Tools for Assessment and Development of Visual Skills
TEACHERS' GUIDEBOOK

By

Elaine Kitchel, M.Ed., Project Leader

LaRhea Sanford, Ed.D. and Rebecca Burnett, Ed.D., Project Consultants

Matthew Smith, Project Assistant

Erica Rucker, Project Assistant

Grateful Acknowledgement is Hereby Given to:

David McGee, Technical Research
Frank Hayden, Technical Research
James Robinson, Technical Research
Tom Poppe, Model Maker

Cary Crumpton, Planning
Lila Adkins, Large Print
Steve Paris, Production Advisor
Anna Fox, Cost
Phyllis Williams, Inventory
David Hines, Engineering
Tony Grantz, Sales
Pat Packer, Braille
Steve Mullins, CD Production
David Manteuffel, Purchasing
Larry Skutchan, Programming
Sandy Maerz, Purchasing
Jack Decker, Vice President

Ralph Bartley, Ph.D., Educational Research
John Aicken, Educational Research
Valerie Cox, Educational Research
Bisig Impact Group, Graphic Design
Matthew Smith, Educational Research
Erica Rucker, Educational Research

and

M. Beth Langley, M.S.
Millie Smith, M.Ed.
Tristan Pierce, M.A.
Rebecca Burnett, Ph.D.
LaRhea Sanford, Ph.D.

for providing talent, expertise, knowledge, and hard work on the ToAD project.

Dedication

This book is dedicated to all those teachers, who have, for decades, made their own kits of materials to perform functional vision assessments and vision development activities for students with visual impairments. Many of these imaginative individuals have provided help their students could have acquired no where else. They have contributed profoundly to the body of information that provides the foundation for ToAD.

Table of Contents

 TEACHERS' GUIDEBOOK
 Introduction
 Preparing to Use ToAD
 Definitions
 ToAD Foam Puzzles
 ToAD Triangles
 ToAD Flashlight and Attachments
 ToAD String Light
 ToAD LED Keychain Light
 ToAD Match 'n Sort Cards
 ToAD Pompon
 ToAD Bowls and Balls
 ToAD Bell Bracelet and Puppet
 ToAD Gift Bags
 Tangle Toys TM and Foam Squares
 Slinky TM
 ToAD Mirror
 ToAD Swirly Mats TM
 Squire ToAD's Puzzles
 References

ToAD: Tools for Assessment and
Development of Visual Skills

Teachers’ Guidebook

Introduction

Every day teachers of students with visual impairments (TVIs) and early interventionists (EIs) conduct functional vision assessments (FVAs) on developmentally young students. Over the years, the American Printing House for the Blind (APH) has received numerous requests to provide professionals with a standardized set of tools with which to conduct the FVAs.

Until now, TVIs and EIs have used assortments of flashlights, toys, cards, Christmas decorations, light-up wands, pencil erasers, ropes, cups, balls all which, at some point, go out of fashion and become unavailable. Practitioners need tools that are easily available and will not fade away with the latest fads. Items that are functional, durable, and designed specifically for the job of performing the FVA have been requested. APH has fulfilled the need by designing and producing ToAD: Tools for Assessment and Development of Vision.

During the development of ToAD, APH staff examined requests for items from teachers who had struggled to build their own kits of materials. Needed items and their functions were compared against a list of visual behaviors necessary for maximum function in the environment. APH employed the assistance of Dr. LaRhea Sanford and Dr. Rebecca Burnett, both experts in low vision and functional vision assessment. They assisted in the review of the tools, and made suggested revisions. The materials have also been field tested and revised according to field test results. It is hoped practitioners and their students will benefit from using this standardized product. The benefits of standardization are these:

 *Once the design and materials of the ToAD Kit are well-known, practitioners and clinicians will have a clearer understanding of how each functional vision assessment is conducted and how the results are obtained.
 *The contents of the ToAD Kit will not become unavailable because APH produces them.
 *ToAD Kits will be available on quota.
 *Practitioners and clinicians can have confidence in a product which has been thoroughly researched and developed with input from the field.

IMPORTANT:
The ToAD Kit and materials may be used for both assessment and training purposes. However, because children respond differently to tests after they have been exposed to materials used in the tests, the ToAD Kit of materials should not be used for both purposes with the same student. The practitioner should make a decision before working with a child whether the ToAD Kit of tools and materials is to be used for assessment OR vision development purposes.

No matter which purpose is selected by the practitioner, helpful information for performing both kinds of tasks can be found in the ISAVE materials, also available from APH. Developed in 1999, by M. Beth Langley, a well-known expert in assessment of students with multiple disabilities, ISAVE provides not only assessment protocols and vision development guidelines, it provides the practitioner with much-needed information about supporting and aligning the student's body in preparation for the use of his vision. ISAVE teaches the practitioner how to prepare the environment for optimal use of vision by the student. It is strongly suggested that practitioners refer to ISAVE for guidance when performing functional vision assessments or vision development activities for young children.

Because ISAVE is widely available, only a few suggested activities for each ToAD tool are included in this guidebook. The practitioner is encouraged to use not only ISAVE, but tried-and-true strategies for obtaining meaningful results. ToAD is not a guideline for conducting a functional vision assessment, ISAVE and other well-known instruments provide that information. Rather, ToAD is an array of tools and materials to be used by the practitioner during assessment or vision development. The teacher's guidebook is a collection of suggested activities, mainly for use with students who are very young, or have communication barriers.

In the future, APH plans to produce additional ToAD tools and materials for students developmentally above the age of five, and for students with typical functioning and achievement in school.

Additional Equipment
To block out unwanted visual stimuli APH recommends the use of Invisiboard, a folding poster-sized device which is black on one side and white on the other. It provides a portable black or white corner in which to do your assessment of vision development activities.

To light up elements of the ToAD Kit such as the ToAD Triangles and the Swirly Mats TM, the APH Mini-Lite Box is a valuable and necessary tool. The Swirly Mats TM are custom made to fit the APH Mini-Lite Box.

To ascertain information about visual acuity and visual fields it is recommended that the ISAVE Grid be used in conjunction with the Invisiboard and ToAD. The ISAVE Grid provides a stand-alone transparent grid which may be positioned near the student for presentation of visual stimuli.

