 And if there are questions, you'll just shout them out to me. I sure will. Yeah, I sure will. Okay, well, welcome, everyone. It's one minute past our starting time. It's Roy McConnell here in Edmonton. Welcome to everyone. We've got Dr. Christine Roman beaming in from Bobby Pittsburgh. So, Christine, I'm going to turn it over to you. Okay. Hello, everyone, and welcome. Today, we're going to talk about CVI and orientation and mobility. And I am an orientation and mobility specialist in addition to being a teacher in the visually impaired and an infant developmental specialist. So, I was the reluctant O&M instructor. I didn't really ever want to become an O&M person. But when I learned how intrinsic it is to the well-being of our students, it seemed like the logical thing for me to follow through with. So, I'm going to share some thoughts with you today about orientation and mobility through the CVI perspective. And as you will know, the O&M stands for orientation in space and then safe and efficient movement through space. And in my practice, I find that I put way more emphasis on orientation in space than I ever thought I would find necessary, but it's just a really, really critical factor. And so, for kids with CVI, obviously, CVI is inherently different from oxygen forms of visual impairment, requiring different assessment instruction and adaptations. So, the same is true for O&M. And Roy, I still can't get the box off the corner of my screen that I see an X on it now that says Sue. It's okay. I just can't always see all the words that are on my screen. Yeah. You know what? I don't know what that is, Christine. I can't see anything. Okay. And I've got your PowerPoint is up and it's just fine. Yeah, there we go. All right. So for me, so it all begins with assessment and the CVI range is used as the functional vision assessment for kids with CVI, whether you're approaching it as an O&M instructor or if you're approaching it as a vision educator. I should tell you that there is some work being done right now on developing a new learning media assessment for kids with CVI. We're not calling it that per se, but it is Matt Teigen and I are working on a thing that we think of more as sensory balance that also, you know, that's part of the repertoire of tests that you use. Obviously as a teacher, the vision impaired, it may or may not impact your O&M instruction that we're going to evaluate additional skills of orientation and mobility, not only the CVI range, but then we're going to also dovetail that with O&M skills. I should say that some of you may have found that the revision of my book came out about 10 days ago. Oh, I see people. Hi, can you see me? I can see you. That's what that little window is. Okay, you're going. And so the book came out about 10 days ago. And then the third book is, so there's the first book, there's the revision and the third book is coming out in about what they say this summer it will be out. And in that book there is a very, very long chapter on orientation and mobility in CVI. So today you'll be getting more of an overview of the concepts that you'll see embedded into this very, it's like an 85 page chapter. It's very big. I think that will help. But some of you also may know this tool, the preschool orientation and mobility screening. And people could just log on within your chat box there to let, I'd like to know how many of you know about the preschool O&M screening that was originally written by Bonnie Dox and Burke and then revised by Bonnie and myself. And the boy that is on the cover of that is a little boy who has CVI actually. Roy, anybody logging in if anybody's aware of the preschool orientation and mobility screening? Yes, no? No, sorry, sorry, Christine. No, I've got a couple of couple of notes. I've not seen this one. Okay, so this has been around Bonnie wrote the preschool orientation and mobility screening originally, I would say in the 1990s. And that was written as part of a project that she did at Vanderbilt University. Bonnie ran a model classroom at Vanderbilt for preschoolers. And out of that came this really important screening. It's used with preschool-aged children, and it looks at not just, you know, the movement skills, but all of the orientation in space skills. And there's a section that integrates the CVI information in there. I'd really, it's available through AER. It's the Association for the Education and Rehabilitation of Blind and Visually Impaired. And it is, but it's AER. If you look at AER publications, it's there. Okay, I also promised I would talk a little tiny bit about the resolution chart. And the resolution chart, the name of this will also change dramatically because the O&M resolution chart, it will now be called the O&M progress chart. And it is intended to do a few things. So once you do the CVI range, then in only after you do the CVI range do you use the resolution chart now called the progress chart. The word resolution has basically been taken out of the entire lexicon of things that are described in my work because we really find that true resolution almost never really happens. Individual pieces of CVI might resolve, but not the whole condition itself. So the resolution chart looks like this. You can see how old it is. And that's why, thank goodness, it got revised. But it is meant to be a way to look at Phase 1, Phase 2, Phase 3, CVI. I wish I could move this box. Phase 1, Phase 2, Phase 3, CVI. And then if you see that the overarching concept is, this is just like, by the way, the resolution chart, the CVI resolution chart that's in my book. This is also in that first book. But this one now we're looking at very specific O&M concepts embedded into O&M. But the phases remain the same. And the overarching goals remain the same. But we're going to talk more about the environmental considerations rather than direct instruction in the classroom or home instruction or interventions. So you'll see also that the CVI characteristics are listed down the left side and across the top under those three boxes for phases are the segments that reflect the segments in Rating 1 in the CVI range. So it says range 1 to 2, then 3 to 4, 5 to 6, 7 to 8, and 9 to 10. So if you look at color, you'll see that there's a statement there that gives an idea about how color may be used. Single color environmental features may be a 10 to 2, but only at near because it's 1 to 2 in the range. All the way through the highest level where it would say safe travel not dependent on color cues. So the entire spectrum is kind of laid out there as you go higher on the range. And that's broken down for each characteristic. So you can look at the effective movement and latency. Okay. And I'm trying to get to the next slide. You see visual field complexity. This light one has been revised to reflect five continuous points of information. It doesn't