who are not yet using formal language and because it starts all the way from those most basic reactive gestures, facial expression that you would get even out of an infant all the way up to formal language, so it really can help you with what a child is doing and how they are communicating. Because we know all of our children are communicating, it's just figuring out the how and what. This is a really nice chart that the New York Deafblind collaborative has created, so if anybody is interested in this, Chris can share this out with everybody. And so it's just kind of a breakdown of the communication matrix that helps give you at each level some examples of what you might recognize in students at that level. Maybe how they're communicating something. And then some strategies for helping them in that -- at that level how to engage with them. How to kind of maybe pull out some more communication and then move them, progress them to further levels. So things we want to be conscious of is where is the student expressively on the matrix, what are levels that they have mastered, and where are some emerging skills. We all know that often we see students do not follow a typical trajectory in how they progress in their communication development. So you might have some emerging skills or some scatter skills and that helps give us a real idea of where to kind of focus our attention in building those skills to become master's level. Are they communicating across different functions of communication. Refusal, trying to obtain something, are they using social skills for communication, and/or informational? And are they able to do those things, those ways that they are communicating, are they communicating them across routine? Are they able to use them across multiple partners or do they only communicate that one thing with mom or dad or only that one thing with their intervener. 

>>Chris: This is Chris. We good? 

>>Jen: I think so. 

>>Chris: I just actually put the -- hold on, one sec, Jen. I just put the document in the chat box, the communication chart that Jen shared with you, so you should be able to click on that to open and download it. If you have any issue with that, you can always reach out to us and we'll give our our e-mail addresses following the session today. So the first question that you want to ask yourself, in addition to completing a comprehensive communication assessment like the communication matrix, which our AAC CVI matrix is partially based on. You want to ask if the student has symbolism, understanding it refers to an event, object, or person. So in the most basic way you can understand symbolism as the student's ability to understand and then expressively use a concrete symbol of any type. The most concrete symbol is an actual part of an object or a whole object. So in order to have symbolism you have to have a symbol. In this case we're using a water bottle cap. That could be attached to a piece of cardboard or a piece of plastic. And the reason for doing that to create a tangible symbol is that it sets it aside and it says that this thing that's attached to a backdrop, this thing that's attached to a piece of cardboard or plastic is separate from the object itself. It's not the object that we're using, it's a symbol and any symbol is going to be given that same background. So does your student or child have the understanding that a symbol refers to something? In order to have that you have a symbol and a referent. So the symbol, the water bottle cap refers to the water bottle itself or to the experience of drinking water. So we're not just communicating with objects as a whole in the action and the experience itself. So on a basic level, does your student have symbolism? Within that we have a lot of choices that we make about iconicity. Iconicity and symbol selection. Iconicity is a scale from concrete to abstract, conceptually and in the case of students with cortical visual impairment, there's also visual iconicity. There's iconicity of visual complexity and it gets very complicated looking at making decisions about what icons or symbols to choose for students with CVI. So some things to consider first are just levels, basic levels of iconicity. On the scale of concrete to abstract, something that's concrete very closely resembles the referent. The symbol bears a strong resemblance. In the case of a child with CVI, bears a strong visual resemblance to the activity or event or the thing that's being referred to. So the most concrete symbol is an icon. So in this case we've got a photograph of a water bottle that represents the water bottle or the experience of drinking water. And it's concrete because we can look at that and we can see that it bears a very strong visual resemblance to the actual thing itself or to the activity itself. From there we have the next step in abstractness, which is an index. And an index does not bear a strong resemblance visually or conceptually but it does bear some resemblance, it's just that we need to have some background concepts and connections from our own experiences and in this case our visual experiences in order to recognize that that index resembles or represents the referent, the thing it refers to. So in the middle here we have an example of a line drawing symbol. It's a line drawing of a little kind of shape that based on our experience we can tell it's a water faucet. It may be a specific kind of water faucet with a handle on the top. It's got that gray color to let us know that it's a silver water faucet but it's a very flat line drawing. Out from the bottom of the faucet there are little lines going down diagonally, almost straight down, and then little wavy lines and that's all filled in blue and we can make the connection in our mind based on our visual experiences and our long history of experiences that that's water. But we make a lot of assumptions when we think that our student can look at that and draw all of those connections. There are a lot of concepts, a lot of abstract concepts and experiences that we pull together in our mind in order to make the connection that that means water. Now, on the far right side you have the most abstract symbol and if anyone can in the chat box, can you explain why that might be an abstract symbol for water? Anybody figure that one out yet? Right, it's H2O. What you see there is like a 2D diagram of the molecules for water. You have the large oxygen molecule and the two little hydrogen molecules coming off of it. I think we would all agree that we would never use that as a symbol for our students to stand for water in a communication system. That would be ridiculous because it's so incredibly abstract and there's no visual connection between that image and the experience of water. But how often do we pick that one in the middle and for our student we're really doing the exact same thing. We're picking something that's so far outside of their frame of reference and we're asking them to distinguish it alongside other images that are not visually distinct. That maybe look similar or that have an equal level of abstractness and complexity. And a lot of the time you will hear people defend the use of these symbols based on their research basis which is really entirely with students who have autism or other learning disabilities. There's no research basis for using a symbol with students who have neurological visual impairment. That's not to say that they're always going to be inappropriate. There may be a student for whom this is appropriate but it wouldn't be my first guess. It would not be my first choice. And like anything we need to be highly individualized in our selection of symbols. These are just some considerations and let's see what we have next. So in addition to understanding the basic ideas around iconicity, you also have the idea of individual experience for kids with CVI. Since the characteristic of difficulty with visual novelty is to impactful to students with CVI, students with CVI, depending on where they are on this range of visual functioning, tend to have an easier time looking at things that are familiar to them as opposed to things that are novel or unfamiliar or new to them. So you have to also ask yourself not only how abstract is this image but also does my student have any experience with this image? Is this your student's experience with water, on the left a plastic water bottle. And then the next one, maybe an individual canteen that they bring with them, their own personal water bottle. Or maybe a paper cup. Or maybe the water fountain. What is your student's experience with water and what we're going to see is that iconicity, like visual novelty, is totally relative to individual experience. 