The eyepatch from the Sensory Learning Kit, and the occluders from the Occluder Pop Pack may also be helpful when obtaining information about the student's monocular vision.

APH is continually striving to build suites of materials for the TVI and the EI to use in daily activities. By making different APH products, such as the Sensory Learning Kit, ISAVE and ToAD compatible, APH provides the consumer with broader uses. Compatibility of products also conserves funds for the consumer. It is the hope of APH staff that ToAD will be a valuable tool for TVIs and EIs in assessing and developing visual behaviors and skills.

Elaine Kitchel, M.Ed.
Research Scientist
American Printing House for the Blind

Preparing to Use ToAD

From Individualized Systematic Assessment of Visual Efficiency (ISAVE) by M. Beth Langley

By obtaining an idea of how vision is used in both natural, unstructured and in optimal, structured settings, you will be able to delineate specific interventions to facilitate and encourage the development and optimal use of vision.

If the student is not physiologically available and prepared for interaction, you may learn only that he is visually unresponsive and very little about functional vision potential for further development and skill expansion.

Perhaps the most critical aspect of the assessment process is that of ensuring that basic physical principles have been met. Eliciting efficient, optimal behaviors will depend on whether the student is:

 1. ready for perceiving and processing information,
 2. provided with sufficient but appropriate amounts of sensory information, and
 3. appropriately physically stabilized.

Preparing and organizing the student for attending, perceiving, processing, and responding to assessment tasks must occur prior to any presentation of stimuli. If the student is tired, has just been fed, is hungry, or medication is wearing off, his performance may not represent typical or optimal abilities; although, diagnostically, information obtained under these conditions is valuable in discerning conditions and barriers that affect the use of vision in everyday experiences.

It will be particularly important to be very attuned to the conditions that will facilitate optimal attending and to behaviors that signal stress.

 *The background lighting should be dimmed and the use of very bright lights should be avoided.
 *When severe physical limitations influence visual behavior, it may be helpful to support the student in a supine position so that his head is raised approximately 30 degrees from the supporting surface. This position is often effective in eliciting a state of readiness and attending.
 *Stimuli should be introduced slowly, calmly, and presented for a short duration in appropriate intervals of time.
 *Allow the student sufficient time to process and respond to the stimulus as well as time to reorganize between stimuli. Behavioral signals of over stimulation and stress include yawning, increased drowsiness, hiccupping, fussiness, eye aversion, and regurgitation. Jan (personal communication) noted that when children with cortical visual impairment are over stimulated, they fade in and out of responsiveness and their vision may simply disappear for several seconds or longer, which may be thought to be seizure activity by those unfamiliar with the child.

Note the student's behavior and regulatory state prior to handling, positioning, and assessing and record it in the appropriate block on your assessment or skills development protocol. Reassess state and range of behaviors periodically as well as at the conclusion of the session. In addition to recording the specific state, it is helpful to describe the concomitant activity and/or stimuli accompanying the state.

Note:
 *whether interaction altered the student's behavior state
 *optimal attending, endurance, and processing time,
 *factors responsible for eliciting optimal attending behavior,
 *offer guidelines to the amount, quality, and nature of stimuli most appropriate to processing and organizational needs.

Positioning

If the student's sitting balance is poor, it will be critical to ensure stabilization of posture that results in better control of head movements. If independent head control is lacking, the student should be positioned supine with the occiput, or base of the skull, of his head secured over a small roll or pillow which will also facilitate midline orientation.

Image 1 - M. Beth Langley carefully positions a young male student in the supine position with his occiput secured over a small cylindrical pillow.
Teacher positioning child with occiput over bolster pillow.

Positions other than supine or sitting should be considered and attempted when assessing the vision of students with athetosis or spasticity. Supported sidelying with the head in alignment with the body and slight lateral flexion on the non-weightbearing side is often a good position in which to elicit efficient eye movements in an athetoid student who cannot otherwise achieve any midline control.

Image 2 - With support from his teacher, a young, male child is positioned sidelying on his right/side, bearing weight on his right arm and leg. His left knee is bent so his left foot is flat on the floor in front of his pelvis. He reaches for a toy with his left hand.
Support sidelying with the head in alignment with the body and slight lateral flexion on the non-weightbearing side.

Image 3 - A young female student is positioned prone with her upper body through the center of an inflatable ring. Her chest is supported by the ring as she watches a toy placed in front of her.
If sidelying is not appropriate, positioning in four-point, prone over a bolster promotes alignment of head and neck, brings the head into midline, and tends to help the eyes center when hyperextension of the head and neck are characteristic postures.

Because of the relationship between the vestibular system and oculomotor function, it is both desirable and often necessary to engage the student in rolling or other forms of vestibular activity prior to assessing visual behavior. The vestibular information serves as an alerting strategy to counteract a lethargic or a drowsy-alert state and to integrate oculomotor behaviors.

Image 4 - A young, male child sits upright on a large cylindrical bolster. His teacher also sits on the bolster behind him. A small pillow is between them. It supports the child's lower back. The teacher, M. Beth Langley, gently pulls the student's shoulders into alignment and supports the child's right arm as he reaches for a toy.
Bolsters provide the opportunity for subtle weight shifts and postural adjustments that maintain mobility and force the visual system to adjust to movement while remaining upright against gravity.

Environmental Controls

The best environment is one which permits observation of the student as he functions in his natural surroundings and which affords a quiet, organized space in which to observe optimal visual functioning. Lighting should be adjustable, even minimally, through the lowering of blinds or dimming or eliminating direct lighting sources. There should be some background lighting available but, in general, during the assessment of functions such as pupillary reactions, alignment, binocular function, fixation, eye mobility, and pursuit behaviors, lighting should be subdued. In contrast, increased illumination may be needed to provide contrast between foreground and background, to highlight visual stimuli, or to provide sufficient lighting for visual functioning when a specific visual impairment is manifest.

For more information see the Preparation to Conduct ISAVE chapter of the ISAVE product.