stop at the third place. Okay. We'll look at distance viewing, reflex responses, novelty. Now, if any of you remember and then visual motor, if any of you remember or have used the O&M resolution chart, I mean, just the CVI resolution chart, you remember that it's also a place in which there's a way to make comments or to make accommodations or awareness when there is a coexisting ocular condition. So the way this chart is used is that you would put an X through any statement that represents a resolved statement, something that no longer affects the child, just put an X through that box. You circle, you highlight any box. So you just put like color highlighter around the statements that are true of the child. And you put an O on the statement that might be, it might never resolve or is influenced by the child's ocular issue. So if a child has, if they have retinopathy of prematurity, stage three, they may have some visual field issues, right? Where are they? They may have some visual field issues that affect their extreme peripheral field, right? That may never resolve. Okay. There's the instructions there. If somebody can put the thumbs on you, I'm hearing a lot of background stuff. Thank you. Okay. So in the way that you use it is all described in the book in here as well. But let's look at some of the more individual critical considerations. Okay. So let's look at some of the characteristics and the way they affect the child who's trying to either become oriented in space or move safely through it. So we have to look at things like the level of complexity. We have to look at the effect of color, the degree of novelty, the child's distance abilities. But let's also take in mind that we have to think about the type of traveler that that child is. One of the first things I try to figure out is whether the child seems to be, whether they're moving independently, moving with assistance, moving with a mobility device, moving with a gate trainer, moving in a wheelchair, somebody moving them, they still will fall into one of these three categories of traveler. Would it be helpful if I describe what they are, route and large space? Should I go ahead? Do you guys just know this already? Or should I describe it? I think you should go ahead. We've got some folks that aren't TBI's yet. So the road traveler is the person who is the most limited, has the most limited skills in traveling. And that person has to, they have to use the exact same route every day. They have to go from point A to point B the same way every single day. And even turn, reversing that route, even turning around and going back, will make it very, very hard for that individual to figure out where they came from and how to get back. So they have to do things the same way. They have to memorize it, and they cannot deviate from that memorized, very simple from point A to point B travel. I often look at kids when I, when they come to Pediatric View in Pittsburgh, I have an activity I often do where I do this sort of simulated treasure hunt thing, and I pick up objects out into the hallway, some that are familiar, some that are novel, and I place them in lots of different locations because I want to find out a bunch of things about their CBI. But after we're done with that activity, I asked the child to get us back to my room. So show me where we came from. Can you take me back to where we came from from my room? And when we do this, there is literally, there are literally two turns to get back. There are two turns, no more. There's no way you could have more than two turns. And I can tell you that fewer than 10% of the kids I see can do that. That tells me those kids are not gathering information incidentally from their environment, and that when they're in a horrible place, they have not sought out any information that tells them sort of like where they are. They're rote travelers. I could maybe teach them how to, you know, get from point A to point B. But if I changed anything about that, so there's a second way to get into my office from there. And if a child is a rote traveler, they actually can imagine some, their flexibility in the way that they consider space. So they not only can get from point A to point B one way, they may be able to reverse that route. They may also be able to have an alternative route, but it's all within a fairly limited space. And those are, they're still fairly rigid. So the person has a little more flexibility in their ability to move independently and to think about where they are. But you couldn't, you would have to sort of build that, those couple of approaches based on a central point that never changed. And they're still pretty rigid in the way that they get to those places. So the, so the rote traveler would be the child who, if they could get back to my office with those two simple turns, I might say to them, well, what other way can we get back to my office? And in fact, there is, there are two other ways, there are two other ways you could get back to my office. If the child knows that they can go, you know, this other very simple direction and make two different three turns, that person is a rote traveler. But what if that person says to me, well, in addition to just going back to your, your office the way I memorized it, in addition to knowing there's one alternative way, but it's still pretty close. It's almost parallel to the first one. I can suggest that we could go down that staircase, go outdoors, go around to the front door, come back in, go up the elevator and come back to the first floor and get back to your office that way. That person is what's called a large space traveler. That person perceives that the route, they understand where they are in space. In a large mapped out way. So they can imagine the destination and lots and lots of space and lots of alternative ways to get back. Now, this is really important because kids at CVI are really impacted on their ability to ever become a large space traveler because of things like complexity and novelty and distance viewing. They're very likely, it's very likely we can teach them to become travelers and we always want to help the child be more than a rote traveler. I also want to mention, if you think about your own travel, think about your own abilities and think about what GPS has done to all of us when it comes to learning large space. We don't learn it as much if we're dependent upon someone else giving us the directions. In 50 feet turn right, in 20 feet turn right, turn right, you now should have turned right. You're so prompt dependent that you don't have the need to gather information about where you are. So heaven forbid your GPS doesn't work or your phone doesn't have any more power, you're just lost, completely lost. That's how our students are, that when we prompt them and say, come on, turn, we're going to the bathroom, come