>>Jen: Chris, I will pose the question to you and to all of our participants, that's recently been on my brain with this discussion, you can't always find a concrete symbol for everything and if we are putting something on a dynamic display, sometimes you need to create an abstract symbol for something or a couple different terms. Through repetition our students can learn what it represents but the question comes up is how many can a child learn at one time? How many can you retain in your visual-auditory memory at one time? If you were to show me one Chinese symbol and teach me what that word means, yes, I might be able to learn that through multiple repetitions over the course of a week or two weeks. But if you showed me ten at one time and asked me to learn ten at one time and then flashed up ten of those same tiny symbols and told me to use them to communicate, am I going to be able to do that and how much time is that going to take me? Just thinking about the quantity our students can learn when we're asking them to learn an abstract symbol. 

>>Chris: This is Chris. Thank you, Jen. Absolutely and that also reminds me that really you're going to find other words or other, you know -- other words that you need to create icons for like core vocabulary, per se, that is just impossible to find something concrete like a photograph for. That's okay. It doesn't mean that our children our students cannot be exposed to or shouldn't be focusing on those words too. That's dependent on the individual student and their communication plan. But probably the biggest consideration for words or ideas that cannot be expressed concretely is that they should look, in addition to how many you present at once, like Jen said, they should look visually distinct from each other. And they should look visually distinct especially from any other symbols that are placed nearby them. So that's where, if you're a speech pathologist, the idea of using a Fitzgerald key where you have an area of the screen on an AAC device that's one color, like all the nouns are yellow or I forget what the color coding is. But it's not that that's an issue in itself, it's that grouping a lot of words together, a lot of icons together and having, you know, ten yellow icons right next to each other, what that's going to do is it's going to make that yellow field of ten icons easy to see and it's going to make those individual icons within those ten yellow ones almost impossible to distinguish. Because what you've done is you've basically made this area of the screen pop out for the child with CVI, but the icons look almost identical to each other that are next to each other. So color coding may be a good option for you depending on your student, but be cautious of putting symbols that look similar to each other, including with color coding, right next to each other. 

>>Jen: Yes, and Maryanna pointed out the more or all done hand PCS images. How much prior knowledge do you have to know what that is? Because ASL is a 3D language so now we're putting it into a 2D format with arrows and parentheses to show movement of how something is moving. That also you need to be able to understand what that's trying to represent. Yep. 

>>Chris: This is Chris, yeah, a lot of those peck symbols require you to understand the concept of an arrow that indicates movement. And you have to be able to follow that arrow and distinguish that that arrow means something. Think about all of the concepts upon concepts that we're layering, let alone those kind of egghead symbols for feeling that all basically look exactly the same as each other and maybe the only slightly distinguishable component is the shape of the mouth or a little tear or something like that. So just be cautious of symbols that look similar to each other. 