Definitions for ToAD Skills and ToAD Tools Chart

Pupillary response: Decrease in the size of the pupil when bright light is presented

Blink response: Closing the eyelids in a protective response to the movement of a hand or object toward the eyes

Pupillary reflection: Light is reflected off the pupil when a penlight is directed toward the bridge of the nose; location of reflections will indicate eye alignment.

Fixate: The ability of the eyes to directly gaze on an object and hold the gaze so the object remains in view

Convergence: The ability of the two eyes to maintain visual focus from distant to near

Ocular pursuit (fixates and follows; crosses midline): The ability of the eyes to fixate on an object and follow it as it moves; midline is the vertical plane that extends from the top of the center of the forehead to the navel.

Shift of gaze: The ability of the eyes to fixate on an object then shift fixation to another object, especially across midline

Scan: The ability of the eyes to move from left-to-right and back again, to visually observe

Acuity: Measure of the ability to distinguish objects, shapes, pictures, numbers, or letters at a standard distance

Visual field: Total area in which objects can be seen while the eyes are focused on a central point; usually measured in degrees

Eye dominance: Preferred eye used to perform a variety of visual tasks

Depth perception: The visual ability to perceive relative distance of objects

Light sensitivity and preference: Visual efficiency under various lighting conditions

Visual closure: The ability to fill in the whole when only parts of the whole are provided

Visual discrimination: The ability of the eyes and brain to perceive similarities and difference in objects, shapes, sizes, colors, patterns and pictures.  Visual discrimination can be demonstrated through activities such as matching, sorting, identifying

 *Matching: The ability of the brain to perceive through vision that two items (objects, shapes, pictures, and others) have the same characteristics
 *Sorting: The ability of the brain to discriminate between like and unlike items (objects, shapes, pictures and others) perceived visually and to categorize according to their similarities
 *Identifying: The ability of the brain to recognize items (objects, shapes, pictures and others) visually and to label them appropriately

Figure-ground discrimination: The ability of the eyes and brain to perceive one aspect of a picture/scene in relation to the entire picture/scene

Visual attention: The ability of the brain to pay attention to visual stimuli

Visual memory: The ability of the eyes and brain to perceive an object visually and to recognize it at a later time; the ability to perceive an object visually and recognize it when it is only partly visible, or recognize that it is missing from the original scene; includes object permanence which is the ability of the brain to perceive something visually, then know that the object is still there when covered-up or blocked from view

Eye-hand coordination: The ability of the eyes and hands to work together to see objects and manipulate them

Visual association: The ability to group objects and pictures according to categories, functions and other features

Visual sequencing: The ability to recognize objects in a series or to categorize objects perceived visually, into a series or pattern

Reproduction of designs: First, the ability of the brain to perceive a design of objects, pictures, or parts of objects; second the ability to reproduce those designs by manipulating objects, pictures or their parts.

Imitation: The ability to imitate an action, sound, expression or motion of a person, animal or object

Activation: The ability to initiate action using physical movement such as the pressing of a switch

Social attentional gaze: The ability to orient and pay attention to faces and facial expression

ToAD
Foam Puzzles

Image 5 - ToAD foam apple puzzle with apples removed.

Items Needed for Activities:

 *2 Apple Puzzles - red & yellow
 *2 Butterfly Puzzles - black & yellow
 *2 Sock Puzzles - violet & yellow
 *2 Snowflake Puzzles - blue & white
 *2 Star Puzzles - black and white
 *Black or white cloth to put under puzzles

Purpose: The Foam Puzzles can be used to assess or develop behaviors of fixation and following, visual closure, visual discrimination (color, size, shape), matching, sequencing, and sorting.

Activities

Fixates and Follows

 1. Place a black or white cloth on the working surface. Remove the largest apple from the puzzle frame and hold it in front of the child at the distance of about 18 inches. Watch to see if the student looks at the apple, even if he quickly moves his eyes away. Once you are sure the student is locating the apple, move the apple slowly across the child's field of view from left to right. Watch the child's eyes to see if they locate and follow the apple.
 2. Repeat the activity with the medium and small apples. Or use other puzzles for the same activity.

Size Discrimination

 3. Remove the blue snowflakes from their frame. Place them in a row in front of the student. Ask the student to touch one of the snowflakes. If he succeeds, ask him to touch the large snowflake; repeat for the medium and small snowflakes.

Visual Closure

 4. Ask the student to place the snowflakes back into the puzzle frame.

Color and Shape Discrimination

 5. Remove all the yellow socks from the puzzle frame. Place them in a row in front of the student along with a red apple from the apple puzzle. Ask the student which puzzle piece is not like the other puzzle pieces. If he points to the apple, let him put the puzzle pieces back in their frames.

Shape Discrimination

 6. Put all the yellow socks from the sock puzzle in front of the student along with a yellow apple from the yellow apple puzzle. Ask the student to point to the puzzle piece that is not like the others. If he succeeds, let him place the puzzle pieces back in their frames.

Sorting and Sequencing

 7. Repeat these exercises with different puzzles, teaching the students to sort by shape, size, and color and to sequence by size.

ToAD
Triangles

Image 6 - ToAD triangles inside plastic lightbox frame. Two loose triangles are outside the frame.

Items Needed for Activities:

 *2 red triangles
 *2 yellow triangles
 *2 blue triangles
 *2 violet triangles
 *Black frame
 *White cloth
 *Mini-Lite Box

Purpose: The ToAD Triangles are designed to be used with the APH Mini-Lite Box. They can be used to assess or develop visual attending behaviors, color identification, matching, sequencing, and understanding parts of a whole.

Activities

Color Discrimination

 1. Place a black or white cloth on the working surface. Place the black frame on the lightbox before turning on the light. Once the light is activated, place the red triangle inside the frame. Note whether the student attends to the red triangle. Talk about the color red. Ask the student to touch the red triangle.
 2. Ask the student to choose the remaining red triangle from among the other ToAD Triangles. If he succeeds, allow or assist him in placing it within the black frame on the lightbox next to the first red triangle.
 3. Now add a yellow triangle into the frame directly opposite from the red triangle. Tell the student this is "yellow" if he does not already know the color name. Ask him to touch the yellow triangle.
 4. Talk about how yellow looks different from red.
 5. Ask the student to choose the remaining yellow triangle from among the other ToAD Triangles. If he succeeds, allow or assist him in placing it within the black frame on the lightbox next to the first yellow triangle. You should now have two yellow triangles in the frame. Compliment the student on his design.
 