on, you can do it, turn again, let's get to that door. Okay, let me push you into the bathroom. They're never going to learn anything more than rote space because we have not asked them to do that. And they are now so fully dependent upon us being their GPS that they don't have a need to seek out information in their world. And that is a very, very big problem. Okay. So remember with kids with CVI that the ocular visual impairment rules just do not hold true. That once every all of us to reconsider our thinking that it's not about contrast like it is with ocular. So with ocular, we often think about black and white is the highest contrast material, very helpful. But for individuals with CVI color is the key. It's not about acuity. So it's not size plus distance. It's about the complexity. One of the things I'll talk about in our short time together is that, you know, when someone, there was no one in person that told me in an IP recently that she was working on lighted intersections with this individual CVI. And I asked her under what conditions and she said, well, we're working on this intersection and we go to this one all the time. And she didn't know what I meant. And what I meant was at different times of the day or under different conditions, if there are more complexity around that intersection, the skill that the child has when the intersections quiet is not the one that the child will have when there's complexity. It's not about increasing light. It's not about just making things brighter. And it's not about being stable in space. It's about moving because individuals with CVI literally see better when they're moving. We're going to make adaptations based on the characteristics of CVI and I'll show you some examples. And one of the big principles to think about is that we need to pair environmental prompts with natural landmarks. So when I'm not a big fan of putting, you know, a bunch of stars like red, shiny stars along a hallway for a child to follow to get from the front door to their classroom. So what I'm more a fan of is pairing that landmark, looking for a natural landmarks like a corner, like a water fountain, like a door, like something that's not going to move and that we actually use as landmarks ourselves and that if you're going to put an adaptation on something, put it on something that eventually doesn't have to be adapted because the child is now noticing the real landmark. If we're just putting stars randomly along a hallway, the child's not really learning what the environmental cues are that can be used long term. So I want to also just make a few mentions of the importance of maps. So a lot of people think that maps are something that you teach a child to read when they're starting to move independently. Like I want you to get from here to, you know, the McDonald's restaurant, if you can call it a restaurant. And I want you to be able to show me on the map where that is. Well, that's all well and fine. But maps can also be things that are simple representations of space that are used in a very cognitive way that start way before a child actually has to find a destination. They can be object-based. They can be representational. So they can be object-based meaning, let's look at this map. This is a map that has some objects on it. And the objects are, you know, this block is your, this rectangle is your door. This little toy bed is your bed. These two squares put together are your dressers, you know, and so on. That's an object-based map. And if we ask the child, all right, so show me, if you're sitting on your bed and you needed to get something under your closet, would you turn right or stop that kind of thing? Representational maps would be something where we would just use, like, the Wheatley Kit or the Chang Kit and say, okay, I've got some shapes here. And these shapes, they don't, you know, this rectangle represents your bed. And actually before I actually mentioned the representation, because the two squares representing the dresser would be representational. If you would use it just object-based, it would be actually a little toy dresser. They can be incorporated into backlit systems. Some of the most successful maps, helping kids understand where they are in space, what's in front of them, what's behind them, what's next to them, how far away something is, how far away two objects are to each other. All those things, all those exercises and activities that are incorporated into a backlit system are so much better for kids with CDI because light, you know, really supports their visual attention. They should be, maps can be used to help children identify the salient environmental features to help become oriented in space. So a salient feature in literacy activities or in, you know, learning activities that are based on school tasks are one thing. We know kind of what those are, but salient features in the environment are also just as critical. And we'll talk about some of those things. Maps should also help the child be proactive in both orientation and mobility. So instead of waiting for someone to prompt them, they actually will think about this very simple representation. And again, if the child's a rote traveler, it's just going to be here are the two points. You know, we know that this little toy door represents the door we go out. We know that this little toy spoon represents the cafeteria, but a map to do that can be helpful because when you come out of the cafeteria, you can say, well, gee, we were at the spoon place because we were in the cafeteria. So now where do we start to go back? These things really matter. So let's talk about some of the characteristics relative to O&M. So color. Color in the environment is just as important as color on materials and math papers and so on. That color, you know, anchors visual attention in all cases. So just as it anchors visual attention when you're using it in a communication, you know, device or you're using it for a child to make choices or you're using it for a child to learn what the shape of a letter or number is, it's also going to anchor visual attention in the environment. It also can help sustain visual attention. And it can assist in identifying salient environmental features. So here's a simple example. OK. Stop signs are read for a reason. They're critical for people's safety. And so red is a color that the brain sees, even if a child has no visual cortex, the brain stem sees red. So red is a really important anchor for, if you see something in the environment that is red, it may be a great assist as a child learning where they are in space. You know, signs that used to be black and white are now fluorescent colors because when vision science taught, you know, safety people that they're much more likely to notice something that has vibrant color, which is helpful for us as O&M people as