Using Reflective Practice to Collaborate With Caregivers and Their Young Children With Cerebral Visual Impairment

Cerebral or cortical visual impairment (CVI) is the most common diagnosis of visual impairment in young children in the United States and other developed economies (Hatton et al., 2013; Pehere et al., 2019). CVI is one of the most complex diagnoses, because the way CVI manifests can be unique to each child. Families of these children have many questions about their children's development, diagnoses, and prognoses. One role of practitioners certified in visual impairment is to collaborate with these families to answer their questions. Using reflective practice is one feasible approach because it is a recommended practice for practitioners in early intervention, early childhood, and related disciplines (Chen & Groves, 2023; Division for Early Childhood, 2014; Freisen & Mihai, 2024; Gatti et al., 2011; Lombadi et al., 2023).

It has become increasingly clear from the literature (Lueck et al., 2021), professional practice, and reports from families of children who have CVI, that the condition, in its varied expressions, has a more global impact in all developmental areas. Therefore, reflective practice is even more critical, since families and professionals must take time to consider the entire gamut of developmental outcomes from a CVI perspective.

In this Practice Report, the authors draw on their professional experiences in serving families and their young children with visual impairments including those with CVI, along with training of early interventionists, as well as teachers in special education and visual impairment. This report discusses components of reflective practice that require self-reflection and reflective supervision (see Table 1 for definitions) and how this approach may be used to collaborate with families of young children with CVI to address their children's developmental needs. A central theme is that reflection requires practitioners to analyze learning experiences while also paying attention to thoughts and feelings about these experiences (Dewey, 1933).

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Table 1.

Definitions of Reflective Practice, Self-Reflection, and Reflective Supervision.

Reflective practice	Self-reflection	Reflective supervision
An approach that promotes professional development and high-quality early intervention services. It is implemented through self-reflection and reflective supervision of practitioners.	A process of thoughtful contemplation of one's feelings and actions related to interactions with families, children, and team members. Self-reflection is most effective when used at key times, i.e., before, during, or after an interaction, and during reflective supervision.	A regular opportunity to discuss feelings and concerns about relationships with families and their young children and to problem solve dilemmas within a nonjudgmental and supportive environment facilitated by a mentor trained in reflective supervision. Meetings may occur individually or with a small group of colleagues.

Components of Reflective Practice

Reflective practice is a dynamic, participatory, and cyclical thought process that involves careful observation and attentive listening during interactions. This practice is particularly helpful to practitioners who are serving families and caregivers in complicated circumstances and children with complex developmental needs such as those with CVI. Uncomfortable and challenging situations tend to motivate practitioners to avoid simplistic solutions and question assumptions about how and what they are doing in their work (Bolton & Delderfield, 2018; Machost & Stains, 2023).

How to Become a Reflective Practitioner

Reflective practice requires making time for reflection, having an attitude of curiosity, becoming a problem solver, and questioning assumptions and the status quo (Larrivee, 2000; Lombadi et al., 2023). Table 2 lists the types of questions that facilitate reflection during an observation of a caregiver–child interaction. Questions listed under “Attitude of Inquiry” are examples of “thinking aloud” to elicit discussion with the caregiver. Questions listed under “Gather Perspectives” are intended to learn about the caregiver's observations, concerns, and feelings. All questions are open-ended and allow the practitioner to ask follow-up questions that are tailored to the specific situation.

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Table 2.

Examples of Reflective Sentence Starters and Questions to Promote Inquiry and Gather Perspectives.

Attitude of inquiry	Gather perspectives
I wonder what it means when…	What would you like to talk about?
I wonder why…	How are things going?
I wonder what would happen if…	What have you noticed when…?
How does the child respond when…	How do you feel when?

Time-Dependent Self-Reflections

Three time-dependent self-reflections are useful to practitioners: (a) reflection for action (Killion & Todnem, 1991), (b) reflection in action, and (c) reflection on action (Schön, 1991). Reflection for action occurs before the activity and involves thinking about an upcoming event based on past experiences. Reflection in action occurs during the activity and requires thinking on-the-spot, improvising as needed, and considering past actions, influences, and potential outcomes (Bolton & Delderfield, 2018; Machost & Stains, 2023). Reflection on action occurs after the activity and involves analyzing what happened and considering the outcome. When applied in early intervention services that focus on promoting caregiver–child relationships, practitioners are likely to reflect for interaction (plan), in interaction (implement), and on interaction (evaluate). See Table 3 for examples of questions to stimulate reflection at these junctures.

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Table 3.

Examples of Self-reflection Questions to Support Reflection for, in, and on Interactions.

Reflection for interaction	Reflection in interaction	Reflection on interaction
How do I gather information about this child and family?	How is the caregiver doing?	What worked, what didn’t, why?
How do I plan interventions that are meaningful and motivating for them?	How is the child responding?	What did I learn today?
Based on the previous visit what specific questions come to mind?	What’s working? What could we try?	What would I do differently should the same situation arise? What would I do the same way?
How might today’s interaction be similar or different to those I’ve had with other children and families?	What could be changed to improve the child’s responses?	How do I feel about what’s happening with this child and family?

An early interventionist serving families and their young children with CVI provided the following reflections on the three time-dependent self-reflections.

Reflection for Interaction

In preparing to observe a toddler with the questionable diagnoses of CVI and autism spectrum disorder (ASD), I reflected on previous encounters with similar circumstances. How can CVI and ASD resemble each other? How are they very different? What language have I used that seemed to help parents and service providers understand these complexities? I reminded myself that there are dual diagnoses, misdiagnoses, and that it takes time to figure it all out.