 Image 7 box 1 - Two red triangles inside plastic frame.
 Image 7 box 2 - One red and one yellow triangle inside plastic frame.
 Image 7 box 3 - Two yellow triangles inside plastic frame.

Matching and Visual Sequencing (reproducing design)

 6. Take all the triangles out of the frame. On the table, next to the lightbox, make a new design using the blue and yellow triangles. Ask the student to duplicate the design on the lightbox within the frame.
 7. Use your knowledge and expertise to make up other activities using the ToAD Triangles. For example, discuss the shape of the triangle. Demonstrate how to make a square from two triangles.

ToAD Flashlight
and Attachments

Image 8 - ToAD flashlight with the white wand attachment on the lens. The red cube and yellow sphere attachments lie beside the flashlight.

Items Needed for Activities:

 *ToAD Flashlight
 *Flashlight attachments: white wand, yellow sphere, red cube
 *Black apron
 *Black gloves
 *Invisiboard
 *ISAVE Grid
 *Your own mini flashlight

Purpose: ToAD Flashlight and Attachments may be used to assess or build visual attending, fixation and following, shift of gaze, crossing midline skills. The flashlight and attachments can also be used to determine gross visual fields.

Activities

Fixate and Follow

 1. Set up the Invisiboard and ISAVE Grid in a dimly-lit corner. Put on the black apron and the black gloves.
 2. Seat the student in an upright or semi-upright position, about 2 feet away from the ISAVE Grid. If the student has physical disabilities, be certain your student is well-supported. Center the grid in front of the child. Adjust as needed if he has monocular vision.
 3. Dim the lights. Standing behind the grid, so the grid is between you and the student, shine the ToAD Flashlight with the yellow ball attachment in the upper right-hand square of the grid. Check to see if the student is attending to the light in that square. Wiggle the light a little if the student is not attending.
 4. Move the light to the upper, center square. Again note if the child visually attends.
 5. Move the light in the sequence indicated by the numbers on the grid below.

 Student's right              Student's left

       3              2              1
       4              5              6
       9              8              7

 6. Note in which sections the student attends to the light. This may give you an idea of the student's visual field. You may want to repeat this activity with each eye occluded in turn, to observe the gross visual field of each eye.

Shift of Gaze and Crossing Midline

 7. Now shine the light in square #1 of the grid and keep it shining while you perform the next step. Hold the mini flashlight so it will show in square #3 when you turn it on. Turn the light on and blink the light to see if the student's attention switches from square #1 to square #3. If it does, the student is capable of "shifting" across midline. Visual shifting and the shift across midline are important visual skills.
 8. Allowing some rest time between exercises, repeat this exercise in other squares in a systematic order of your own devising. This will give you an idea of where the student has usable sight and if he is capable of visual shifts, especially across midline. It may also give you valuable information about the student's visual fields.
 9. If the student does not attend to the yellow ball attachment, switch to the red cube. Some children see certain colors better than others, and some children have color preferences.

Shift of Gaze at Greater Distance

 10. Another activity would be to have the student shift gaze from the ToAD Flashlight to a non-lighted object such as a shiny pompon. The ISAVE Grid would not be needed and the activity could take place at a distance of 3-6 feet from the child.

ToAD
String Light

Image 9 - Photo of coiled string light.

Items Needed for Activities:

 *ToAD String Light with Cricket Sound Module
 *Black cloth
 *Black apron
 *Black gloves
 *Invisiboard

Purpose: The ToAD String Light was developed to assist teachers in helping their students develop behaviors of visual attending, fixation and following, crossing midline, and visual reaching. If the cricket sound module is not already attached to the battery pack of the string light, attach it with Velcro TM coins included in the kit.

Activities

 1. Place a black cloth on the working surface. Set up the Invisiboard in a dimly-lit corner. Put on the black apron and the black gloves.
 2. Seat the student in an upright or semi-upright position, or in a sidelying position. Be certain the student is well-supported as needed. Make sure the environment is free of distractions. Dim the lights.

Visual Attending, Fixate and Following, Crossing Midline

 3. Standing behind the student, turn on and gently dangle and bounce the String Light in front of him at midline at a distance of about 18 inches from his face. If he does not seem to notice it, bring it in to a distance of about 12 inches. If he still does not attend, press the button on the cricket module to activate the sound.
 4. If the student attends to the light, gently move the light about 6 inches to the student's left and note if he attends in that position. Leave the light in that position for at least 10 seconds. Return the light to midline and leave it there for another 10 seconds.
 5. Now move the String Light 6 inches toward the student's right. Note if he attends it there. Give the student plenty of time to make the visual shift from center-to-left, and center-to-right.

Visual Reaching (Eye-Hand Coordination)

 6. Note if the student reaches out to touch the string. Although it is safe to touch the String Light, it may become damaged and inoperable if the student pulls on it.
 7. Some students may perform better if you place the string light on a flat surface in front of them instead of dangling it.

ToAD
LED Keychain Light

Image 10 - Photo of LED keychain light.

Items Needed for Activities:

 *LED Keychain Light
 *Black apron
 *Black gloves
 *2nd LED light
 *Invisiboard
 *ISAVE Grid

Purpose: The LED Keychain Light has been selected to do visual attending, fixation and following, shift of gaze and crossing midline distance activities. Observations regarding gross visual fields may also be made. Do not shine the LED Keychain Light directly in the student's eyes. It is very bright. The LED Keychain Light can be used for students whose vision is too poor to perceive the ToAD Flashlight and Attachments, or to do distance activities.

Activities

Note:  The ToAD LED light is for use only in distance activities, or for students whose vision is so dim or occluded that the ToAD flashlight will not do the job. The ToAD LED light is very bright. Take care to never shine it in the student's eyes.