well. Exit signs are an example of something that is a very common and very available environmental feature that in most cases looks like this. It has both light, low complexity and red. The child doesn't have to be able to read the word. We can just say there's a word up there. It's spelled E-X-I-T. It's exit. And what that means is that there's a way out here. This is the way out. This is their doors here. Also, most exit signs are located in a fairly non-complex place in the environment, just like this picture. They tend to be up closer to where the decorations are not. This is a color, an example of a color post that is in some cities. In Pittsburgh, for example, they're everywhere at certain crossing areas where there's a crosswalk. These posts are put there to keep cars from coming up onto the curb. And it's for public safety, but boy, and it's not going anywhere. So it's a great landmark. And it's extraordinarily helpful for a child to identify a corner. Let's talk about the characteristic of visual fields. That's a very important one. Most children with CVI have visual field issues. So even if they've been to the eye doctor, even if they've had a low vision evaluation, please do your own assessment. Do your own field assessment because functional visual fields are very different than the ones that are elicited sometimes in the electronic ways that fields are evaluated in many offices. Even in phase three, visual field differences can affect O&M for sure. And it's important to recognize that most, I would say, 85% of kids with CVI have lower field losses. And those are not the projected lower field loss of like looking ahead of you on the ground. It's that one that is an extreme lower field that is sort of where your toes are. So kids with CVI might be able to see there's a curb coming, but when they get to it, they can't be sure where it is in space. So drop offs are particularly dangerous, particularly dangerous. And drop offs that includes descending stairs, okay, curbs and surface changes are all really hazardous. So a lot of kids with CVI that are ambulatory are thought to be clumsy because they don't seem to notice something on the floor. Parents will just find themselves saying, no, I never let them walk down the stairs without grabbing the railing with two hands, so it's also not terribly safe. But they, you know, they talk about how, you know, they might say something like this happened just this week. The parents said, oh, I don't think he has any trouble with curbs. And they said, oh, tell me what happens at curbs. And they said, well, as we're getting closer, I just grab them. And that's why they don't have any trouble because, you know, the child's not doing it themselves at all. So field, because of visual field differences, a cane along cane may be necessary. If you have a child with CVI who uses a cane, could you just enter that into the chat box? And maybe at some point I can hear about that. So it's fascinating to me how, how very, so first I should tell you that I have pediatric view data that are on almost 500 children that we've seen at West Penn Hospital at pediatric view of those 500 children. I have a record of all the services that the children receive. And whether they received them now or anytime in the past, it's documented. And of those nearly 500 children, only 50 of them have received received orientation and mobility sometime in their life. And I find that shocking actually. Of the children who do receive O&M, many, many, many of them use a cane. And it's, again, really helpful to begin as early as possible, even if the child doesn't use it, you know, in their school or in their home. It's a great thing to put in their hand to teach them a constant contact method or with a big red ball tip to not only anchor them to the ground, but to the feedback that you get through your, the kinesthetic proprioceptive feedback you get that comes through the shaft of the cane itself. And also it's a great thing to find drop-offs in obstacles in your lower field. By doing so, kids at CVI often can, for the first time, pick their heads up when they're out in space, out in the environment, and actually try to seek out those cues and landmarks. They're really teeny little cane. This is a place that shows how color it was used, color and movement, because there's shiny stuff there, to, as a place where this child, a child would hang their cane. And this is a little video clip of a child with difficulties in their lower field. So I hope this works and you can see it. Oh, fully, it's not going to work. Why is it not working? But what it showed was of a little boy, the little boy in the white shirt at the bottom, he, he's going once, he, his goal is to go across the floor to see his sister sitting in a chair over there. And that's the nearly impossible task because he doesn't, he looked at all these toys, he knows you're on the floor, but he can't, when he gets too close to them, they just seem to disappear. All right, let's talk about movement. So, you know, humans are inherently attracted to targets that move. It's part of our dorsal stream response that keeps us safe. So when there's something moving, we don't think about it often, it's a subconscious response to notice. We just do it. So dorsal stream vision is pretty much subconsciously where ventral stream or detail vision is a conscious visual act, response to movement and other dorsal stream targets are unconscious. And individuals with CVI have this like hyper focused need to notice movement because it's one of the few things their brain can perceive clearly. And so individuals with CVI can more readily locate targets that have movement properties. But it's also important to remember that movement can be a source of distraction and also a danger. So things, this is a, we'll get to the danger thing in a little while, but this is a Brody's seat. And this shiny thing is the brain thinks they're moving and red is a color that attracts him. By the way, lots of times it doesn't have to be red, you know, just attraction to color in itself means that is a way a lot of kids respond to doesn't always have to be one color, but color is critical. But because of the movement Brody can actually get to his seat at the table independently, where before he always had an adult leading him or he just found it randomly. The same thing is applied to the doorknob because this is just a little prompt. This is something that is paired with a functional task of finding the doorknob and trying to open it. Instead of him just kind of careening in the direction of where he thinks the door is he actually locks on visually and moves in the direction of that object. The Braille by the way is for another child in the class. Some things have movement properties that we don't always think up. So these are shiny silver buttons at an elevator that in and