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The use of different strategies to compensate for difficulties in recognition of people for a  child with CP and Cerebral Visual Impairment (CVI)

Early Intervention: MDVI

Tove Gulliksen Borch

Special teacher/ Senior Counsellor

Huseby National Resource Centre for the Visually Impaired

Gamle Hovsetervei 3

0768 Oslo

Norway

+47 22 02 95 00

tove.borch@ks-huseby.no

Problems in visual perception for people with CVI are complex and can vary throughout the day and in different situations.  I wanted to study the phenomena of CVI in more detail, and particularly to get a thorough insight regarding the problem of visual recognition of people.  I initiated a single-case study to explore this subject. The child chosen for this study has the above mentioned diagnosis and subsequently suffers great difficulties in interpreting different visual stimulus. The aim was to see how this specific difficulty occurred in daily life, and what strategies the child used to compensate for his problems with recognition. Perhaps it would be possible to transfer gained knowledge to other children with similar difficulties. This would be especially useful when it comes to children who function at a lower stage of development. Hopefully this can give caregivers and professionals some guidance in their pedagogic attitude towards the children concerned.

The study

John is 4 years old. He has Cerebral Palsy, left sided hemiplegia and Cerebral Visual Impairment. He is a charming, social and talkative boy, who likes to spend time with adults. He seems to be rather curios, and he asks a lot of questions on topics like cars, people's family relations, about what is going to happen during the day etc. He demonstrates adequate cognitive capacity, and has a good memory. As to his problem with recognition of people, he can instantly tell who people are the moment he hears their voices or some sound they might make like the sound of their laughter, footsteps etc. His visual acuity is about 6/30 (0,2), and he can discover tiny crumbles on the carpet. Further he has a left-side homonymous hempanopsia. When he sits in his wheelchair, he can easily move about in the kindergarten. He seems to avoid obstacles very well. In addition of having problems in recognition of people, he has difficulties in recognising and interpreting pictures in a book

Due to his visual impairments, links could possibly be drawn to his avoidance of playing with constructive toys as puzzles, putting boxes on top of each other, match shapes etc.

To reveal his “secrets” of what strategies he uses to recognise people, I interviewed six persons who know him well. In addition I made video-recordings in both free play situation as well as more constructed circumstances surrounded by people he knew and enjoyed being together with.

I considered whether I could use John himself as an informant on his visual perception problems. In some respect he was the "owner" of his specific visual problem, but at four years of age, it is rather unlikely to have the ability to decentrate and understand that other people perceive the surroundings different from oneself.  For me, this opened up for a lot of questions of more philosophical character. I settled to regard John an excellent subject for others to observe.

Discussion of the results

The conclusions from the interviews where they all thought his main source of recognition was through the auditory system. He had developed an expertise in detection of voices and sounds. At times he was so good at it that people who did not know him, would not think he had a visual perception problem. A majority of the informants claimed that:

All together he used a great variety of strategies.

The people participating in the video-recordings were asked not to use words or any sounds that could easily reveal their identity. I wanted to “provoke” John’s non-auditory strategies of recognition.

Together with the informants I analysed six video-episodes where John’s strategies of recognition were of interest. These observations showed:

It is interesting to notice the differences in the results from the two collection methods.

One should be careful to put more emphasise to one method than another. However, I do think it highlights that each informant had his or her way of interpret or categorise John’s behaviour, and the videoepisodes expose his performances without this interpretation.

The new knowledge that the results from the two data collection methods revealed was:

  1. The degree of familiarity or emotional closeness did not influence higher level of recognition.

If John had bee able to see and distinguish between people’s faces, he would probably have shown more excitement and more rapidly recognised those he favoured. This behaviour could also been explained in the light of his rightsided brain damage. Humans use their right hemisphere when putting details into meaningful whole. Whilst the left hemisphere deals more with details. The informants claimed that John could see details, and this was confirmed by the video episodes.  But to put all the detailed information from the faces (nose, eyes, mouth, shadows), acquires additional abilities in which John does not possess.

  1. His use of smelling did not help him to recognise people, and can not be considered as a good strategy of recognition for him.