 1. Seat the student in an upright or semi-upright position, about 8 feet away. If needed, make certain the student is well-supported. Stand facing the student so you are directly in his line of sight. Make sure an observer is near the student where he can observe the student's eyes without being a distraction.
 2. Put on the black apron and the pair of black gloves and dim the lights. At the student's eye level, hold the 2 LED lights, one in each hand, arms stretched as far apart as possible. Turn on the LED light in the left hand. The student should have to look slightly to his right to see it. The observer should quietly give information about whether or not the student is attending to the light. Leave the first light on, holding it in the same position.   Now turn on the LED light in the right hand. The student should shift his gaze from his right to his left. The observer will be able to give information about the student's eye movements.
 3. If it appears that the student is not attending to either light, move in to a distance of 6 feet and pull arms in about 8" on each side, and try again. If needed, continue moving toward the student in stages until the observer is certain the student is attending to the lights. Remember to pull your hands together as you move closer. Do not move closer than 3 feet from the student. Do not shine the lights in the student's eyes.
 4. Continue to do the exercise until the farthest distance at which the student attends to the lights is noted. At this distance, check not only for right-to-left shift of gaze, but also check left-to-right, up-to-down and down-to-up.

ToAD
Match 'n Sort Cards

Image 11 - Photo of ToAD Match 'n Sort Cards showing socks, spoons and assorted cards.

Items Needed for Activities:

 *Match 'n Sort Cards
 *Foam apple puzzle with red apples
 *Butterfly puzzle with yellow butterflies
 *Red ball
 *2 red Delicious apples
 *Foam squares
 *Black apron
 *Black cloth

Purpose: Match 'n Sort Cards may be useful in assessing or developing visual attending, size and shape identification, color and shape matching, sequencing, and sorting skills.

Activity One

Identification and Matching

 1. Set up the Invisiboard in a dimly-lit corner. Put on the black apron and the black gloves. Place the black cloth on the table in front of the student.
 2. Within the child's field and range of vision, show the child two, red Delicious apples. Allow the child to touch and feel the shape and texture of the apples. Point out that these apples are red and look similar to one another. Use the word "apple" while pointing to each one.
 3. Show the child the two, red Delicious apples and the red and yellow apple card. Point out the similar shape and color of the apples. Use the word "apple" while pointing to each one. Allow the child to touch and manipulate all the apples.
 4. Introduce the largest red apple from the foam puzzle alongside a real apple and the red and yellow apple card. Point to the foam apple and talk about the ways that it is similar to the other two apples.
 5. Take away the real apple. Add the large yellow foam butterfly from the foam butterfly puzzle alongside the foam puzzle apple and the red and yellow apple card. Identify the butterfly and the apples with the child.
 6. Remove all the items from in front of the child. Place two foam butterflies from the butterfly puzzle, and the foam apple from the apple puzzle in front of the student. Ask him to point to the apple. If he succeeds, go on to the next step. If he does not succeed, repeat step 3 and 4 again.
 7. Place the red and yellow apple card, the foam puzzle apple, and the 3-inch, photo of the apple in front of the student. Point to the photo and explain that it shows an apple. Now place the yellow ball and another apple card in a separate array a few inches away from the first. Ask the student to pick out the apple from the second array and put it with the other apples in the first array. If the child does not succeed, repeat step 4 substituting the sock for the foam butterfly.

Activity Two

 1. Set up the Invisiboard in a dimly-lit corner. Put on the black apron and the black gloves.  Place the black cloth on the table in front of the student.
 2. Within the child's field and range of vision, show the student the 3-inch card with a red apple photo card. Explain that this is a picture of an apple. Show the student the large red foam apple from the foam puzzles. Ask him to name the item. If he can't, simply tell him it too is an apple. Ask him to place it beside the picture of the apple. If he does not have adequate motor skills, do it for him and show him how they are alike.
 3. Now show the student the red and yellow apple card. Ask him what it is. He should be able to indicate that it is an apple. If not, repeat Activity One. If he identifies it as an apple, put it beside the other apples in the array.
 4. If the student succeeds at step 3, show him the 2-inch, multi-color graphic of an apple. Ask him to identify it. If he does, ask him to place it with the other apples in the array. If he does not succeed, repeat step 2, substituting the 2-inch multi-color graphic of an apple with the 3-inch one. Adjust the working distances and/or the sizes of the objects as needed and continue to practice the concepts.

Activity Three

This activity should be done only after the first two activities have been done successfully.

 1. Set up the Invisiboard in a dimly-lit corner. Put on the black apron and the black gloves. Place the black cloth on the table in front of the student.
 2. Within the student's field of view and preferred working distance, show the student the 2-inch red and yellow, line art card of the apple. Ask the student what the name of the object in the picture is. If he responds correctly, move on to step 4.
 3. If he does not respond, or responds incorrectly, tell him it is an apple and show him the 3-inch red and yellow card and the foam apple from the foam puzzles. Talk about how the three apples are alike. If you are working on development activities, repeat this step until the student achieves the recognition of the 2-inch, red and yellow, graphic of an apple.
 4. Now show the student the 3-inch black and white, line art graphic of the apple. Ask the student to identify the object in the photo. If the student achieves recognition, place the card in front of him with the 2-inch, red and yellow card mentioned above.
 5. Repeat step 4 using the 1-inch, black and white, apple card. Remember it may be necessary to move the card closer to the child. Note the working distance for each image size.

Sorting

 6. If the child successfully achieves the desired result in Activities One, Two and Three, place an array of apples in front of him using the red ball and foam puzzle pieces, including assorted sizes and colors of apple cards. Include a few butterflies and snowmen. Ask the student to retrieve all the apples and put them in a pile.
 7. Repeat this series of activities using different image cards from the match 'n sort card set.

ToAD
Pompon

Image 12 - Photo of the gold and yellow pompon.

Items Needed for Activities:

 *Pompon
 *Black apron
 *Black gloves
 *Invisiboard

Purpose: The Pompon is needed mainly to elicit visual attending, fixating and following behaviors. When the student does not attend to objects, it is sometimes helpful to use something shiny, metallic and colorful. The pompon provides an added benefit of a rustling sound.