>>Jen: While we're talking about symbols and what we're choosing and the order we choose symbols in, this hierarchy is very similar to what you'll find on the APH website, we need to start out with students with that whole object and maybe the identical object to what they're using, so their shoe, if you're choosing a calendar system or communication system, whatever it is, it might need to be their exact object, their shoe, their spoon, their cut that you're going to pour the liquid in and they get to drink right out of it. They directly correlate that object with its function or the activity that it's being paired with. And then once the student learns that, then we can move to some more of a partial or an associated object. If we're looking at miniatures in that format in any way, we're choosing miniatures that can still get all of the features of that object. So, for example, a bus might not be something that we want to use in a miniature format because our children with CVI might not be able to fully take in and capture all of the visual aspects of a bus. The size, the color, the wheels, the doors. All of those pieces. Their visual and tactile experience is going to be more limited to things that they can touch, what's directly in their field of vision. Maybe it is the doors and the stairs or it's the strap that they use, whatever that might be. So making sure objects are associated with that child's experience with the activity. Photographs, of course, we want to choose regular photographs before we're moving to picture symbols or print or Braille gets even more abstract. And then spoken words or signs are our most abstract in this discussion, because once they're out there, they're gone. Once we say you're going to music class or we sign it to them, they don't have that concrete thing to refer back to again and again. Oftentimes some of our children need some repetition. Some redirection from a transition from one point to the other. So having something concrete that they can hold in their hands allows them that to refer back to. And there's a question in the chat. When a child is always choosing the symbol or picture that is red in color, how would you present symbols to help them differentiate them? Because red is their preferred color? Is that why that symbol or picture is being chosen? Correct. So red is their preferred color so they're always going for the things that are red. So you can add in their preferred color in a way or form into other things. We can modify that and adapt that, adding in a little bit of red, red tape on something, red flashlight, highlighting something so we can add some red to other symbols. 

>>Chris: Another question there, that also suggests maybe that the student doesn't know the meaning of the symbols and is just -- unless I'm interpreting that incorrectly. If the student is selecting something based on it is visually attractive. And not based on understanding of the symbol itself, right? So if that's the case, then I would work on -- well, depending on the student's visual status and visual needs, if the student is able to look at other colors besides red, like bright yellow, bright green, something like that, then I would use those colors to distinguish visual icons that you're trying to teach the student. And I would almost shy away from red a little bit unless it's to sustain visual attention, to elicit visual attention. That's an interesting case and definitely like a bigger conversation too. 

>>Jen: I literally needed an example of Braille. That's the only reason the Braille word isn't shoe, because that's what Google had as a visual example. If anybody can help Google images to have more diversity in their images of what Braille looks like, that would be great. That's a question too, where is the student on the CVI range. If they are a phase one student, they might be gearing more towards red symbols. You know, because that's their preferred color. As we talk about it in the matrix, we're going to need to add in more tactile properties demonstrating those objects because at that point they're not able to visually make those distinctions. 

>>Chris: This is Chris. Also, we should come back to that question too. If you still have additional questions about it, when we get to actually show you the CVI/AAC matrix. I think maybe some of the answers to that question are there but they're unique to your student. Jen, is this me or you? 

>>Jen: It's you. 

