Vision in OT Practice: facilitator notes

Presenter cues

• Open by asking the room how many referrals last year said "reverses letters" or "poor tracking." That phrase is where the module lives.
• Anchor scope early: OTs measure occupational performance under visual demand; eye care providers diagnose the eye and prescribe optical correction. Both are licensed, independent judgments.
• Make the point that referring out is not deferring — you refer in parallel and keep your own plan running.
• Read the referral triggers slide slowly. This is the safety slide of the whole course.

Answer key

Which of those three observations is OT-reportable as written?

Only the working distance (15 cm) is a directly recorded, objective performance observation. Squinting is observable but should be documented as a behavior under a stated condition ("squints when copying from the board at 3 m"), not as evidence of a refractive problem. The headache is self-report — record it verbatim in the student’s words and route it to eye care.

What is the one sentence you send to the family, and what do you not name?

Model sentence: "During classroom observation and OT screening, [student] worked at 15 cm from near materials, squinted during board-copy tasks, and reported headaches after sustained reading; we recommend an eye examination and are sharing our observations with your provider." You do not name convergence insufficiency, accommodative dysfunction, tracking disorder, or any refractive condition, and you do not recommend lenses, prism, or vision therapy.

Examples to read aloud

• Weak: "Poor visual tracking noted." Strong: "Lost place 7 times in a 120-word passage, requiring 3 adult prompts to resume."

Watch-outs

• Someone will ask if they can say "convergence insufficiency" because the eye doctor already diagnosed it. Answer: you may quote a documented diagnosis with attribution ("per Dr. X’s report dated ..."), but you never generate it.
• Another will ask about ordering red/green glasses. Reframe: anaglyph materials are activity media inside an OT plan, not an optical prescription.

Presenter cues

• Say out loud that this module is intentionally the longest — everything after it hangs on the ladder.
• Teach the ladder bottom-up once, then immediately demonstrate reading it top-down from a referral question.
• For each level slide, ask the room for one student they have right now who fits that description before you advance.
• On the "two rules" slide, land the phrase: bottom-up to stabilize, top-down for meaning.
• The VML resource slide is the "Monday morning" payoff — name specific library items rather than the category.

Examples to read aloud

• L1 signal: moves paper to catch window light, complains about glossy worksheets.
• L2 signal: accurate for four minutes, then rate collapses and finger-tracking appears.
• L3 signal: cannot find the correct answer in a dense field, but copies accurately once it is isolated.
• L4 signal: knows what the letter should look like, cannot produce it at speed on ruled paper.
• L5 signal: everything looks intact in the therapy room and falls apart in the classroom.

Watch-outs

• Participants collapse Level 3 (processing) and Level 4 (visual-motor). Separate them with the pencil test: if you remove the motor output and performance is fine, the breakdown is at 4, not 3.
• Participants treat a level as a diagnosis. It is a location for intervention, nothing more.

Presenter cues

• Define the difference in one line: a screen decides whether to measure; an assessment measures.
• Emphasize that a passed screen with degraded strategy is still a flag — write it down in the moment.
• Walk the setup fidelity slide as a checklist you physically run before item one.

Answer key

When does a flag become a Full VPA™?

Any probe failed at or below the expected level for the band; any probe passed only with degraded rate, endurance, or heavy strategy; a teacher/caregiver report that contradicts a passed probe; or any red-flag ocular symptom (which also triggers referral independently).

Watch-outs

• Clinicians estimate distance instead of measuring it. Hand out a tape measure image and make the point that 60 cm and 40 cm are data, not decor.
• Screening results get written into IEPs as findings. Screens flag; they do not establish present levels.

Presenter cues

• Have participants rewrite one of their own present-level statements live during this module.
• Insist on numbers plus conditions in every sentence: what, how much, under what demand, over what time.
• Note that documentation and billing requirements vary by state and payer — verify locally.

Answer key

Which level does this pattern implicate, and which levels must you clear first?

Endurance decay with place loss and a passed acuity screen points to Level 2 (visual efficiency). Clear Level 1 first by confirming acuity and contrast at the measured working distance with habitual correction worn, and rule out validity threats (fatigue, time of day, attention) before naming Level 2.

Write the present-level statement in one sentence, with numbers.

Model: "During near copying at 40 cm, [student] maintained 92% accuracy for the first 3 minutes and declined to 58% by minute 9, with 7 place-loss events, limiting completion of written classwork within the allotted time."

Write one annual goal that a reviewer would call educationally relevant.

Model: "By [date], during a 10-minute near copying task at 40 cm, [student] will maintain at least 85% copy accuracy with no more than 2 place-loss events in 3 of 4 consecutive data sessions, as measured by OT probe using the baseline task." The occupation, the condition, the number, the criterion, and the measure are all present.

Watch-outs

• Goals written as protocols ("will complete pencil push-ups 3x/week") are out of scope and not educationally relevant. Goals live at the occupation.

Presenter cues

• Run each pattern as a live poll: treat, accommodate, refer, or monitor — then reveal the reasoning.
• Repeat the four-step sorting rule after every case so it becomes automatic.

Answer key

Bottom-heavy: what does the degradation curve tell you that a single accuracy score cannot?

