... Title: The Role of Occupational Therapy in the Care of Children with Cortical/Cerebral Visual Impairment; a Narrative Review Daria Seccurro May, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Beth Ann Walker, PhD, MS, OTR, QIDP Abstract Objective: This paper describes functional impairments experienced by children with Cortical/Cerebral Visual Impairment (CVI) and how occupational therapists (OTs) play an important role in the evaluation of functional vision and intervention guided by the PersonEnvironment-Occupation (PEO) model. Background: Prevalence of CVI in children is increasing; however, there is lack of consensus on diagnostic practices and few studies evaluating interventions for children with CVI. Some papers discuss the difficulties children with CVI experience in areas such as self-care, play, education, and mobility, but there is minimal evidence to support OT efforts. Methods: A narrative literature review was conducted to identify relevant research. A comprehensive search was performed across multiple databases. Studies that met the inclusion criteria were synthesized for key findings. Discussion: Findings supported that children with CVI face challenges with functional vision impacting daily living skills. These daily skills fall within the OT scope of practice. Although evidence-based interventions specific to OT are limited for CVI, existing literature reports deficits in ADLs, IADLs, play, education, and social participation, emphasizing the need for OT specific interventions for children with CVI. Conclusion: Due to OTs focus on daily activities (occupations), environmental and activity modification, and emphasis on client-specific care, they have a distinct role in caring for this population. Key Words: Cortical Visual Impairment; Cerebral Visual Impairment; children; occupational therapy; rehabilitation Introduction Cortical/Cerebral Visual Impairment (CVI) is the leading cause of visual impairment among children in developed countries (McConnell et al., 2021). CVI is a brain-based visual disorder associated with damage to the posterior portion of the brain, causing the inability to process visual information (Lueck et al., 2019). More than 40% of the brain plays a role in vision and is responsible for visual processing (Dutton et al., 2006). As a result, the brain is unable to process the information coming in from the eyes causing impairments in visual functioning. The impairments associated with CVI vary and span a broad range of severities (Orbitus et al., 2011). The location and extent of the brain insult often plays a factor in the level of impairment (McConnell et al., 2021; Sakki et al., 2022). Vision is a vital sense used in daily activities to interpret the environment. Although most children impacted by CVI often have some level of visual functioning, visual dysfunction plays a significant role in a child's development, learning, mobility, and overall quality of life (Merabet et al., 2017). In addition, CVI profoundly impacts one's ability to complete daily activities which constitute a large portion of life. The daily activities and skills that makeup life are known by occupational therapists as occupations (American Occupational Therapy Association [AOTA], 2020). Within the occupational therapy profession, active engagement in occupations is what supports, facilitates, and promotes participation in life (AOTA, 2020). Occupational therapists have distinct knowledge, skills, and qualities that enhance the occupational process (AOTA, 2020). Contributors in this profession exhibit qualities to complement cornerstones of practice which include but are not limited to client-centered practice, occupation-based practice, evidence-informed practice, theory-based practice, and leadership and professionalism (AOTA, 2020). Occupations are core components to a clients health, identity and sense of competence that are meaningful and viable to that client (AOTA, 2020). Occupations are meaningful everyday activities and include things people need to, want to, and are expected to do (AOTA, 2020). However, a persons context, made up of both personal and environmental factors, largely influences engagement in occupations. Occupational therapists accept the idea that people who achieve full participation must function and engage comfortably in their own contexts (AOTA, 2020). As a person enters different stages of life, their occupations may shift depending on their roles and responsibilities. Occupations commence in infancy and develop throughout life. Although a childs occupations may look vastly different from those later in life, occupations are present across the entire lifespan. A child's daily activities and occupations involve learning, playing, exploring, eating, crawling, among many others. Unfortunately, CVI impacts a child's ability to perform these occupations. However, adapting the activity and/or environment can make it easier for children with CVI to visually process, and increase participation in the activity. The unique needs of children with CVI are often affected by their environment, impacting their ability to function; however even small changes in ones environment positively impact a child (Tsirka et al., 2020) The principle of recognizing the environment's impact on participation in occupation provides a holistic perspective and distinguishes occupational therapists from other professionals trained to care for children with CVI. According to the Person-Environment-Occupation (PEO) Model, occupational performance is the outcome of the interaction between a person, their environment, and an occupation or task (Law et al., 1996). Assumptions from this model presume that the three components continuously overlap to enhance or impede ones ability to achieve occupational performance throughout life. In this model, the person is defined as a unique individual made up of various qualities, experiences, and skills that influence the capacity to engage in occupations and interact with the environment (Law et al., 1996). The person is viewed as an ever-developing individual made up of characteristics that can, in some cases, be responsive to