TIES TIPS Communicative Competence
TIP #24: Learners with Cerebral/Cortical Visual Impairment (CVI) and Augmentative Alternative Communication (AAC)
Cerebral/Cortical Visual Impairment, or CVI, is one of the leading causes of visual impairment in school-aged children (Williams et al., 2021). Children with CVI may have difficulty processing the images their eyes see, which can affect many areas of basic visual functions such as the ability to see visual detail, certain visual fields, or visual-motor performance (Lueck & Dutton, 2015). Let’s learn more about CVI and how it relates to learners with significant cognitive disabilities who use Alternative and Augmentative Communication or AAC, with a particular focus on inclusive environments.
The use of AAC has been shown to effectively support communication and speech development for learners with sensory loss and significant cognitive disabilities (Romski, Sevcik, Barton-Hulsey, & Whitmore, 2015), including children with CVI. One of the more challenging aspects of using AAC with children with CVI is that it may not be clear what communicative behaviors are affected by the child’s visual impairment as the effects of CVI might not reveal themselves until the child is in a visually demanding environment, like school. In addition, the children may not realize that they are seeing differently from their peers with typical vision. Although CVI affects each child in different ways, the following communicative competencies may be challenging for some learners with CVI (Lueck, Chen, Hartmann, 2022):
- Maintain and use eye contact
- Comprehension of facial expressions
- Interpret gestures as communication
- Imitation of communication
- Use vision to engage in communication, such as objects, pictures, or photographs
CVI refers to cerebral/cortical visual impairment. CVI is a brain-based visual impairment, in contrast to ocular-based visual impairment, although students might have both CVI and ocular visual impairment (Mazel, Morse, Ely & Zatta, 2020).
Augmentative and Alternative Communication (AAC) refers to communication methods (other than oral speech) used to express thoughts, needs, wants, and ideas.
Multimodal communication is the identification of communicative forms the student uses, including AAC, to express a variety of intents. A student may use facial expressions, body language, gestures, signs, and vocalizations, as well as an AAC device to communicate a variety of intentions.
Preference identification helps the team recognize the most efficacious multimodal communication forms when the student engages with preferred items, activities, topics, or people. Identifying highly preferred items, activities, or people creates topics for conversation and increases the probability that the student will use the device to request highly preferred items or actions.
Functional vision and visual functioning are how learners use their vision in an environment. Students with the same visual diagnosis of CVI can have very different functional vision. Careful observation of how the learner uses vision across many different environments throughout the day and then using that data leads to a better understanding of how the learner uses vision to communicate, engage with AAC, and engage with academic tasks. It may be important to consider behaviors such as visual attention, color preferences, and lighting methods.
Motor planning helps the AAC user with CVI find the words on the device. Vocabulary arrays should maintain the position and organization of the symbols so that the learner can find them easily.
Using AAC with learners with CVI doesn’t need to be complicated. The first step in understanding CVI and AAC is to take a collaborative and curious approach, and conduct observations of visual behavior.
1) Collaborate with family, vision educators, and medical professionals to understand CVI and the unique needs of the learner with CVI.
2) Observe the learner using AAC throughout the day in a variety of places and situations to understand visual functioning and visual behaviors. Information about visual functioning and behaviors will assist the team in selecting the best access method for the AAC system.
3) Identify visual preferences – Observe what the student attends to visually. Some colors, like red, green, and yellow, may be seen more easily than others. Black backgrounds may remove visual distractions and allow the student to focus their visual attention. In the example below, there are two images of core word arrays. One image has a black background for each symbol and one image has a colored background for each symbol. The display of symbols with black backgrounds may be easier to see.
4) Determine the dimensionality, size, arrangement, and complexity. Consider how the student responds to a variety of media:
- Real objects
- 2-dimensional picture symbols or photographs
- 3-dimensional or tactual symbols
The image on the left is a real object in a student’s preferred color, the middle example shows 2-dimensional picture symbols, and the image on the right is an array of 3-dimensional or tactual symbols. Photographs may also be considered. The best option may depend upon the student’s functional vision, but others could be used in the future as the student’s needs change.
In thinking about symbol size, a student with CVI may need bigger symbol images, like the array on the left, or smaller symbols, like the image on the right.
When looking at the examples below, also consider the visual complexity of the symbols. The varied colors and placement of the symbol in the array on the right may be too visually complex. Black symbol backgrounds on a whiteboard may reduce the visual complexity. The image on the left has a white background, but the background for each symbol is black. The image on the right has a black background, but each symbol has a colored background, which some learners may find visually complex.