Reflection in Interaction

A mother seemed completely uncertain as to how to help her baby. She did her best to participate, but her body language communicated utter exhaustion. Then she mentioned a little song that she had written for her baby. I recognized the importance of that moment, even if it seemed unrelated to the baby's CVI and the purpose of my home visit. I asked if she would sing the song, and she did. Her demeanor softened, her baby smiled, and this mother seemed energized.

Reflection on Interaction

After visiting the zoo with a family of a 32-month-old child named Drew (a pseudonym), I reflected on what I learned about his CVI manifestations. He sucked on his fingers, which he never does at home, perhaps trying to self-soothe. He was disinterested in the out-of-reach animals, but keenly interested in touching trees and twigs. He ran up and down a ramp or jumped off the same step, repeatedly. Looking at animals was meaningless to him. He could not localize a squawking bird, while his younger cousin had no trouble finding it.

Reflective Supervision

In comparison to time-dependent self-reflections, reflective supervision occurs with a trained mentor, consultant, or supervisor, in a collaborative, regular, and contemplative process (Hause & LeMoine, 2022). Reflective supervision may occur individually or in small groups and promotes practitioner self-reflection as essential for reflective practice (Heffron et al., 2016; Rumming & McFarland, 2022).

Benefits of Reflective Supervision and Reflective Practice

A “birth to three” program in a western state serving families and their young children with visual impairments mandates monthly group reflective supervision meetings, which are typically conducted via a virtual platform. Meetings are facilitated by an experienced mentor who has completed the state-required training in reflective supervision for early intervention programs. One-on-one reflective supervision, preferably in-person, is also highly encouraged. To build a trusting mentor–practitioner relationship, meetings must feel safe and occur regularly. Practitioners are encouraged to discuss accomplishments and dilemmas. The mentor facilitates self-reflection by asking open-ended questions. Ideally, practitioners identify solutions on their own.

Practitioners in these meetings identified positive outcomes that enhanced their professional relationships and competencies. Development of trusting relationships facilitated learning and permitted sharing vulnerabilities and overwhelming feelings within a safe environment with supportive colleagues. Modeling self-reflection supported new colleagues and strengthened relationships with existing colleagues. This process created a ripple effect of collaboration and mutual respect throughout the program.

The literature on reflective practice and reflective supervision in early intervention and early childhood programs (Cigala et al., 2019; Gatti et al., 2011; Machost & Stains, 2023; Rumming & McFarland, 2022; Susman-Stillman et al., 2020) reports the following results: high-quality services and positive outcomes for children; increased collaborative communication with colleagues, families, and children; gathering other perspectives; and a shift from justification of current practice to questioning what might be done to work more effectively. Moreover, individual, team, and group reflective practice have been reported to support the emotional well-being of early intervention practitioners.

An Example of Applying Reflective Practice: CVI Manifestations

When engaging in reflective practice in collaboration with caregivers, practitioners may ask “How is CVI manifesting in this child?” Applying principles of reflective practice to understand the many manifestations of CVI requires an understanding of the root causes of each child's CVI through analyses of medical records, observations of behaviors, interviews, and informal and formal assessment methods. CVI can manifest in subtle and unique ways. The list of manifestations, such as in the CVI Profile (Lueck et al., 2021), keeps expanding as more individuals with CVI share their personal experiences.

Multiple methods of assessment can be used to analyze data and pinpoint how each child's CVI manifests. It is important to question assumptions about root causes that may or may not be correct or may be incomplete. Then, root causes can be used to generate hypotheses about how a particular child operates, guiding intervention approaches that might be most beneficial. Alternate hypotheses may arise from the application of multiple assessment methods, which can be further investigated to determine which ones most facilitate progress at a certain time for a particular child.

Unforeseen behaviors may be discovered that relate directly to a child's CVI and need to be addressed. The reflective practitioner must be open to uncovering these unexpected variations and then determine if they can clearly be attributed to a child's CVI or are more likely related to other causes. For example, when a young child does not fixate and follow a moving target, it may be due to a variety of causes such as reduced visual acuity, oculomotor concerns, simultanagnosia (inability to see more than one or two objects at a time, especially in a crowded environment), visual field limitations, or visual neglect. Depending upon the root cause or causes, interventions for the identified behaviors might be different.

Through careful, multidisciplinary methods of assessment and thorough reflection on the data collected through these methods, the root causes are more likely to be identified to pinpoint appropriate interventions. Reflective practice can also be used to monitor and refine the development of interventions. For instance, using diagnostic teaching with preschoolers with CVI can include self-reflection and questions to promote an attitude of inquiry to scrutinize and adjust teaching methods to fit each child's learning needs. In this approach, assessment and instruction interact and inform each other (Koenig & Holbrook, 1995), and self-reflection is an integral part of this assessment process. Through reflective practice, methods are revised to ensure that instruction is productive and on target, and assessment results are revised based on what is learned during the instructional process.

Conclusion

Reflective supervision supports practitioners in their use of reflective practice to provide high-quality services. Reflective practice is well suited for practitioners collaborating with caregivers of children with CVI because it supports an attitude of open-mindedness, problem-solving, and curiosity. Given the complex nature of CVI, reflective practice empowers practitioners to handle the discomfort and uncertainty that may arise when learning how CVI manifests in each child. Practitioners who are reflective will improve outcomes for children, caregivers, and themselves by taking the time to understand and learn from their professional experiences while resisting the inclination to find quick solutions.