change with intervention (Law et al., 1996). The environment is the context in which occupational performance occurs and can positively or negatively impact a person or an occupation (Law et al., 1996). An environment can affect occupational performance but is said to be more easily modified than the person. Last, occupations include the tasks and activities a person engages in across various environments to meet their needs (Law et al., 1996). In regard to the PEO model, the term occupation is described as a complex task or activity that a person engages in throughout the entire lifespan. These three components continuously overlap and adjust as the person, environment, and occupations change. In order to achieve optimal occupational performance in life, one must balance all three components to maximize the personenvironment-occupation fit (Law et al., 1996). The relevance of the PEO model and occupational therapy poses an avenue to help connect the dots to improve the lives of children with CVI and their families. Occupational therapists use the PEO model as a foundation in practice to encourage individualized, patientcentered care (Law et al., 1996). The needs of this population vary depending on the person, the environments they interact, and the occupations meaningful to them. The number of children diagnosed with CVI is increasing due to advances in medical care. Therefore, there is a need to better understand and gain consensus on the methods of diagnosis and increase evidence supporting interventions for this unique population. However, there is a lack of knowledge across the medical field about CVI and even less evidence on the role of occupational therapy practitioners in treating children with CVI. In order to understand the unique role of occupational therapy in children with CVI, one must first understand the needs of this population and the abilities of OT practitioners to meet those needs. This narrative review focuses on the challenges children with CVI face impacting their occupational performance and explores the specific role of occupational therapy in this unique population. Specifically, this narrative review aims to identify the needs of children with CVI that fall under the OT scope of practice which have been documented in previous literature, and explore how these deficits impact the person, environment, and occupation/task indicating an important role for OT in children with CVI. Background Visual processing is different in children with CVI compared to a child with typical vision. Due to the unique characteristics of CVI, this condition can be hard to diagnose and commonly unintentionally missed (Dutton et al., 2017; Williams et al., 2021). Traditionally, the diagnosis of CVI is given by ophthalmologists due to the impact on visual impairment, but neurological components may require involvement of neurologists (Pehere & Jacobs, 2019; Jackel, 2019). A comprehensive evaluation used to diagnose CVI consists of structured history taking to determine factors of predisposal, parent/caregiver reported observations and insights through interview, a functional vision assessment, eye examination, neurological assessment, and may include neuroimaging (Chang & Borchert, 2020; Itzhak et al., 2021). Children with CVI often present with abnormalities in visual processing that are not explained by the eye exam. Children affected by CVI commonly have a variety of comorbid medical conditions that take precedence early on. As a result, children with CVI demonstrate behaviors and characteristics attributed to their co-occurring medical conditions and are not further evaluated or assessed as disruptions in vision (McConnell et al., 2021; Tsirka et al., 2020). The uncertainties and lack of formal diagnostic protocol can sometimes cause a significant gap in receiving a diagnosis and ongoing care for children with CVI (Sakki et al., 2021). The most crucial time for intervention early in life to optimize brain plasticity (Chang & Borchert, 2020; Chokron & Dutton, 2016; McConnell et al., 2021). Therefore, children with CVI should be offered early intervention for the best outcome in visual processing (Roman-Lantzy, 2007). Martn et al. (2016) expressed that now, more than ever, there is a great need for improved accuracy in diagnosing, assessing, and developing compelling education and rehabilitation programs for individuals with CVI. CVI is a dynamic diagnosis that impacts all areas of life making interdisciplinary care important to maximize support for this population (Jayaraman et al., 2021; Pehere & Jacob, 2019). Beyond receiving a diagnosis, interventions and treatments for CVI have been explored in pharmacology and neurology-based approaches but researchers feel evidence-based assessment and intervention strategies are still lacking (Tsirka et al., 2020). Children with CVIs care is managed by various professionals including ophthalmologists, optometrists, pediatricians, occupational therapists, and nurses (Philip & Dutton, 2014). Other medical and educational professionals who commonly provide support for children with CVI include speech-language pathologists, physical therapists, teachers of students with visual impairments (TVIs), assistive technology specialists and orientation and mobility specialists (Blackstone et al., 2020; Jayaraman et al., 2021; Kran et al., 2019). Initial literature searches revealed two studies that involve occupational therapists' caring for children with CVI. Therefore, the present review comprises literature that is not occupational therapy specific but will reflect on impairments and areas of occupation in which OT intervention could be impactful. Additionally, this review will compile previous researchers' findings on the challenges this population faces and explain how occupational therapy practitioners have the unique skill set to address the needs of this population through the lens of the PEO model. Since children with CVI experience complex challenges in many areas of life, greater attention must be brought to the complexity and extent CVI plays on childrens development. As a result, a comprehensive analysis of the functional challenges that