of themselves have movement properties because of the shininess. Now if I wanted to help the child always find the fifth floor. I actually also put, you know, like a red disc or put something fluorescent on that five, but just to find the plate where the buttons are. It's actually very attractive on its own, because of the shininess the sense of movement. There are some things out in the environment that have movement properties. I would have put a, I should have put a flag of Canada in here shouldn't I. I'm going to avoid saying something political right now, but you know what I'm thinking and I'm with you Canada totally. Anyway, as many of you know I want to be Canadian, but since they won't let me in much anymore. But, okay, so flags and things there certain things in the environment that we just ignore we just are subconscious just says oh yeah movement, and then you get a wash of that information and you know to flag now this. You know, there are, you know, as you know there are a lot of houses that have decorative flags there are flags that represent the outside of the school, you know there are flags that are used for all kinds of reasons. I've seen slides that are hung outside classrooms. They're actually a great way to help the child find a target, because they do have inherent movement properties as well. But movement can make orientation in space much more difficult, much more difficult. This is reminded me of a girl that I worked with in Hong Kong, and she was she became an isolated activities or the activities of lessons that we did near her apartment building. She was absolutely fabulous to keep a straight line of direction. She kept her head up she knew, you know where the target was that she was trying to find she understood how to use the map, but those very same skills in a complex environment because of all in this case movement, you know, all kinds of random, you know, multi directional movement was enough to just, I actually saw her with her cane start to veer into the street. Extremely unsafe. This is such an important lesson for any of us that work with kids with CVI to remember that a skill learned in isolation in a controlled environment must also be taught in environments that have increasing amounts of novelty and complexity and movement. Otherwise, we're only setting the child up for one condition. And I, if I had a quarter for every time I had to ask people to think about that because, you know, traditional O&M is, you know, you practice the skill out in real space, of course, but the impact of something like this like this movement often does not get the child disoriented. Let's talk a little bit about the characteristic of light. So we know that light is a really important target for kids with CVI, and it's not unusual for some individuals with CVI to be able to report that actually night travel is easier for them. Or they don't need as much help at night. And think about this. Think about the fact that we've turned the room lights down for many students with CVI and add light to a target we want the child to look at. It really helps direct attention and it suppresses and dampens all that complexity. It just gets rid of it. If you look at the top picture, do you notice that, so you know, of course, the less light there is, the less likely it is that you'll perceive color. But look at the one color that you really do see there. So the lights themselves give off a yellow hue, but you see a color somewhere in that top image. It's red. I mean, it's just a great example of how, you know, red is just such a powerful color to our brain. The picture at the bottom shows how light can also be, you know, used to help this child really differentiate their particular location, something they're looking for help prepare them for the steps that they're about to encounter. There's that picture of Pittsburgh. I just had to put that in. Sorry. But this whole issue. This is distance. I want to say something else about light and light is that I had a picture in here somewhere as well that showed a child that has CVI and light was used. Light was used as a little target. I'll give you two more examples light was placed at the hook where the child hangs their backpack. Now, even if the child can't hang it themselves motorically, it certainly helps the child be feel more in control of their world. If the if the paraprofessional or the teacher or parent, whoever's taking the child into the class says, let me know when we get to where your backpack goes, or you put a light inside the cubby that is theirs where their stuff goes. That child is instantly able to lock on to that location. Like can also be added. I have a video clip of a child who is who used to go joints, join circle time in a preschool class by somebody leaving them there. They put a little lighted ball there and put it next to a bright yellow cone. And so he kind of looks for the light that sits sort of at the top of the yellow cone. And the light and the color make him just make a beeline right for the seat where he's supposed to go. Those things paired with a real destination can really help. So over time those things would be faded back as his range for goes up, but there's a time and a place where light will actually help the child achieve something that is a small victory and independence, but not so small to that child. So distance viewing, let's talk about that and the impact of that on CVI. So distance of, of course, is a characteristic that's closely related to the complexity of array. So the further away an object exists, the more likely it is to fall into the background array. So think about why we use, you know, low complexity backgrounds and light. If you go to a movie theater, and you're surrounded by all these people you're in maybe the last row or the second to the last row in the theater. You've got all these people in front of you. Some of them are doing something, you know, they have something interesting on or they're, you know, you're looking at their popcorn or whatever it is. How does, how does the, how does the business owners get you to really just how to get everybody really to look at the same thing. They turn the room lights down, and they use a lighted target, the movie, which has movement in it as well. And so in a, in a way, you can see how these adaptations, like trick the brain into thinking or support the brain in thinking that there's really no target between them and this main event if you've suppressed all that information, but in the real environment you can't do that. So this is one distance viewing experience that's pretty phenomenal has light color and movement. Actually, a child with CVI would probably be able to see this. And the reason I took this picture is that when I was in Iceland, not only did I get to see this wonderful thing and probably you folks in Canada see it all