5) Observe the impact of lighting. Variations in lighting can impact what a student can see and learn. For example, lighting from certain angles can cause a shine that obstructs visual discrimination. The image on the right has shiny reflections from the overhead light.
Using a slant board or adjusting the lighting, if possible, may help this problem. Backlighting on a tablet or monitor may support visual attention or hinder visual attention by providing too much visual stimulation.
6) Consider visual preference when identifying preferred toys, activities, and communication partners. Doing this may lead to more enjoyable and meaningful communication exchanges where vision is used.
7) Adjust visually demanding environments to optimize functional vision use. For example, reduce visual clutter and background noise by carefully considering where the students are seated and what direction they face during visually demanding tasks. To reduce visual clutter, try a black tri-fold board or a black fabric board and leave space between symbols. A typoscope/occluder is a low-tech tool that can be used when engaging with books or other images as it can block out irrelevant visual information.
8) Observe and adjust specially designed or modified communications methods as learners’ visual and communication skills develop over time and within daily routines. Stay curious and collaborative as you make these adjustments.
Remember, no one modification, accommodation, or AAC support will work for all learners with CVI because their visual functioning is unique. A learner’s visual functioning might vary day-to-day, meaning what you implement one day may not work the next. Designing and implementing AAC methods and devices requires ongoing observation and problem-solving. We encourage you to be curious, observe closely, collaborate with your team members, and stay flexible in your approach.
Abner, G. and Degrant, J. (2022). Paths to Literacy Blog. Retrieved (2022) https://www.pathstoliteracy.org/power-communicating-tactile-symbols/
- Lueck, A., Chen, D., & Hartmann, E. (2021). Developmental guidelines for infants with cerebral visual impairment: A companion guide for early intervention. American Printing House for the Blind.
- Lueck, A. H., & Dutton, G. (2015). Vision and the brain: Understanding cerebral visual impairment in children (Vol. 2). Arlington, VA: AFB Press, American Foundation for the Blind.
- Mazel, E., Morse, M., Ely, M., & Zatta, M. (2020). Role and Responsibilities of Vision Educators (TVIs and O&Ms) when Learners have CVI.
- Romski, M., Sevcik, R. A., Barton-Hulsey, A., & Whitmore, A. S. (2015). Early Intervention and AAC: What a Difference 30 Years Makes. Augmentative and Alternative Communication, 31(3), 181–202. https://doi.org/10.3109/07434618.2015.1064163
- Williams, C., Pease, A., Warnes, P., Harrison, S., & Hyvarinen, L. (2021). Cerebral visual impairment-related vision problems in primary school children: a cross-sectional survey. Dev. Med. Child Neurol., 63, 683–689.
TIPS Series: Tip #24, August 2022
The information in this Brief is not an endorsement of any identified products. Products identified in this Brief are shared solely as examples to help communicate information about ways to reach the desired goals for students.
All rights reserved. Any or all portions of this document may be reproduced without prior permission, provided the source is cited as:
- Hartman, E., DeGrant, J., & Kearns, J. (2022). Learners with Cerebral/cortical Visual Impairment (CVI) and Augmentative Alternative Communication (AAC). ( TIPS Series: Tip #24). Minneapolis: University of Minnesota, TIES Center.
TIES Center is the national technical assistance center on inclusive practices and policies. Its purpose is to create sustainable changes in kindergarten-grade 8 school and district educational systems so that students with significant cognitive disabilities can fully engage in the same instructional and non-instructional activities as their general education peers, while being instructed in a way that meets individual learning needs. TIES Center is led by the National Center on Educational Outcomes (NCEO) at the Institute on Community Integration, University of Minnesota, and includes the following additional collaborating partners: Arizona Department of Education, CAST, University of Cincinnati, University of Kentucky, University of North Carolina – Charlotte, and University of North Carolina – Greensboro.
TIES Center is supported through a Cooperative Agreement (#H326Y170004) with the Research to Practice Division, Office of Special Education Programs, U.S. Department of Education. Opinions expressed do not necessarily reflect those of the U.S. Department of Education or Offices within it. Project Officer: Susan Weigert
The information in this publication is not an endorsement of any identified products. Products identified in this publication are shared solely as examples to help communicate information about ways to reach the desired goals for students.
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