commonly occur in children with CVI is needed to identify the methods which lead to acquisition and/or preservation of everyday skills. Finally, this narrative is intended to raise awareness and better inform healthcare professionals across all settings about the unmet needs of children with CVI and their families to inform quality care better. Method A narrative review methodology was used to conduct and report the research findings regarding the role of occupational therapy in children with cortical/cerebral visual impairment. A narrative review is a comprehensive synthesis of literature that has been previously published and aims to present the broad perspectives of a topic and serve as thought-provoking pieces of literature (Green, 2006). According to Ferrari (2015), narrative reviews do not present new data but intend to assess what is already published; therefore, this style is appropriate for the specific aims of this paper. There is relevant literature regarding children with CVI, but few OT-specific publications. However, discuss issues that could be improved by including OT intervention for children with CVI. Narrative reviews have been popular among authors and readers, making up the largest share of all medical text types and impacting doctors in their clinical practice and research, deeming them a staple of medical literature (Baethge et al., 2019). A structured and in-depth literature search focused on the role of occupational therapy in CVI. Due to the limited literature on this topic, no databases were excluded when searching for relevant literature. Similarly, since the current body of evidence on OT for children with CVI is limited and the objectives of this paper are broad, the inclusion and exclusion criteria for this review were flexible. The authors primary search terms included Cortical visual impairment OR cerebral visual impairment, OR brain based visual impairment, OR CVI, AND children, functional vision impairment, functional vision in children, pediatric, childhood. Articles were excluded if the target population included adults because the challenges, presentation, and prognosis for CVI in children are vastly different. Since research relevant to daily life skills and/or functional challenges is sparse in this population, foundational articles from the late 1980s and 1990s were included. Articles that reported on children with low vision or other visual impairments and CVI were included if an accurate definition of CVI was given. Similarly, articles that discussed exclusively children with low vision, ocular visual impairments, or visual acuity were excluded. Line-by-line examination was utilized during full-text review to identify articles with information that could be related to the role of OT in this population or the CVIspecific characteristics and/or challenges related to the OT scope of practice. Person Visual Characteristics in Children with CVI One of the most significant components in children with CVI are their functional vision deficits, noted in literature as early as 1987. Children with CVI have unique visual traits and behaviors that help them function and/or compensate for decreased visual abilities. One of the most considerable challenges associated with children with CVI is the variable visual abilities that can change from one day to the next (Jan et al., 1987). This concept was reported in 1987 by Jan et al. and has since been verified by many of CVIs top researchers (Chang & Borchert, 2020). However, in recent years, researchers have gained an understanding as to why performance of children with CVI appears to vary frequently and have associated reasoning for this phenomenon. In short, it is now understood that the childs ability to use vision depends greatly on their physical environment, biobehavioral state, performance demands of the task, motivation, and their familiarity with the objects and people in which they are interacting (Lueck et al., 2019). The article by Jan et al. (1987) is one of the earliest works of literature that describes the behavioral characteristics seen in children with CVI. Notable findings documented in this article include improved vision in a familiar environment, impaired visual attention and visual curiosity, and signs of fatigue with visual learning (Jan et al., 1987). More than half of children in this study were reported to use touch to supplement vision during exploration and bring items close to eyes to use vision. Other behaviors noted by the researchers include inaccurate depth perception, need for movement of objects, looking away when reaching, light gazing, and restricted visual fields (Jan et al., 1987). Orbitus et al. (2011) echoes similar findings also indicating the child may fatigue easily when using vision, struggles to maintain focus during tasks, and rely on other perceptions to implement for vision. Various studies have been published over the last 30 years reporting similar behaviors and characteristics in children with CVI. In a study by van Genderen et al. (2012) researchers found that more than 40% of the children with CVI in their sample had challenges using vision in complex visual scenes, 53% had impaired visual fields, and 30% had nystagmus. A Delphi study by Pilling (2022) obtained expert input on various skills and behaviors common in children with CVI. Among this list are behaviors such as the child positioning their head in distinct ways to use vision, looking out of the corner of the eye, avoiding visual input by looking away, and commonly bumping into things when walking (Pilling, 2022). Children with CVI often experience high level visual processing issues such as difficulty with visual discrimination, orientation and need for additional visual processing time (Philip & Dutton, 2014). Similarly, children with CVI often display challenges with delayed visual latency, difficulty with facial recognition, navigation challenges, and inability to process moving objects (Good et al., 2001). Philip and Dutton (2014) summarize the varying abilities of children with CVI fall into three categories including children with profound visual impairments, children with impaired