the time. But as a woman I met in Iceland was who's an adult with CVI. And she's 22 years old and she's quite bright if you're coming to the pediatric cortical visual impairment society meeting in Omaha this year in June. She's actually going to come and speak and talk about her own experiences with CVI growing up. But one of the things she can see could always see where the northern lights. Interesting. This is that same location. Same location. At this time, what are we looking at here? We're looking at the different angle, of course, one from the water looking in. But distance viewing the further away a target exists in a naturally lit setting, the more elements are visible. And the more elements, the harder it is to sort it. Okay, the harder it is to sort. So it's important to remember that light and distance. Oh, I do have those pictures. I got these slides in the wrong order. So forgive me, but we're going to talk about these things together. I'll get back to distance a minute, but this is another comment about light. I have no idea how this got in the wrong place. So again, life serves as a visual anchor to help with attention, but it might also be a distractor. There's a picture of Brody getting to his little feet as I mentioned, I knew I had these in there. There's another target in the environment that has lights. Okay, now for the child with CBI, the complexity behind this light source is really a problem. I mean, it really can be a major problem, but children in walking down hallways and seeing this lighted target at the end of the hall. That's an anchor. That's going to give that child the ability to get from point A to point B. All right, so I guess we're going to skip past distance for a minute. I would like, I don't know what happened here, but as I said, distance is really an important factor. Obviously, I'm going to say a few more things about distance though, that when a child with CBI, remember that kids in CBI can often see a target much further away than we think they can. For example, parents will often report that their child with CBI generally does tasks that, you know, two feet away, but they know for sure that that child sees them as they move across the room six feet away. That's true, because a moving familiar target may be seen at a greater distance, but by and large that, you know, the distance viewing is the distance at which the child can see anything. Under any conditions. So keep in mind that if you're, if you're thinking about the distance viewing issue for a child with CBI, ask yourself the question, you know, if you say the child has this favorite, you know, a, I don't know, a favorite cup that they use or a favorite water bottle that they use or thermos. And you ask them, how far away could I put this object, but not in this classroom somewhere they've not been before and know that they can find it, even that they'll notice it without me even saying anything. If I said to them, is there something that belongs to you here? That's their distance viewing. How far away can they find that object under any circumstances. So latency is another characteristic and it is a major safety concern, major safety concern and often not terribly, people are not terribly aware of how much of an issue it can be. So what could happen here? This is this I searched for this picture because this is such a classic risk for a child with latency, a young child that would go out until playground. And they are moving or being moved or they somehow can, you know, get themselves moving. By the time these kids, you know, their movements, most of us notice the rhythm of someone moving and we either move far enough away that we're not going to get hit. Or we judge when we think that that person's going to encounter us based on time and space temporal relations, how far away are they, how far, how what amount of time is it going to take for them to get from where they are now to where my body is. But with you have latency. By the time you notice something, it could already have hit you that that delay in being able to judge where something is in space. The delay can make all the difference between you having an unwanted encounter with it or not. So, whether a ball is being, you know, thrown to the air, or a car is coming or child on the playground. And I also have to say that kids with TV I have told me a couple times now about how they don't like movies because they can't their visual latency makes it impossible for them to put in sync. What they hear, and what's happening on the screen that there's like a little delay between everything they see. So the audio is always out of sync with the video. And that's frustrating enough, but imagine so imagine the challenge see I just putting their head down and listening, but imagine if there's something much more important on the line like you're going to get whacked and knocked over. It's or, or even worse complexity. This is of course a huge characteristic and has a lot of implications for kids to see the eye. And when we judge complexity we're judging for complete areas we're judging how complex can the surface of the object be how complex can the viewing array be how complex can the sensory environment be and still have the child visually attend and the complexity of faces. So, we're asking the child as I alluded to earlier what is salient what are the definite where the defining elements in the complexity of the natural environment and that's what we want the child to really anchor themselves to. Okay, again this has a lot to do with both near and distance complexity. So, in this business area, and there are, you know, plenty of kids that live in really busy areas. You know it may not be true for all the places that you serve kids but there certainly are places that are very busy and where you are and certainly where I am. And this kind of an environment is so complex, not only distance viewing not only movement, but I want to ask yourself if you when you if you can possibly wrap your brain around it it's too late now because it happened, you know, a minute and a half ago. What do you think the first things were that you saw when you looked at this image. And my guess is, and from the research that Krista Wilkinson has done with communication symbols that it's probably the sign that the red sign that says liquors. No, that's no, that's no comment on what you prefer. It's just a comment on what our brains notice. So, this complexity of this environment may even give us a false sense of what we should look at because in all of that craziness that sign is against a little less complexity and may stand out more but may not be the salient thing for the child to look at. What we want the child to look at is the red light and the patterns of the traffic of the cars and the people. So, to compare that to this kind of an environment, and this is a