>>Chris: Cool. All right. So this is a shortened version of something that we provide a lot of information on in the appendix of the CVI/AAC matrix and if we had another hour we would probably spend at least a half an hour on these things, but this is just to remind you, just like with the ASHA definition of AAC, that AAC is not just high-tech. There are a lot of pre-symbolic and concrete communication strategies that are really important to our students' communication program, even if they are also using some abstract forms or some high-tech forms. We're not going to go through each one of these things but if you need additional information on any of these bullet points, any of these strategies and approaches, all of that is spelled out extensively in the appendix, which we'll show you. Especially around, you know, touch cues, name cues. We're going to talk a little bit now about tangible symbols but just give you the five--minute version. I think it's important to emphasize that tangible symbols, I'm sure you all or at least most of you are familiar with tangible symbols and concrete symbols and the many kinds of tangible symbols that are out there. I think it's important to emphasize that tangible symbols or concrete communication is really not a level of communication development. It's more like a bridge or a stepping-stone in between pre-symbolic and abstract communication. So what that means is that everything before on this chart you have tangible symbols kind of in that middle place where the arrow is pointing to. Everything above there is pre-symbolic communication. Communicating through behaviors and gestures. And at the very earliest level, even just through reflexes and action. Everything after that is the beginning of actual language and first words. So a lot of our students, many of our students who have visual impairments and complex communication needs and other adaptive needs really need to have a stepping-stone between pre-symbolic communication and the acquisition of first words and very often that stepping-stone is the use of tangible symbols. I wanted to emphasize that because I think very often tangible symbols are considered sort of an end goal and tangible symbols should not be an end goal. They are a means to achieve the end goal, which is language, which is symbolism. So once you have symbolism, you need to build on it. And that's especially important to understand because we need to create systems that can grow with the child as they grow. We need to have systems that can expand but they can also turn into other systems. And I'll show you an example of that on the next slide. So this is an example that we've pulled from past literacy. It was, I believe, created by the parent of a child with CVI and this is a really nice example of the transition from basically the sequence of communication development as the student goes from communicating through concrete objects to communicating with a more abstract transitional and symbolic communication system. But what's unique about this is that not only does the communication system expand and grow on a conceptual level, on a communication level, it also grows on a visual level because for a child with CVI the student's vision is improving at the same time as their communication is expanding. So in the first slide on the left we have a basic calendar box system. The student is communicating through the objects themselves. We go to our calendar box and we get our lunch out of calendar box. Now we know it's lunchtime and we're going to actually take the object itself that we use in the activity. So that's not really symbolic communication. That's communicating through objects themselves. And we go and put it in a finish box, we come back and get the diaper, we know it's toileting time or changing time. On the next image on the right we see that system growing into a tangible symbol system. So now we have 3D parts of objects used as tangible symbols. On the next one here -- there we go -- we've got those same symbols transformed into 2D symbols because presumably this student at this point now was able to view two dimensional materials, probably a child in mid to late Phase 2. Now, at the same time as we're doing that, we may also be creating a transitional communication system. On the next one you'll see that those same symbols and more can be used on a communication board. And there's always the question of when do we start this part. You can start this part at any time if it's providing exposure to that language and to that system. But expecting the student to use that independently, this large-scale, you know, complex communication system, whether it's a physical/manual board or a high-tech board, the student might not be ready for independent use of that until they're a little further along. Go ahead. So this is another example, and I think this pretty much speaks for itself, by Rachel Bennett, a parent of a child with CVI, who also works for Perkins now, also on literacy. If you go to the next one you can see it larger. This is a board she developed for her son with CVI around this photo, around mid to late Phase 2. Able to use photos of real objects but those photos have specific adaptations to them, black background, yellow highlight to make the shape of that photo, shape of that image pop out. And then we've got one of those APH black-rimmed trays with yellow tape to distinguish the before and after or first and then a little green dot on the left and a red dot on the right to also make that really pop out. Visually very simple and appropriate for a child in mid to late Phase 2. Okay. Back to you, Jen. I think you're going to show them the matrix itself. 