functional vision combined with cognitive and sometimes motor challenges, and children who have impaired functional vision but are capable of working at or close to the expected level for their age (Philip & Dutton, 2014). The CVI Range (Roman-Lantzy, 2007) is an assessment tool as well as a method to understand the varying characteristics and abilities of children with CVI by describing functional vision through scores organized into levels. Children with a score 1-2 have minimal visual response, score 3-4 exhibit more consistent visual response, score 5-6 use vision for functional tasks, score 7-8 demonstrate visual curiosity, and score 9-10 spontaneously use their vision functionally during most activities (Roman-Lantzy, 2007). Co-occurring medical conditions and other visual impairments Along with the brain based visual challenges children with CVI face, researchers have revealed most children with CVI have additional diagnoses and/or comorbidities that challenge development. The most common cause of CVI is an injury to the brain due to a lack of oxygen during the birthing process or shortly after birth (Parajuli et al., 2020). Other associated medical conditions include Periventricular Leukomalacia (PVL), Hypoxic Ischemic Encephalopathy, Cerebral Vascular Accident (CVA), Traumatic Brain Injury (TBI), structural malformations, infection, and metabolic disorders (Chang & Borchert, 2020). CVI is also associated with children born premature, and those who have other neurodevelopmental disorders such as cerebral palsy and seizures disorders (Chang & Borchert, 2020). There have also been findings of children with autism spectrum disorder (ASD) (Chokron et al., 2020), hearing impairments (Matsuba & Jan, 2006) and developmental coordination disorder with CVI (Chokron & Dutton, 2016). Vision plays a significant role in learning motor skills. For children with CVI that have co-occurring motor diagnoses like cerebral palsy, physical performance may be impaired. Children with CVI may have difficulties with motor activities such as walking (Jayaraman et al., 2021) and reaching due to the demands of functional vision use (Baker-Nobles & Rutherford, 1995). Lack of motivation to interact with people and objects may be a direct result of visual dysfunction (Fazzi et al., 2015). Many children with CVI are often delayed with fine motor skills such as reaching, grasping, and pointing because of the inability to process stimuli in the environment, limiting their ability to interact with objects though these skills (Fazzi et al., 2015; Chokron & Dutton, 2016). Similarly, researchers have reported how vision plays a large role in learning postural control and stability important for motor tasks in development (Chokron et al., 2021; Guzzetta et al., 2001). Children with CVI also have co-occurring diagnoses impacting cognition. Chokron and Dutton (2016) explain the impact vision has on all areas of development and how failure to address the visual needs of CVI leads to decreased learning and presents as an intellectual deficit. Matsuba and Jan (2006) reported in their study of 423 children, 86.7% also had cognitive impairments classified as moderate to severe. The researchers report that of the remaining children with high cognition had underlying learning difficulties (Matsuba & Jan, 2006). Finally, co-occurring visual impairments may be present in addition to CVI. Pehere et al. (2018) describe the most common disorders of eye movement control in children with CVI include: strabismus, nystagmus, unstable fixation, inaccurate fast eye movements (dysmetric saccades), deficient smooth pursuit movements, and paroxysmal deviations, in which the eyes intermittently deviate upward. The researchers in this study believe that due to the difficulty in examining childrens vision, many visual issues are often missed (Pehere et al., 2018). Sensory, Behavioral, Psychological Challenges When thinking about CVIs impact on a childs sensory system, vision is the most apparent sense associated. Since vision is impacted for these children, their other senses such as touch and sound are often heightened, and the children use them to compensate for their visual deficits and weak vision (Pehere & Jacob, 2019). Therefore, when the other senses are more easily stimulated children can experience sensory processing difficulties requiring minimizing sensory input in order to focus on use of vision (McKillop & Dutton, 2008). For example, some children with CVI may be sensitive to auditory stimuli, and face additional struggles in environments with a lot of auditory stimulation (Morse, 1999). Similarly, many children early on implement the use of other senses or multiple senses to compensate for a lack of vision to explore their environment (Pehere & Jacob, 2019). Adverse behaviors are another area that can be challenging for children with CVI. This is often attributed to external causes such as complex sensory environments, difficulties with communication, and mental health challenges such as frustration, anxiety, and issues with selfesteem (Goodenough et al., 2021; Lueck et al., 2019). Chokron et al. (2021) indicates how humans naturally adapt to the environment they are in, however if a person cannot see their environment, then they are unable to respond to it. Further, they describe how individuals react emotionally when faced with frightening or stressful events, requiring one to adapt behavior appropriately to overcome the circumstance (Chokron et al., 2021). Researchers connecting this scenario back to children with CVI explain that they are similar in the way they react; however it may be viewed as a behavior disorder or concern (Chokron et al., 2021). The difference between other children that display similar behaviors and children with CVI is that their impacted vision is causing these emotions and behaviors. For example, many children with CVI might be easily frustrated due to the constant visual challenges encountered and have been reported to become fearful when certain visual landmarks are removed that they use to help them identify the environment (Lueck & Dutton, 2015). This may lead to misinterpretation of their