low complexity environment, and this one has parked cars in one moving element, the child can absolutely orient themselves to that moving element without becoming overwhelmed if they're in, you know, mid phase to or above, though it would probably be to really see that all those vehicles on the street that child will probably need to be in phase three. So, in other words, if this environment changes for whatever reason, you know, there's a school bus stop here, there's a city bus stop here there's something else that happens from time to time and it turns it into this sort of then the child who could cross it safely at one point is likely to be very unsafe when the complexity changes. I can't overemphasize this. This is why when somebody does O&M with a child in a school and they say the child's really good to go, we've practiced this in the hallways a million times, they can get to any of their classes. They know the numbering system, they've got it all. My question would be, did you do it, you know, in the beginning of the school day when there's a lot of kids in the hallway, did you do it during exchange time if the child's in middle school or did you do it during an assembly? Did you do it so that you can really test out all the conditions? There are places people like to do decorations, again with the American flag, you guys must think I'm a real nationalist. Anyway, but this is actually a hospital space and this is the accreditation office of the College of American Pathologists. But, you know, this certainly could be anybody's classroom, right, in the U.S. And what happens is that the information gets so degraded because of the complexity of array that using something like this window or even something near this window like a number, if there were a number that was somehow on that window that said this is room 42, no way the child's going to find it or at least not reliably. And even worse, these decorations were put up for Independence Day and they're going to come down and they're not going to be the same after July 4th. There are certain things that we should also look at that this has to do with complexity of array, lighting and novelty that, you know, an individual, there's an interview of a young man with CBI a teenager who talks about how his dad took him into a Walmart and he was looking out these certain cards that he liked to collect and that he always could go to the right aisle, his dad took him to the right aisle and he would always find it. And people thought, well, he is like resolved, he's fine. Until one day the store, you know, policy was such that they move things around to be categorized in a different way, and the individual couldn't have no earthly idea how to find them. So, you know, even moving something from the top shelf to the bottom shelf could be a problem. Do not confuse two things. Don't confuse looking at something with interpreting it. And don't confuse memorizing the location of an object with really solving the problem of where it is. So for most of us, consciously or unconsciously we are categorizing information. We know that if we're in the catch a file we're likely to find barbecue sauce right. So we have we have formed those schemes, but for kids and CBI this is just a giant kaleidoscope of meaningless information. But so to our places in the classroom. If this is what the teacher's desk looks like, or this is what, you know, the OT desk looks like and you pull the child up with CBI to do some work with you at the table and there's this much stuff on the table. This stuff's also going to be disoriented and what was once a very familiar space becomes something that might be unrecognizable. So this is why we teach. We create some saliency and talk about where you know what we're looking for and how we can recognize a certain place and add complexity over time. So what about this. What about this. So this is has something to do with the number of the characteristics we talked about. So this is, these are stair descending stairs obviously from the angle that we're at. And these have been highlighted with red tape on the, the riser of the step. It's a very traditional way to help kids and adults know there's a step right. But for individuals with CBI remember that extreme lower field loss and remember that as the individual gets closer to it that red stripe disappears. And I think it's extremely unsafe to use this as the only way to help a child know where a step is. So another, a recommendation that was used involved putting the red tape at the beginning of the railing. And at the end of the railing because in the end and this is another version of that. They also tried putting it right on the railing, which is also, I think acceptable because they wanted the child to be safe. So they said what we really need you to do is find the railing, grab it and then wait a moment and get oriented about where you are and then put more red tape at the bottom of the railing so the child knows when they're almost at the bottom. So instead of again having to look where their feet might be and be very unsafe, they're using something a little bit more neutral position. Also, kids with CBI see better in their lateral field. So by putting something to their, in their lateral field that has shininess to it or movement. In other words, the child's more likely to see it. There's lots of ways you can do this adaptation and I think fluorescent colors are better than just primary colors. But I think that's something to think about. I don't think this is always the same thing. Also, she see that light reflection on toward the bottom step. There is a great likelihood this in fact I remember that this individual would actually thought that where the light was was the floor the bottom. And so that's why again, it's important to put that color to give the child the anticipation that we're almost near the bottom. There's a lot of variations in terms of complexity that we have to be very careful that again just like visual complexity and movement that if there's a lot of noise around. If there are competing sources of sound if there is, if there are adults talking and music playing and somebody doing some activity on the computer and somebody mowing the lawn outside, the child may act like they can't see. Because there's so much competition to their auditory channel that they can't really get to vision. So, for some kids that's one sound will make that happen for some, they can handle a familiar sound but that's all. Other kids can handle a low volume sound that's all other kids can handle, maybe up to two sounds, and those, there are some rare children who can handle much more. So this is a, you know, this is a kindergarten classroom. And how is the child with CVI supposed to manage use of vision when the sensory environment is always, or nearly always going to have a lot of