>>Jen: Yep. And we're quickly running out of time. Time is quickly going but there is a good question in the chat box about what would be a good tangible object to represent bathroom for an older student in Phase 2 that is more socially acceptable. So, again, this goes back to what is that -- it would have to be individualized to what that student's experience is in the bathroom. Is that potentially a roll of toilet paper? Is that potentially, you know, a glove because they experience the adults wearing gloves when they're in the bathroom. Is that, you know, could they -- if they are late Phase 2, could it be a picture of the sink where they wash their hands after they go to the bathroom. What is that student's experience still within that activity? And then choosing a more appropriate -- socially-appropriate item. I will tell you Sandy oftentimes will choose a photograph or the 3D of male or female sign that you typically will see outside of a public bathroom as a way to represent bathrooms because that helps teach our kids when they're going out in public as a way to recognize what a restroom, that is usually the symbol you see for restroom and help them identify where the bathroom is out in the public setting. All right. Let's move over now to the matrix itself. And so here is the document that we created and a quick run through of it is you will all have access to this. This is going to be shared out as one of the handouts so everybody can go through it themselves. But really we just kind of have an intro and a before you get started information. If anybody needs more information on CVI or the communication matrix itself, there is a ton of one-line resources. There are a ton of webinars, opportunities on YouTube around the communication matrix. So really there's a wealth of vision out there if you need to learn more about either of those. And then we get into some of the information that is included is stuff that we have gone over or will go over in this presentation. So just a little bit of background, tips, ideas, what Chris is talking about creating a schedule that grows with the child from 3D to 2D and then to print as they're capable. And then we get down to really what we like to highlight today just is that so in the communication matrix itself there are seven levels of communication identified and in this document here that we've created, we break those down into three. So those three pre-symbolic areas of preintentional behaviors, intentional behaviors and the difference between those is what is behavior that a child is doing to gain something or get out of something versus behavior that they are directing at someone to communicate something. We kind of incorporate those all in that pre-symbolic section. Then we have our concrete communicators who are using concrete objects, tangible symbols, photographs, whatever that might be, and then our abstract communicators. There is some just overarching general considerations for CVI around the different phases just to help everybody to keep in mind with all of our students with CVI. There is a chart here where you guys can plot where the student's at, taking their CVI range score and their communication matrix score and plot where you want to go in the matrix, the area you want to focus in on and look at. Student might be in more than one area on this so you might need to check definitely in regards to Christine Roman's sensory balance, when she talks about her sensory balance chart, some students who might be able to be able in 2D in one section might be of a concrete or abstract communicator, might need something more concrete in certain situations or given their multisensory complexity. Just being able to look across different areas. It gives you that option. And then we break it down by phase, initially. Everything's broken down by phase and in each phase there are three columns, one for the emerging pre-symbolic, one for concrete and one for abstract. And we break down early and late Phase 2, because those can be very different for our students. You know, that's before 5 on the CVI range. We might be looking more at the tactile or the concrete, the 3D. And then as we get above 5 and we can start getting some more object content, we might be accessing some more 2D information. So it gives you really the changes and the considerations are just the considerations for 2D pretty much between the early and those late Phase 2 considerations. It includes some things to consider for sign language and other tactile input systems for those students who are Deafblind. And then everything that we talk about or mention in the matrix itself we have an appendix of terms that covers all those things, gives you examples, places to find additional information, more resources, and hopefully anything you could ever want. All right. All right. Let's see if I can get back to our PowerPoint. There we go. So what we're doing -- Chris, we've got about ten minutes there. Are there things you think we should highlight specifically? 

>>Chris: Yeah, this is Chris. Yeah, I mean, I think we don't need to get detailed about each phase because that's really all in the matrix. What you want to do is Jen just showed you the matrix itself. You need to know, as she shared, what phase the student was in. Even if you don't have a comprehensive CVI range score, you would do a phase estimate and you need to know which of those three levels of expressive communication your student is currently in. And then you're just going and looking at the considerations there. So did you want to point out anything specific about Phase 1? 

>>Jen: Not so much Phase 1 as I think I would like to show them the system created. 

>>Chris: Yeah, let's do that. So one thing to say really quickly there is that this is something that comes up very often. You may have a student who's able to access a high-tech device with a complex array using motor planning, using motor memory. That's totally okay. If you do have a student who's accessing an array using motor memory effectively, you want to still make visual adaptations. And the reason for doing that, even if the student isn't using it visually or accessing it visually is you want to reduce the visual complexity of the array so that you are at the same time reducing the amount of fatigue that the child is experiencing based on having that busy array in front of them. And I have seen a child who was in maybe early to mid Phase 2 using a high-tech array as complex as this one on the screen here, like a lamp or chat screen, and was doing it all through motor memory so the extent that when we actually covered up or dimmed the screen, he was still able to do it. So that's great. It was working fine for him as a system but having it be so visually complex was actually causing him to be fatigued over time. So just keep that consideration there too. 

>>Jen: Chris, this is a question for you. Any opinions about preferred CCTVs for students with CVI? 

>>Chris: The thing about CCTVs is that the purpose of a CCTV for a child with CVI is not to increase the size of something. It's to decrease the complexity of that thing or to offer some of the other options that CCTVs have which is containing something in a contained space in front of the child at eye level rather than down at the desktop level for their visual field. And also, you know, most CCTVs have a reverse contrast or even like the yellow on black contrast, which can be pretty good for a lot of kids with CVI. But, remember, it's not for the purpose of making something bigger, it's for the purpose of reducing the complexity. You know, models of CCTVs, everyone has opinions. I think Vizio books are pretty good just in terms of their portability and durability. 