environment leading to confusion, fear, and being overwhelmed. There is also evidence that due to decreased ability to identify objects/people in public, children with CVI may also have heightened anxiety or fear of getting lost or injured (Lueck et al., 2019). Parents from Goodenough et al. (2021) indicated how anxiety regarding accessibility at school and in the community affected their child. As children with CVI age, many often struggle with self-concept and self-image challenges due to their experiences socially comparing themselves to other children and/or the expectations (Goodenough et al., 2021). Environment A child with CVIs ability to visually process is dependent on the set up and familiarity of their environment. In particular, children with CVI have more difficulty processing in environments that are new, complex, and stimulating. Physical Ones environment plays an important role in how they interact. Children with CVI are no different, except that environmental challenges and barriers are often more influential to their functioning and much harder to overcome. Physical environments most often associated with children are their homes, school, playground, or stores. However, even these frequently visited places can propose environmental barriers based on external factors. For example, crowding and complexity in the environment can have a negative impact on children with CVI (Philip & Dutton, 2014; Roman-Lantzy, 2007). Environmental complexity proposes too many visual stimuli to process at once for the child and complicates use of functional vision. This frequently leads to visual shutdown in children with CVI or other adverse behaviors. For example, a busy playroom with toys all over the floor is very hard for children with CVI to function (Pehere & Jacob, 2019; Philip & Dutton, 2014). Challenges in an environment like this are hard for children with CVI to focus and are overwhelming to visually process. They often experience additional challenges in unfamiliar environments especially during navigation and often prefer familiar toys and faces (Good et al., 2001; Roman-Lantzy, 2007). Other environmental barriers that can create challenges for children with CVI to use their vision are the level of lighting (too low or bright), low contrasting of colors, and noisy environments (Roman-Lantzy, 2007). Children with CVI often need objects and stimuli brought close to them and struggle to function with stimuli at a distance (Baker-Nobles & Rutherford, 1995; Swift et al., 2008). This especially creates challenges in environments like school and stores. Social, Cultural, and Institutional Researchers from an article by Goodenough et al. (2021) facilitated interviews of parents of children with CVI. In this study parents expressed that many medical professionals do not recognize CVI as an actual condition, nor do they understand challenges associated with CVI (Goodenough et al., 2021). This same sentiment was echoed by Pehere et al. (2018) indicating that awareness about CVI needs to increase in the ophthalmic community and also in general society. The same concept was echoed later in the study when a parent explained that within the childs institutional environment at school, there was lack of training and support from staff and professionals causing more challenges for the child (Goodenough et al., 2021). Further, parents from this study go on to reflect the large amount of time they spent communicating and educating others about their childs needs, as well as taking time off work to create and supply learning materials and resources for their child to use in school (Goodenough et al., 2021). In a follow up study, it was reported that children with CVI can also be greatly affected by their social and cultural environment. Socially, the lack of awareness and understanding of CVI can create barriers for this population, as well as unmet expectations from parents and/or teachers (Lueck & Dutton, 2015). Occupations Our daily activities and tasks change throughout life and continue to develop and change. Children with CVI face barriers in various aspects of life affecting their ability to participate in tasks, activities, and occupations. Occupational therapy practice categorizes occupations as activities of daily living (ADLs), instrumental activities of daily living (IADLs), health management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2020). ADLs The challenges associated with CVI impact daily activities that prevent children from interaction and participation in various tasks. Commonly, children with CVI face more challenges with everyday activities such as dressing, grooming, toileting, bathing, and eating. Challenges associated with dressing include orientating garments correctly while putting them on, locating and/or fastening buttons, finding clothing in a pile or closet, locating and putting on shoes and socks, and localizing the position of lower body dressing to put legs in the correct holes (Philip & Dutton, 2014; Salavati et al., 2015). Other tasks associated with dressing such as tying shoes have also been reported as challenging in this population (Orbitus et al., 2011). Other self-care activities that may be problematic include brushing teeth, due to struggles during application of toothpaste, orienting toothbrush correctly, and locating toothbrush on similar colored surfaces (Salavati et al., 2015). Additionally, challenges with brushing hair might also occur if they cannot locate all areas needing brushing or struggle to position brush correctly in relation to their body (Salavati et al., 2015). Toileting is another skill that occurs daily and can be troublesome for children with CVI. Most commonly, navigation to the bathroom, correct orientation of body in relation to toilet (sitting and/or standing), and challenges with adequately performing toileting tasks (Salavati et al., 2015). Functional skills related to bathing may cause obstacles for children with CVI. For example, navigating placement of bath time materials (soap, washcloth, towel, etc.), not being able to determine the height of the bathtub/shower, need for additional lighting, and failing to rinse