Activities

Visual Attending and Fixate and Following

 1. In a dimly lit corner created with the Invisiboard, and with a black apron and black gloves on, hold the Pompon in the center of the student's visual field at a distance of 24 inches. If the student does not immediately look at it, rustle the Pompon. Watch the student's eyes to see if he looks directly at the Pompon or uses eccentric viewing. Observe physiological and visual responses. For more information on non-verbal attending behaviors, see the chapter in ISAVE, titled Minimally Responsive, also available from APH.
 2. Once the student is attending to the Pompon move it to his left for a few seconds. Note whether or not he follows the Pompon, or searches for it. Once he attends to it on his left, move it slowly back to midline, holding the position for at least 10 seconds. Then move the Pompon to his right. Once again, note whether or not your student attends to it on his right.
 3. When the student can reliably attend to the Pompon at center, left and right, you may substitute other items that are not so shiny, and see if he attends to those as well. Move the objects to up and down positions if the student succeeds at left and right.

ToAD Bowls
and Balls

Image 13 - Photo of ToAD bowls with red, yellow and blue balls.

Items Needed for Activities:

 *Red, yellow, and white bowls
 *Blue, red, and yellow balls
 *ToAD Velcro Board or black cloth
 *Black gloves

Purpose: The ToAD Bowls were developed to assist the teacher in teaching the concept of object permanence. The balls are included in the ToAD Kit to provide a stimulus in developing imitation, activation, and visual pursuit behaviors.

Activities

 1. Lay out a black cloth or ToAD Velcro Board. While wearing the black gloves, show the student the red bowl as you place it on the cloth in front of the student. Then show the student the blue ball. Put the blue ball inside the red bowl and let the student take it out and put it in the bowl.
 2. Turn the red bowl upside down. Leave the blue ball sitting beside the bowl. Pick up the ball and place it under the upside-down bowl.
 3. Observe to see if the student looks for the ball under the bowl. If he does, the student understands object permanence.
 4. If the student does not look for the ball under the bowl or anywhere, he must be taught object permanence.
 5. Repeat the activity using different combinations of colored bowls and balls. Ask the student where the ball went.
 6. If the student is successful with the balls, hide other objects under the bowls. Once the student understands to look under the bowl, no matter what the object, begin hiding objects in other places such as in the gift bags, or behind a stuffed animal. See if the student can transfer his understanding of object permanence to other objects.

ToAD Bell Bracelet
and Puppet

Image 14 - Photo of red, fuzzy, Billy Bird puppet holding bell bracelet in his beak.

Items Needed for Activities:

 *Bell bracelet
 *Billy Bird puppet
 *Black apron
 *Invisiboard
 *Black glove

Purpose: The Billy Bird puppet is designed to attract the student's attention and to assist the teacher in helping the student develop skills in pursuit, shift of gaze, crossing midline, and imitation. The puppet may also be useful in developing social attentional gaze and convergence. The bell bracelet will provide an audio cue if the student has difficulty attending, locating, or scanning.

Activity One

 1. Work in an area that is quiet and not visually stimulating. The Invisiboard may be used to block out visually stimulating areas of the room. Wear the black glove on the hand not using the puppet.
 2. Wearing the black apron, put the Billy Bird puppet on your dominant hand. Hold the Billy Bird puppet about 18 inches from the student in the area in which he has his best vision. Watch the student's eyes to see if he attends to the puppet. (For more information about subtle attending responses see the chapter on Minimally Responsive in ISAVE.)

Visual Attending, Ocular Pursuit, Shift of Gaze, Crossing Midline

 3. If the child is attending to the puppet, move the puppet gently to the left. Hold and wiggle the puppet on the left side for 10 seconds. Note the child's attention. If the student is not attending, put the bell bracelet in the puppet's mouth and shake it gently. Now note if the child attends when the sound cue is added. (More time may be needed for students with CVI to respond.)
 4. Now move the Billy Bird puppet, with or without the bracelet, depending upon the student's need, back to center and hold that position for 10 seconds. Move the puppet gently to the right. Wiggle the puppet gently if the student is having difficulty pursuing or locating the puppet. If the student still has difficulty after your wiggling the puppet, add the sound cue. Steps 3 and 4 may need to be repeated several times until the student can visually pursue the puppet left, right, up, and down.
 5. If the student responds well, move the bell bracelet (without sound) separately to see if the student will pursue left, right, up and down with the smaller object. You can always add the sound cue if the student has trouble pursuing the object.
 6. Note: Do this part of the activity if you suspect the child uses one eye only. Hold the Billy Bird puppet 24 inches from the child in the center field of vision. Slowly move the puppet closer to the child's face. Stop about 4 inches from his nose. If the students eyes turn inward, he has convergence. If the eyes do not turn inward, he may have only monocular vision and this could influence his program needs.
 7. Use the puppet and the bell bracelet to provide interest, color, motivation, or sound cues to activities with other elements of the ToAD Kit.

Activity Two

Imitation of Action

 1. Once the student has learned to attend to the Billy Bird puppet hold the puppet at a good working distance from the student.
 2. Make the puppet do motions or sounds for the child to imitate. Ask the student to do what Billy Bird does. Some suggested behaviors are:
   *Nodding
   *Shaking head
   *Opening and closing "beak"
   *Scratching Teacher's head
   *Dipping head
   *Making bird noises

ToAD
Gift Bags

Image 15 - Photo of two shiny gift bags with small items in and around them.

Items Needed for Activities:

 *Colored Gift bags
 *Colored balls
 *Foam squares
 *Tangle Toys TM
 *Invisiboard
 *White cloth

Purpose: The gift bags are included in the ToAD Kit to assist the teacher in helping the student develop skills in object recognition, imitation of action, eye-hand coordination, and object permanence.

Activities

Object recognition, Eye-Hand Coordination, Imitation of Action

 1. Work in an environment that is free of distractions. Use the Invisiboard to block out stimulating backgrounds. Place the white cloth on a clean surface.
 2. Place the yellow ball on the white cloth in front of the child. Show him how the ball can be rolled short distances. Roll the ball, then place it in the student's hand and ask him to roll it.
 3. Keep modeling the behavior until he is able to roll the ball. Use hand-under-hand technique if needed.
 4. Show the student a gift bag. Show him how to put a ball in the gift bag. Allow the student to practice putting the ball in and out of the gift bag.
 5. Repeat this exercise by putting a Tangle Toy TM in and out of the gift bag.
 6. Now show the student a completely new item such as foam squares. Put the new item in the gift bag after the student has looked at it.