It separates capacity from endurance. The student can do the task; they cannot sustain it. A single early-session score would have been recorded as a pass and the referral question would have gone unanswered. The curve also gives you your progress measure — the minute at which accuracy drops.

Bottom-heavy: what is the first disposition decision — treat, refer, or both?

Both, in parallel. Refer to eye care if any symptom or acuity/contrast finding is present, and simultaneously begin OT work on the Level 2 floor plus an immediate access change the teacher can keep (chunked work periods, reduced copy volume, line guide).

Top-heavy: which level do you target first, and why not start at the top?

Target Level 4 (visual-motor integration). Starting at Level 5 with more writing practice loads the failing system without changing it — you get volume, fatigue, and no transfer. Stabilize the graded motor output, then re-embed it in the writing occupation.

Top-heavy: how do you grade the writing task to isolate the visual-motor contribution?

Hold the linguistic demand constant (copying, not composing), then vary only one visual-motor parameter at a time: line width and spacing, print size, model proximity (adjacent vs. far model), and speed. If legibility recovers with an adjacent model and wider ruling, the constraint is visual-motor, not language.

Flat low: what validity threats must you rule out before interpreting?

The five: setup drift (distance, lighting, positioning), state (illness, hunger, medication timing, time of day), attention/effort inconsistency across comparable items, language or instruction comprehension, and missing or outdated habitual correction. A flat low profile is a validity question until proven otherwise.

Flat low: what is your referral obligation before writing an OT plan?

Confirm a current eye examination with habitual correction verified. If there is none, or if any red-flag symptom is present, refer now and document that interpretation is deferred pending that information. You may still write access accommodations in the meantime.

Spiky: what must you confirm before writing a goal on an isolated skill?

Replicate it. Re-probe the same skill on a different day with a parallel item set and confirm the pattern holds; a single spike can be an attention or item-familiarity artifact. Also confirm that the skill actually constrains an occupation in this student’s day.

Spiky: how do you tie a Level 3 finding to an occupational outcome?

Name the classroom task that carries that demand: figure-ground shows up as locating a problem on a dense worksheet, a word in a glossary, or a locker in a crowded hallway; spatial relations shows up in graph paper math alignment, diagram reading, and map work. Write the goal at that task, not at the perceptual skill.

Presenter cues

• Be explicit that honesty about evidence strength protects the profession and the provider approval.
• Contrast the two columns line by line; ask participants which column their last progress note lived in.
• On the UDL slides, hold the line that prevention is not optional politeness — it is the tier that reduces referrals. Accommodation without design just moves the burden onto the student.
• Point participants to the free UDL Quick Checklist (/udl-checklist) and to the UDL panel that appears inside every VPA™ result; they can leave the course with a Monday plan.

Answer key

Turn one flag into a three-tier plan (Level 2 + Level 4 fourth grader).

Prevention: the teacher gives a printed copy of anything written on the board and formats handouts at 14-16 pt with one task per page — this helps the whole class and removes the board-to-desk transition demand. Accommodation: 504 language for reduced copying volume (cloze notes), extended time on written work, and content graded separately from handwriting. Intervention: OT targets near-far transition efficiency and sustained visual-motor output inside her actual copy and writing tasks, measured as minutes-to-legibility-breakdown and place-loss count per 2-minute passage, with a written hand-off so the teacher can sustain the supports.

Write the FITT-P line for a four-week block (Level 2 floor, 10-minute board-to-desk copy).

Model: "Frequency: 2x/week, 30-minute sessions, plus a 5-minute daily classroom routine. Intensity: begin at 4-minute copy bouts with a line guide, progressing to 10 minutes unaided. Time: 4 weeks. Type: graded near-far transitions and scanning drills embedded in the actual copy task, with print and lighting controlled. Progression: remove the line guide, then lengthen the bout, then restore classroom-realistic clutter and noise — one parameter at a time."

Name the re-probe and the criterion that would move you up a level.

Re-probe is the identical baseline task — the same 10-minute copy passage at the same distance and lighting, scored the same way. Criterion: at least 85% accuracy sustained through minute 10 with no more than 2 place-loss events across two consecutive probes. Meeting that criterion moves work to Level 4/5 demand; missing it twice means change one parameter, not the whole plan.

Watch-outs

• Someone will want a claim that vision work raises reading comprehension scores. Hold the line: state task-specific gains and the conditions under which they were measured.

Presenter cues

• Close with the chain said out loud: occupation → level → dose → probe.
• Point participants to Course 2 for level-by-level measurement and to the Treatment Templates for dosage.

Answer key

Which level is unstable, and which levels do you clear first?

Level 2. Acuity passed, so Level 1 is cleared once you confirm the measurement conditions and correction; the 4-minute-to-60% decay with 8 place-loss events is an endurance/efficiency signature, and the reduced writing volume is the Level 5 consequence, not an independent finding.

What is your session shape and dose for the next four weeks?

Four-part shape every session: (1) baseline probe with the same copy task, (2) graded floor work on Level 2, (3) occupation-embedded practice in the real classwork, (4) teacher hand-off with one support to keep. Dose roughly 2x/week direct plus a short daily classroom routine, progressing bout length before removing supports.

What is the re-probe, and when do you run it?

The identical baseline copy task under identical conditions, run at fixed intervals — weekly data point, formal re-probe at the end of the four-week block. Never re-probe early because a session went well.