soap adequately can all cause disturbances during bathing (Philip & Dutton, 2014; Salavati et al., 2015). Children with CVI may also experience adverse challenges associated with feeding and eating due to the inability to see food on plate, using utensils and vision together to obtain food, or seeing a spoon or bottle as it approaches when being fed (Lam et al., 2010; Philip & Dutton, 2014). Other challenges are drinking from a cup with a straw, and frequently spilling food and drinks (Philip & Dutton, 2014; Salavati et al., 2015). Good et al. (2001) reports that another element of feeding that may be impacted in this population is chewing. Due to chewing being partially learned through vision during early development, this can cause challenges with feeding that may lead to other medical issues such as aspiration (Good et al., 2001). Proper positioning during mealtime is also important and may be challenging for children with CVI due to having to focus intensively on vision use, especially when paired with co-occurring motor challenges (Lam et al., 2010). IADLs When performing IADLs, safety is one of the largest areas of concern in children with CVI. Children with CVI may experience problems that could hinder safety such as not seeing traffic because of impaired movement perception, experience difficulty identify the family car in a parking lot, and getting easily lost in crowds or malls due to too much visual input (Philip & Dutton, 2014; Salavati et al., 2015). Similarly, grocery shopping can cause distress from the overwhelming visual and auditory environment combined, inaccurately navigating locations due to inability to interpret signs (Lam et al., 2010; Pehere & Jacobs, 2019; Philip & Dutton, 2014). Education Research also indicates children with CVI struggle with education activities. Some studies that are specific to children with CVI in the school system have shown children experience issues with school related tasks such as reading depending on complexity of books, writing, viewing materials on a board, loud sensory environment of a room, among others (Philip & Dutton, 2014; Swift et al., 2008). Chokron et al. (2021) reviews the common obstacles children with CVI face and the impact they have on issues with reading. Issues in the classroom may also include slower processing time, struggling to see worksheets, trouble staying in the lines, and difficulty copying items from the board (Philip & Dutton, 2014; Swift et al., 2008). Literature indicates most children with diagnosed CVI have an IEP (Jayaraman et al., 2021) and often receive services from a TVI within the school system. Jackel (2019) conducted a survey on parents of children with CVI and found that parents felt their TVI was competent in treating CVI but other school professionals and staff were not. The same study reports that most parents indicated receiving appropriate accommodations for their child within the school system to be very challenging (Jackel, 2019). Researchers from Goodenough et al. (2021) reiterates similar experiences in their study and reports the importance of the parent in the childs success at school. Also not indicated in literature but an issue to think about is the challenges kids have at school with eating, toileting, navigation, and play which also take place at school every day. Some children with CVI need technological accommodations and work better on tablet/ipad/computer (Baker-Nobles & Rutherford, 1995; Swift et al., 2008). It is important to consider that if accommodations are not made at school and in classrooms, children have a decreased chance to learn and gain knowledge (Goodenough et al., 2021; Jackel, 2019). Social Participation Although occupational struggles are not well studied in children with CVI, an occupation that is often mentioned in professional level works is the challenge this population faces with social participation. Pehere and Jacob (2019) explain how most people identify and recognize people through use of vision, as well as gain information about their emotions from body language and facial expression paired with tone of voice. Children with CVI often have difficulty making eye contact and often miss social cues or fast facial expressions impacting social functioning (Morse, 1999; Philip & Dutton, 2014). They may also struggle to look at someone or something while listening at the same time, leading to either looking away or inability to divide attention (Philip & Dutton, 2014). Literature also shows children with CVI often frequently position themselves in unique ways to use their vision best and may not see a hand presented for a handshake if placed in a non-preferred visual field, further leading to embarrassment and/or appearing rude (Philip & Dutton, 2014). Children with CVI struggle to recognize faces, which is one of the largest documented factors associated with their social struggles; therefore, sometimes even recognizing family members or friends can be challenging (Fazzi et al., 2009; Orbitus et al., 2011; Philip & Dutton, 2014). Socially, parents have reported children with CVI have anxiety surrounding unfamiliar social environments due to fear of getting lost or not being able to find their friends (Philip & Dutton, 2014). Functional Mobility Another large area that impacts children with CVI is functional mobility and navigation. Children with CVI often struggle with navigation for many reasons. Most commonly, lower field deficits make navigating different surfaces more challenging and lead to safety concerns. Children with CVI have also been documented to have challenges with mobility on stairs and uneven surfaces (Lam et al., 2010; Orbitus et al., 2011). Additionally, when in an unfamiliar environment, navigation is more challenging, as well as distance vision impacting ability to see signs or familiar landmarks (Lueck & Dutton, 2015). Functional mobility is often impacted in children with CVI with reports of them commonly falling over clearly visual objects and commonly running into things during mobility (Pilling, 2022). Another challenge is transferring most commonly in the bathroom. Children with CVI often run into things and struggle with