Object Permanence

 7. Set the gift bag with the item in it about 12 inches away from the student. Observe if the student reaches for or otherwise goes after the gift bag and looks for the item inside it.
 8. Repeat item 7 until the student consistently pursues the bag and the item inside it.
 9. Now add another gift bag so the child sees two gift bags sitting side-by-side. Put the item in the unfamiliar bag and ask the student to watch. Observe which bag the student chooses in which to search, the familiar or the unfamiliar. Repeat this activity, sometimes putting the item in one bag and then the other. When the student consistently reaches for the correct bag, he has developed object recognition and object permanence behaviors.

Tangle Toys TM
and Foam Squares

Image 16 - Photo of Tangle Toy TM with three foam squares threaded onto it. An array of foam squares is spread out below the Tangle Toy TM.

Items Needed for Activities:

 *Tangle Toys TM
 *Foam squares with holes
 *1/2" Wooden dowel (with ends sanded for smoothness)

Purpose: The Tangle Toys TM and foam squares are included in the ToAD Kit to help teach the student eye-hand-coordination, sequencing, and figure/ground discrimination.

Activities

Eye-Hand Coordination

 1. Make sure the student is in a setting free from distraction. Place a white cloth on the table in front of the student.
 2. Place one Tangle Toy TM and three foam squares of the same color in front of the student. Pop the Tangle Toys TM open at one joint, then show the student how to thread the squares onto the Tangle Toy TM.
 3. If the student has trouble, it is helpful to obtain a 1/2-inch wooden dowel to practice the task. Be sure to smooth the ends of the dowel with a piece of sandpaper before use.
 4. Once the student develops the eye-hand coordination to thread squares on the Tangle Toy TM, improve eye-hand coordination by letting the student take the Tangle Toy TM apart and put it back together. Mix and match colors among the Tangle Toys TM in the kit.

Figure Ground Discrimination and Sequencing

 5. Use the Tangle Toys and foam squares to complete color sequencing activities.

Slinky TM

Image 17 - Photo of Slinky in an N shape.
Items Needed for Activities:

 *Slinky TM
 *Black or white cloth
 *Bell Bracelet
 *Invisiboard

Purpose: The Slinky TM is included in the ToAD Kit in order to help the student develop attending, pursuit, and eye-hand coordination behaviors.

Activities

Visual Attending

 1. Work with the student in a setting that is free from distraction. Use the Invisiboard to block out distracting items and activities from the student's view.
 2. Place a black or white cloth in front of the student and put the Slinky TM on it.
 3. If the student does not attend to the Slinky TM, jingle the bell bracelet near the Slinky TM until the student locates it.
 4. Note if the student reaches for the Slinky TM. If not, make sure you are working within the student's field of vision and show her how to play with the Slinky TM. Even if the student grabs the Slinky TM and lets it dangle, it should count as an activation response.

Eye-Hand Coordination

 5. If the student has poor eye-hand coordination, you may continue to show her how to work the Slinky TM. Either dangle the Slinky TM or move it back and forth between your hands.
 5. It may be helpful to place the student on her back, supporting her head and neck with a bolster pillow. Hold the Slinky TM over her and put her hands on the Slinky TM with your hands guiding hers. Help her to play with the Slinky TM appropriately.
 

 Image 18-01 - Photo of adult hands with child's hands in the palms thereof. All hands are palms-up. Half the Slinky TM is in the child's right hand and half in the left. The adult gently elevates one hand slightly, then the other. This action makes the Slinky TM pour from one hand into another.
 

 7. Once a rhythm is achieved with the bulk of the Slinky TM moving from one hand to another, watch to see if the student visually pursues the movement of the Slinky TM.
 

 Image 18-02 - Photo of adult's hand and child's hand, both palms-up, fingers facing away from the body. Adult's fingers are laced between the fingers of the child's hand which is on top.
 If the student does not maintain hand contact while the hand-under-hand technique is employed, gently lock fingers with the student to facilitate continuous contact.

ToAD
Mirror

Image 19 - Photo of the ToAD mirror is shown with an red ball sitting on it to show reflection.

Items Needed for Activities:

 *Mirror
 *Invisiboard

Purpose: The mirror is included in the ToAD Kit to facilitate the teaching of social attentional gaze and convergence behaviors.

Activities

Social Attentional Gaze

 1. Work with the student in an area free of distraction. The Invisiboard will be helpful in blocking out visual distractions.
 2. Hold the mirror in front of the student slightly to the left of midline, in a position where the student should be able to see his own face. Start at 18 inches away from the student. Note if the student attends at that distance. If the student smiles or recognizes a face, he may be exhibiting social-attentional gaze behavior.
 3. Slowly move the mirror to a position slightly right of midline, in a position where the student should, again, be able to see his own face. Maintain the distance of 18 inches.

Convergence

 4. Move the mirror to a midline position where the student can see his own face. Note if the student observes the image. Now slowly move the mirror to 12 inches away from the student's face. Note if the student's eyes turn inward as the mirror comes closer.
 5. Repeat steps 2 through 4 at the 12-inch distance. In step 4 slowly move the mirror to a distance of 7 inches from the student's face. Note if the student's eyes turn inward as the mirror moves closer. Note if the student's eyes begin to turn inward, then stop and look past the mirror. Note the distance at which the student eyes lose the ability to converge. (Students 9 months and younger should be able to converge at 5 to 7 inches.)

The inability to converge may mean the student is viewing with one eye only. Note this for student programming needs and for feedback to the low vision clinician.

ToAD
Swirly Mats TM

Image 20 - Photo of one pink and one yellow-with-red Swirly Mat TM shown side-by-side.

Items Needed for Activities:

 *6 Swirly Mats TM CVI (3 very simple), FVA (3 complex)
 *APH Mini-Lite Box
 *Invisiboard
 *White tabletop mat

Purpose: The purpose of the Swirly Mats TM is to provide a bright, colorful, fluid medium that can be backlit, in order to capitalize on light-gazing behaviors to develop visual attending, activation, color and shape identification behaviors.