>>Jen: We're highlighting some different areas in the matrix itself, which you guys will be able to see. Just considering that the difference in concrete symbols for students with CVI, we are looking at them based more on their visual properties, not their tactile properties but initially, if that student is starting out as a pre-symbolic communicator is going to need to be tactually distinct for them to be able to identify it. This is a visual example of a light switch that the child can have to turn on and off the light, whatever that represents. But it adds that visual cue to them that the yellow color, the light helps make it a more visual engaging thing. And I think we're just going to skip over the video itself but this is a student who started out, as you'll see, with this 3D communication system using tangible symbols. She's got a lot going on with some support visual. You'll see the black background. We have CVI support here. We've got the black background. We've got the red rim around the object that's for her current activity, the red rim around the finished box which helps with her lower field access. And then she is a student who is, as you will see in a later photo, so the system builds with her. When we're talking about building from a 3D to a 2D system and for different purposes. That was her schedule system. Here is a visual representation that they have taken from 3D objects for her favorite song that she listens to. And so we use the choice options that we have then made into a 2D option either low tech or high-tech. Again, we're growing with the student both complexity and language-wise and options and ways they can communicate, as well as visual. Visual fields and, Chris, what are some things that you want to kind of highlight? 

>>Chris: Yeah, this is Chris. This is another frequently asked question, what about eye gaze systems and when are they appropriate. Eye gaze systems are only going to be appropriate, even possibly appropriate for a child with CVI if they are able to establish eye contact as opposed to visual regard, that looking past or through something that children with CVI often do. That's at the very earliest at 4 to 5 on the CVI range but also consider the amount of fatigue a child is going to experience if they're expected to utilize a device like this. I've seen a student who was able to use -- who tested very well for a Toby eye gaze device and was referred for one because the testing environment was a nice quiet room with no other distractions and the child was well positioned and there was no auditory input or other physical input that the child was dealing with. That same child in the classroom was completely unable to use that device at all when there were additional multisensory input. Consider that. Also consider what two dimensional icons you're using and the difference between exploring a visual system of icons versus just playing a game, which is a lot of what you see in the testing modules. Question about the PRC accent 1,000. It's mounted on the back of the student's chair because he doesn't use his vision to make selections. Is that a problem? You mean is mounted on the back of his chair, not even in his view? He's memorized the word locations and seems to be quite proficient. If the student is proficient then I wouldn't say that there's a problem. But like with this example right here, the speak for yourself full array, just because the student's able to use it doesn't mean that you might not make additional adaptations to reduce fatigue. Yes, switches to scan by hearing, sure. If that's working, that's working. Just consider that all of our students are multimodal communicators just like we are so there might be additional modalities to use in settings where that device isn't working for the student. Oh, wait, what happened to those -- oh, did you move the slides around? 

>>Jen: Nope. What do you want? You want these? 

>>Chris: Awesome. Okay. This is just to show you, we wanted to wrap it up by showing you a couple of examples of complex 2D systems. So these are examples that I've really seen from real students and their teams were kind enough to let me use them in the presentation. So this is an interesting idea here. The yellow star means want. The blue triangle means play. The green arrow means go. The red heart means like and so on. One of the ways that I like to test how well is this working. And of course this is not going to be for every child but this is a good sort of gauge to see is this working, is this visually distinct? If you're looking at your laptop right now or your computer screen, don't look directly at the screen. Look at the top left corner of the screen. Fixate on the top left corner of the screen. Try, can you touch the yellow star, which means want. Can you touch the blue triangle, which means play. Can you touch the green arrow which means go. Can you touch the red heart, which means like? Not too bad because these are visually-distinct icons. They pop out. However, they are conceptually very abstract. So if we go to the next slide we see the exact same concept with sight words. That's not to say that your student already recognizes sight words but sight words are just as visually complex but they are conceptually more concrete. They're more understandable to a wider number of people and they're more conventional. Try again, look up at the top left corner. Can you hit the green word go? Can you hit the red word like? Can you touch the orange word help? Can you touch the blue word play? Can you touch the yellow word want? So if you're going to do the latter, why not do this one? And if you're doing that, you might also consider making a cutout window in the exact size or shape of the icon itself to be able to provide partner-assisted scanning or to show the student where to look. Or even to model communication for you SLPs out there or teams who model your own communication on the device that you're using with the student. Instead of using a touching or pointing model, use a visual model for a student with a visual need. So a visual prompt rather than a gesture or verbal prompt. And I think that's about it. Jen, do you have anything else you want to wrap up with? 

>>Jen: I think we're good.