depth perception making navigation increasingly challenging (Philip & Dutton, 2014). Another aspect of CVI is the inability to realize movement of an object. This is most likely relevant for safety during navigation especially when crossing the street or walking in public due to the inability to recognize moving structures such as a car (Philip & Dutton, 2014) Play The most important occupation for a child is play. Play is not only how children enjoy life and spend their leisure time but is also a huge element connected to cognitive development early on in life. For some children with CVI, play can be difficult. They have issues with structured play like games due to complications following directions (Salavati et al., 2015). Kids may also have challenges with sports due to the environmental factors (Lam et al., 2010). Similarly, children with CVI often struggle to discriminate between 2-D imagery and prefer 3-D items. This is a barrier in tasks such as puzzles, games, and matching activities, due to it being hard for them to process (Orbitus et al., 2011). Other activities that children often enjoy such as riding a bike or kicking a ball can also be hard due to decreased coordination and balance, and difficulty with safe navigation. Philip and Dutton (2014) list similar activities as challenging such as jumping into a swimming pool due to not being able to judge the height of the water and going down a slide from inability to see the slide when seated. Some children with CVI also have delayed/impacted reflexes which may impact tasks like throwing and catching a ball (Philip & Dutton, 2014). Numerous studies have also mentioned challenges of children when finding a toy in a complex environment such as toy box (Bennett et al., 2019; Philip & Dutton, 2014). Occupational Therapys Role A key role in OT intervention planning includes conducting a detailed occupational profile to help understand specifics to improve both visual and functional outcomes (Harpster, in press). Additionally, in order to better understand ways that occupational therapists can adapt environments to better meet the needs of the child and the occupation, they must be informed on appropriate modifications. Use of the CVI Range can be helpful when implementing interventions due to breakdown of phases in the tool (Roman-Lantzy, 2007). The basis for this functional vision assessment examines the 10 key characteristics of CVI including color preference, need for movement, visual latency, visual field preferences, challenges with complexity, need for light, difficulties with distance viewing, atypical visual reflexes, limited visual novelty, and absence of visual motor skills (Roman Lantzy, 2007). Based on assessment of these components, children are placed into a phase to better understand their current level. The three phases are grouped by scores from 0 (no functional vision use) to 10 (typical functional vision for age and no CVI) into five levels, further classified into three phases to target intervention methods (Roman-Lantzy, 2007). Phase I intervention aims to build consistent visual behavior, phase II targets integrating vision with function, and phase III works on refining CVI characteristics (Roman-Lantzy, 2007). Researchers from Salavati et al. (2015) emphasize that due to the high number of children with CP and CVI together, both occupational and physical therapists need assessment tools available that are adapted for children with CVI in order to gain accurate performance results to inform treatment. Similarly, an intervention study focused on telemedicine for children with CVI involved the Canadian Occupational Performance Measure (COPM) as a primary outcome measure (Schwartz et al., 2021). The results of this study indicate occupational therapy interventions via telemedicine can lead to functional improvements and an increase in satisfaction of goal performance through use of the COPM (Schwartz et al., 2021). As previously discussed, OT are skilled in adapting environments to better suit functioning through task and environment modification. Morse (1999) emphasizes how intervention should analyze the environment the child is in, the activities they participate in, the sensory-motor demands, and time pressure and other variables. Similarly, since OT are skilled to treat children with co-occurring diagnosis of CVI (Chang & Borchert, 2020), therefore, they need to know how to incorporate functional vision use during treatments in order to facilitate visual progress while working on other challenges. Another large element that could be beneficial in treatment of children with CVI is parent education. Parents are very important in teaching their challenge and need the knowledge to modify environments and materials correctly to better support the childs functional vision use and improve daily living (Pehere & Jacob, 2019). The engagement of caregivers/parents is essential, and OT can advocate and teach them how to better understand their child and help meet their needs. Discussion Many of these children experience impacts from CVI in all aspects of daily living, creating functional and developmental challenges. Because occupational therapy provides services exclusively for the persons tasks and occupations, the role of occupational therapist in caring for children with CVI is crucial. CVI affects children in a variety of ways and is a diagnosis that varies from person to person requiring client specific care to individualize treatment to best fit their skills and abilities. A key element important in relation to intervention is that visual functioning in CVI has been proven to improve if the child receives specialized care (Roman-Lantzy, 2010). This reiterates that children with CVI can make improvements overtime. Occupational therapy intervention may focus on specific occupations, context, and environments, and/or performance patterns and skills (AOTA, 2020). Common interventions in OT scope include therapeutic use of occupations and activities, interventions to support occupations, education, training, and advocacy (AOTA, 2020). However, OTs expect that due to the dynamic involvement of a person, environment, and