complexity. That's always a challenge. So this job may not be able to get oriented very easily with all that center or when there are times when there's a lot of movement and sensory output. You know, we're almost done. I just want to say something about novelty here that that the individual may have very different responses as I said to outside familiar areas. I honestly, I can't believe how many kids don't get O and M instruction because people say they do find in their school or they do find in their home. But, but, you know, take the child to a playground they've never been to before and watch what happens. So, for, you know, for kids and CVI, being in that new playground is about like me being, you know, in parts of Hong Kong that I just, you know, I have no idea where I am. And none of these signs that everybody else seems to be able to use help me. So teaching ceiling features can help the individual become oriented in novel space. And I mentioned all these things before so I just want to reiterate that we're. This is another activity that was done to help a child with a power wheelchair get learn to find a visual target and move toward it. This was a little bit of a training exercise to help the child learn how to negotiate doorways. So we use movement and color and low complexity to help that child learn how to orient himself through a doorway. This is not the end point. This is the beginning of the teaching. Okay, so I think I'm right one minute before the finish. So do you have any questions for me? Are there any questions? You're right, Christine. Now we're pretty close to the end of the hour. If folks want to use the hand icon to put it up, I'll call on you and can ask your questions. I'm just scanning. Okay. Go ahead, Janice. Okay. You're unmuted. Okay. I can hear you. Can you? Yes. Oh, great. My question is we, as you know, have many, many, many more CVI students coming. What's your advice for helping us to convince our leaders in the education system how important this field is and how we need more TVIs that can work with these students more than twice a year. Honey, you would say ask me that. Yeah. For the past two weeks, so there are some of the pediatric cortical visual impairment society in the meat in Omaha has a parent component, so, you know, educators, physicians, therapists, parents all come together at this one meeting in Omaha once a year and there's a big advocacy arm of this we're only seven years old this year, but parents have become organized and just this, this since the new year they have been contacting university programs. They've been asking for the standards to be changed for what's been being taught in the university programs to include much more about CVI. They are asking organizations like the American Foundation to the blind and the American printing house to the blind. They wrote, they had a very, very impressive call with them about, you know, why are they're not, why is it not more emphasis on this in your field or in our field. And so, I, what this teaches me is that parents are the ones who are going to change this and helping parents get organized is a huge task, but that's where I think it's going to happen. And I think that the other thing is, at least in the states and I know you guys have some version of IEPs that that you do as well, that we really, I think getting it into that document is very, very important. You, I don't know what to what degree it do process you have but I know that parents are beginning to really not sign IEPs and not agree to programs that don't give their child an adequate set of options. There's really all about advocacy because I think at this point, there's plenty of information out there now. They just isn't there just, you know, just such an emphasis, because we were all trained in ocular visual impairment that emphasis continues to be the one that is primarily taught in higher ed. The University of Massachusetts has is the first place in the states in the first vision program that has a mandatory course in CVI it's not it's not an add on or an elective. And another university called Salis in Pennsylvania is the second one that is starting it so it's about being loud and being noisy and helping people know that these kids really have a right to, you know, an equal equal access to an education. That's a great question. But thank you for that. Thank you for that. I've had a lot on my shoulders for many, many years and I'm so happy to have these parents beat a voice that you know I feel like I can. I can take a huge cyber release not that we're there we have a long, long, long way to go, but it's in motion it's in motion I don't think it's going to change so. Christine, I've got a couple of questions in the chat one of them is, what was the group called pediatric blank, the pediatric cortical visual impairment society PCV is and our new president starting this year is from Canada. Okay, who's that. I'm familiar from Toronto. Okay, great. And then the second question is there any video that shows a child's development from phase one to phase two or three to bring your finding to life that could demonstrate the impact on quality of life for these children. We do have some we do I never used to we do have some, and that's why I'm asking parents now more and more, please take videos of your children when they're in phase one, you know, and they'll kind of look me say because when they're in phase three, you're going to want to be able to show people like where they came. So there are some I don't own them right now but we're trying to, we're trying to integrate that into some of the Perkins courses that it's such an important point, such an important. In fact, two years ago at the pediatric cortical visual society meeting. There was a person who presented Dr Sandy new come presented just such a case, and she showed a child's evolution from phase one to phase three. The deafblind child is nonverbal. So it's not like she you know this is a child that you would think oh well of course that child's going to know this is really complex child so it's pretty cool. Great thanks. Any others. Right here. I'm sorry I don't have the raise hand option on my screen. I'm just wondering if it's possible to get the link to the last two recordings I've been asking Sandy for it and she said for me to ask on this I just care if you care did you register through ELC. Yeah. Okay I've got your email there, and I'll send that link out to everybody who registered on on ELC. Sadly, it's a little bit. It's a little bit buried in the Alberta professional learning consortium website. So I will send it out to everybody. Thank you so much and it was amazing. No, my honor. My honor. Thank you. Okay, fantastic. Christine, thank you very much for your time and enjoy the I'm going to call it warmth in Pittsburgh. Okay, thank you. Okay. You bet. Good night.