Activities

 1. Set up the Invisiboard to block out extraneous light, noise and visual stimuli. Set up the APH Mini-Lite Box as well. If you set the lightbox up so it is on an incline, you will need to flip the Swirly Mats TM occasionally. To avoid flipping, use the white table top mat included with the Swirly Mat TM materials, instead of the APH Mini-Lite Box.

Visual Attending, Activation, Fixation, Eye-Hand Coordination

 2. After the student is positioned, supported, stabilized and ready to use his vision, place the pink Swirly Mat TM on the panel of the APH Mini-Lite Box and turn it on. The pink gel inside the Swirly Mat TM will become very bright and colorful. Watch the student's eyes to see if he is locating the Swirly Mat TM or any of its elements. If he is, the student may reach toward the Swirly Mat TM to touch it. This action, if repeatable, may count as an "activation" response because the liquid in the Swirly Mat TM moves at a very slight touch and changes its design. Ask the student to touch the pink or touch the clear part of the mat, to check for color discrimination.
 3. Using hand-over-hand technique, if needed, let the student use his finger to flatten and/or chase a spot of pink liquid across the mat. After the student has mastered locating, attending, and activating the pink Swirly Mat TM, move on to the red and yellow Swirly Mat TM. This mat is more complex and requires better discrimination on the part of the student. (If these mats are too complex for the student, investigate the Swirly Mat TM CVI Set, which is a set of mats without much complexity.)
 4. Make certain the student is still positioned, supported, stabilized and ready to use his vision. Place the red and yellow Swirly Mat TM on the panel of the APH Mini-Lite Box and turn it on. The colored gels inside the Swirly Mat TM will become very bright and colorful. Watch the student's eyes, or ask for a verbal response to see if the student is locating elements within the mat or attempting to touch the Swirly Mat TM. Does he locate a certain spot of red or yellow, or does he locate a brightly-colored, metallic shape within the Swirly Mat TM?

Color and Shape Discrimination

 5. Once the student is locating and attempting to activate, ask the student to touch certain elements seen within the Swirly Mat TM. Again, ask the student to participate in color discrimination, shape discrimination, or simple activation activities.

Note: Swirly Mat TM may be used on the white, vinyl pad included in each Swirly Mat Kit, where use of the APH Mini-Lite Box is not possible or indicated.

IMPORTANT:
Many students will have fun just playing with the Swirly Mats TM. Swirly Mats TM provide a never-ending display of ever-shifting color, shape, and movement that is so interesting to students with low vision.

The liquids inside the Swirly Mats TM are mainly vegetable oils and water. They are non-toxic. The vinyl casing of the Swirly Mats TM is double-thickness but the Swirly Mats TM are still vulnerable to puncture. Please take care during use and storage to keep them away from sharp objects, folding or bending, and children's teeth. If punctured, the contents of the Swirly Mats TM will leak and possibly stain.

Store the Swirly Mats TM in the protective folder at temperatures between 60 and 85 degrees Fahrenheit, for longest life and best performance.

Squire ToAD's
Puzzles

Image 21 - Photo of one of Squire ToAD's puzzles.

Items Needed for Activities:

 *Squire ToAD's Puzzle Book
 *Black or white cloth or Velcro Board
 *APH Grandstand

Purpose: The Squire ToAD Puzzles were developed to provide practice toward development of figure/ground discrimination, sequencing, object recognition, visual discrimination, and visual closure concepts.

Activities

 1. Work with the student in a setting free of distraction.
 2. Place a Squire ToAD Puzzle on a white or black cloth background in front of the student.
 3. If needed, provide additional lighting and bookstand so the student can adequately see the puzzles. Make sure to protect the student against glare. Do not let task light shine directly in the eyes of the student.
 4. Squire ToAD's Puzzles have individual instructions with them. Follow the instructions the first time the puzzles are used with a student.

References

Graham, C. H. (Ed.). (1965). Vision and Visual Perception. New York: John Wiley & Sons, Inc.

Humphreys, G. W. (Ed.). (1999). Case Studies in the Neuropsychology of Vision. East Sussex, UK: Psychology Press, Ltd.

Jan, J., & Groenveld, M. (1993). Visual behaviors and adaptations associated with cortical and ocular impairment in children. Journal of Visual Impairment and Blindness (JVIB), 87, 101-105.

Jose, R. T. (Ed.). (1983). Understanding Low Vision. New York: American Foundation for the Blind, Inc.

Langley, M.B. (1998). ISAVE: Individualized, Systematic Assessment of Visual Efficiency for the Develop mentally Young and Individuals with Multihandicapping Conditions. (Vol. 1). Louisville, KY: American Printing House for the Blind, Inc.

Levack, N., Stone, G., Bishop, V. (1991). Low Vision: A resource guide with adaptations for students with visual impairments. Austin, TX: Texas School for the Blind and Visually Impaired.

Lueck, A. H. (Ed.). (2004). Functional Vision: A Practitioner's Guide to Evaluation and Intervention. New York: American Foundation for the Blind, Inc.

Lueck, A. H., Chen, D., Kekelis, L. S. (1997). Developmental Guidelines for Infants with Visual Impairment: A Manual for Early Intervention. Louisville, KY: American Printing House for the Blind, Inc.

Rapp, B. (Ed.). (2001). The Handbook of Cognitive Neuropsychology: What Deficits Reveal About the Human Mind. Philadelphia, PA: Psychology Press, Ltd.

Scholl, G. T. (Ed.). (1986). Foundations of Education for Blind and Visually Handicapped Children and Youth: Theory and Practice. New York: American Foundation for the Blind, Inc.

South Carolina Department of Education. (1992). South Carolina Functional Vision Assessment. Columbia, SC: South Carolina Department of Education.

Smith, M., Sensory Learning Kit Routines (2005). Louisville, KY: American Printing House for the Blind, Inc.

Stirling, J. (2000). Cortical Functions. London: Routledge

AMERICAN PRINTING HOUSE FOR THE BLIND, INC.
Cat. No. 7-08152-00
APH Contact Info 800-223-1839