the occupation the ability to adapt, change or develop in certain areas will impact other areas (AOTA, 2020). Because occupational therapy practitioners are taught to analyze the physical and environmental demands of an occupation, they can provide a unique insight into appropriate adaptations and modifications needed in children with CVI during engagement in occupations. Through the use of activity analysis, occupational therapy practitioners can assess the physical and contextual demands of an occupation, specific to the client and their abilities (AOTA, 2020). For children with CVI, their ability to engage in an occupation is variable depending on the context and environment they are in. Therefore, intervention for children with CVI cannot solely disassociate the person from the environment or occupation. Instead, intervention for this population must be inclusive of all three components and provide constant reassessment to determine optimal balance to gain occupational performance. However, modification and intervention can be implemented at the person, environment, and occupational level. The next three sections include general recommendations for OT to use at the person, environment, and occupation level, but do not fully capture all recommendations. For the person, some methods might include allowing extra time for visual processing, adequately address cooccurring challenges such as taking sensory breaks to help maintain focus, being aware of the impact of visual fatigue associated with CVI so planning harder activities earlier in sessions, practicing social participation situation with a child to help increase confidence, implementing emotional regulation strategies for the child to use when overwhelmed or frustrated, and provide the child with skills to advocate for themself and their needs, among many others (Baker-Nobles & Rutherford, 1995; Philip & Dutton, 2014; Swift et al., 2008). Environmental modifications can include but are not limited to adapting the light to be more or less stimulating with a light box, decreasing visual clutter by presenting items one at a time, use of contrasting colored backgrounds such as presenting toys in front of black sheet, adding shiny materials that can be eye catching such as holographic tape on the stairs, placing stimuli at close viewing distances, elevating material with slant board, and avoiding patterned tables or flooring (Baker-Nobles & Rutherford, 1995; Pehere & Jacob, 2019; Philip & Dutton, 2014). Occupational and task adaptation during intervention may involve choosing occupations/tasks meaningful to the child, implementing verbal guidance and cueing during activity, using visual attracting elements during activities, ensuring food on a plate is a contrasting color during eating, placing a mirror in front of the child for dressing to help with fastening buttons, giving verbal directions before games to ensure the child understands rules, and implementing consistent routines (Good et al., 2001; Pehere & Jacob, 2019; Swift et al., 2008). Other characteristics important for occupational therapists to consider when providing interventions is that treatment and intervention methods for children with low vision or other visual impairments will not suffice for children with CVI due to the impairments in CVI being at the brain level (Gorrie et al., 2019). Pehere and Jacob (2019) emphasize that whoever is leading intervention for these children should choose stimuli specific to the childs interests and continually make adjustments to facilitate ongoing engagement. They also suggest that intervention for children with CVI should be carried out through regular childhood development tasks including play, learning, communication, and movement. This specific suggestion further validates the role of OT in caring for this population due to centering all treatment around regular tasks and activities, known to them as occupations. OTs are skilled in environmental modification and task adaptation, which are evident as the forefront of CVI functioning. Because OT professionals are trained in adapt environments to better meet the needs of the individual and optimize their independence. Since children with CVI often exhibit many visual challenges, one of the most important intervention methods is environmental adaptation. Although limited evidence has been proven to examine the difference in how these environmental modifications help children with CVI, there are a few works of literature that have explored parent reports about caring for children with CVI. Many of the unique modifications can be recommended by therapists and applied in the childs natural environment. As a profession, occupational therapists pride themselves on implementing evidencebased care for all clients. However, the evidence and literature for tested intervention is minimal, causing the inability to implement evidence-based care for this population (Harpster, In press). Researchers in Williams' (2021) article mention the growing concern about unmet needs, failure to achieve potential, and avoidable mental health problems like anxiety and poor self-esteem that may be seen in children with CVI whose difficulties go unrecognized over time. Due to OT's broad scope of practice, occupational therapists could be the key to bridging these caps and maximizing care. In order for occupational therapy practitioners to obtain competence in caring for this unique population, they must first have evidence-based literature to guide them in care. Conclusion Due to OTs focus on daily activities (occupations), environmental and activity modification, and emphasis on client-specific care, occupational therapists can provide a unique skill set to help this population. The role of OT as part of the interdisciplinary care team for children with CVI is imperative. In order for healthcare providers to ensure children with CVI are receiving quality care, evidence-based interventions need to be explored in the literature. As the increase in CVI continues to rise, the need for research to support treatment for this population should follow. 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