Preverbal Visual Assessment for Screening CVI

Preverbal Visual Assessment for Screening Cerebral Visual Impairment: Diagnostic Accuracy and Clinical Utility

Karen L. Harpster, Terry L. Schwartz, Alaina Johnson, Reena Donofe, Li Lin, Melissa L. Rice

Main Research Question

Can the Preverbal Visual Assessment (PreViAs), a caregiver-completed questionnaire, serve as a reliable screening tool for identifying cerebral visual impairment (CVI) in young children?

Summary

Cerebral visual impairment (CVI) has emerged as the leading cause of visual impairment in children across high-income countries. Unlike ocular (eye-related) vision problems, CVI originates in the brain, affecting how visual information is processed rather than how it is seen. The consequences are broad. Children with CVI may struggle to recognize faces, track movement, or interpret complex visual environments. These challenges can also negatively affect communication, mobility, learning, and social development.

Despite its high prevalence, CVI is often diagnosed late, frequently not until preschool age or beyond. By then, critical windows for early intervention may already be closing. This gap between onset and diagnosis underscores a pressing need: practical, accessible tools that can flag concern earlier, especially in infants and preverbal children who cannot describe what they see.

This study explores whether one screening tool, the Preverbal Visual Assessment (PreViAs), can bridge that gap.

Methodology

A retrospective chart review was conducted at a pediatric academic medical center, examining cases from a five-year period (2018–2023). From an initial pool of 205 records, 98 children met the study criteria. Of these, 81 had been diagnosed with CVI, while 17 had not.

All included participants completed the PreViAs questionnaire, a 30-item caregiver-reported tool designed to capture observable visual behaviors. The questionnaire is organized into four domains:

• Visual attention
• Visual communication
• Visual motor coordination
• Visual processing

Each response contributes to a score that falls into one of three categories: no concern, monitor, or area of concern.

To evaluate how well PreViAs aligned with clinical diagnoses, the researchers analyzed sensitivity, specificity, and overall diagnostic accuracy.

Key Findings

The results point to a clear pattern: PreViAs was highly sensitive in identifying children with CVI, especially when both “monitor” and “area of concern” scores are treated as indicators of risk in this retrospective review.

Among the four domains, visual processing was most sensitive. Nearly all children with CVI (94%) showed concern in this area, and it demonstrated the highest sensitivity overall. Visual motor coordination and visual communication followed closely behind.

Visual attention, while less frequently flagged, revealed something equally important. It offered the most balanced performance, capturing a meaningful proportion of true cases of CVI while avoiding excessive false positives. In other words, it may be particularly useful for distinguishing which children truly need further evaluation.

Another key insight emerged when the researchers broadened the definition of “concern.” When only the most severe category (area of concern) was considered, the tool’s effectiveness dropped. But when “monitor” scores were included, sensitivity improved significantly, and the relationship with CVI diagnosis became statistically meaningful across multiple domains.

Age also played a role. The differences between children with and without CVI were most pronounced in the youngest group, those under 12 months. In this early stage of development, all four domains showed significant distinctions. As age increased, those differences became less consistent, suggesting that PreViAs may be especially valuable as an early screening tool, when intervention opportunities are greatest.

Significance: What This Means for CVI

This study marks the first time PreViAs was evaluated specifically as a screening tool for CVI. This study reinforces the idea that early detection is not only possible, but also practical. A brief caregiver questionnaire, requiring no specialized equipment, can meaningfully contribute to identifying children at risk.

Second, it highlights the value of caregiver insight. Parents and caregivers observe children across contexts and over time, often noticing subtle patterns that may not emerge during a clinical visit. PreViAs captures those observations in a structured way, translating them into actionable information.

Finally, the study supports a shift in clinical thinking. Rather than waiting for clear deficits to emerge, clinicians can use tools like PreViAs to flag concerns earlier and refer children for comprehensive evaluation sooner.

Main Conclusions

The authors conclude that PreViAs is a sensitive and clinically useful screening tool for detecting cerebral visual impairment in young children. Importantly, they recommend that any level of concern, whether “monitor” or “area of concern”, should prompt referral for a full CVI evaluation.

This approach prioritizes sensitivity over specificity. While it may lead to some over-referral, it significantly reduces the risk of missing children who would benefit from early intervention. In the context of CVI, where delayed diagnosis can have lasting developmental consequences, that trade-off is both intentional and appropriate.

At the same time, the authors are careful to frame their findings as preliminary. The study reviews past patient records, has a relatively small sample size, and focuses on a high-risk population, limiting how broadly the results can be applied.

Limitations and Future Directions

Several limitations shape how these findings should be interpreted. The sample was drawn from children who were already referred for CVI evaluation, which may overrepresent more severe or obvious cases. Additionally, PreViAs was used as part of the diagnostic process rather than as a standalone screening tool, making it difficult to fully assess its independent performance.

Future research will need to address these gaps. Larger, prospective studies, particularly those involving broader high-risk populations, will be essential. Comparing PreViAs with other screening approaches could also provide valuable context, helping clinicians understand where it fits within a larger assessment framework.

Final Takeaway

PreViAs offers a promising step forward in the early identification of CVI. It is simple. It is accessible. And, perhaps most importantly, it works, especially when used early and interpreted with a low threshold for concern.

In a field where timing can shape a child’s developmental trajectory, that kind of tool has the potential to make a meaningful difference.

Harpster, K. L., Schwartz, T. L., Johnson, A., Donofe, R., Lin, L., & Rice, M. L. (2026). Preverbal visual assessment for screening cerebral visual impairment: Diagnostic accuracy and clinical utility. Developmental medicine and child neurology, 68(5), 688–695. https://doi.org/10.1111/dmcn.70005