The video episodes revealed this quite clearly. Although he put his nose close to a person and seemed to use his smelling sense, he mistook in three out of three occasions his grandmother and two other women for his mother.

  1. His visual recognition did not improve by getting people closer to him.

When people came closer, they looked bigger, but this enlargement did not help him in recognition. I will interpret this and presume that his problem with recognition is not dependent on magnification, but rather disturbed by his difficulties in dealing with many details and putting them together into a understandable whole. 

Occasionally John did recognice people only with help of his vision, but this happened more frequently when he saw people at some distance rather than close up. I think that he by observing at a distance could profit of seeing the whole person. This would include the appearance, way of movement and perhaps even the colour of the clothes.

The correlating results from the interviews and the video observations were:

  1. He used all available senses to obtain information about people

When he tried to establish whom he dealt with, he foremost used his auditory capacity. He has  a very good memory and by listening he could easily recognise familiar voices and sounds. This was his preferred sense to obtain information about people. When auditory clues were absent, he tried to use touch and smell.

  1. He used his memory and other cognitive abilities as basis for asking and guessing

Most of all, he asked questions and made guesses on who it might be that was present. Both the answers the informants gave, and the video-observations revealed and confirmed this strategy. When he was unsure, he started to ask who it was. When not having any answers, he started a guessing procedure based upon a kind of “calculation of probability”. He seemed to evaluate who was likely to bee present at the moment, in that specific room, at that time of the day, in that context. To be able to use this strategy he was dependent upon his memory. Secondly to have been given the necessary information and use his knowledge as basis to make an educated guess. In other words, he was dependent upon a reliable structure to make it possible for him to use his guessing strategy and make his conclusions. 

On one of my first visits to John’s kindergarten, he focused at me and asked “Who are you, and where am I going now?” At that time, I did not know that through this question, John himself gave me the reply to some questions quoted in my study. He revealed that he noticed a person he did not recognise approaching, and therefor asked who it was. And then he added the question that I now suppose was based on his need for structure and to get an overview of the situation. If he knew what was going to happen later it would facilitate his use of the guessing strategy.

Conclusions

To help other children with CVI to recognise, we have to present ourselves in a way and through the sense by which the child itself seems to get the most meaningful information of people from. As to John, it was easy to see what was his primer sense. For other children that are more passive motorically and/or function on a lower level cognitively, it can appear much more vaguely. As described in this study, their primer sense can be revealed by thorough observation with focus upon the child’s use of different senses: How and in what way do the child use its hands to seek information and check out people? Is the child using smell to get the decisive information of people or is it through sounds and words the child primarily recognises?

In addition to and independent of what is the child’s primer sense for recognition, the result of this study emphasises the importance of structure for the child. I learnt from this study and which was also a striking reminder of the value of organising the surroundings and activities in a structured way. The sequence during the day must be clear. It must be possible for the child to survey the situation and get knowledge of in which context it will interact. With the structuring factors clarified, the child will have a far better basis to predict what is going to happen and to make out whom he is dealing with. The child has been given the clues in which he will make his calculations. Where am I, what activity is going to start, who is it most likely to be present? A starting point is formed to use the strategy of guessing. The term “calculation of probability” is useful to illustrate what might be going on when a child tries to recall, to understand and thereby recognise.

Another result that this study underlines, is the value of the information given to and the knowledge of the people who spend time with the CVI affected child. In John’s case, I saw that the fact that he had a homonymous hemianopsi did not seem to influence upon his ability to recognise. All the informants and people, who were together with John in the video episodes, were fully clear of his hemianopsi and what that meant. They drew the consequences of this and conducted themselves in a way that diminished his problems.

Knowledge of neurology and neuropsychology will also be of importance as it comes to children with visual interpretation problems. “The most important weapon in the armament of those who work with perceptually disordered patients is a working knowledge of the neuropsychology of vision.” (Ratcliff 1987:258) The best basis to organise a pedagogic curriculum for the child to diminish the problems with recognition will probably be a mixture of knowledge and insight into the child and the medical condition and in addition be able to take the child’s perspective.


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