Why Visual Performance Matters: Foundations for Occupational Therapy Practice: facilitator notes

Presenter cues

• Open with the poll before any content. It gives you the room’s baseline scope anxiety in 30 seconds.
• Land the scope line early and repeat it verbatim all day: OT describes and treats occupational performance under visual demand; eye care diagnoses and prescribes.
• When you read a milestone, immediately convert it to a referral rule so it does not feel like memorization.

Answer key

What visual-performance questions would you want answered before assuming this is an attention or behavior issue?

Steer toward six: (1) What is the working distance during calendar time, and does the student move closer? (2) Can the student locate a named item in a busy visual array? (3) Does performance change when the array is decluttered or the target enlarged? (4) Is there head tilt, eye rubbing, closing or covering one eye, or squinting? (5) Do the transitions problems occur only in low-contrast or cluttered spaces (hallway, carpet edge, doorway)? (6) When was the last comprehensive eye exam — not screening — and is correction worn? Accept any answer that converts "not paying attention" into an observable condition-and-performance pair.

What is the one sentence you would write in a consult note, and what referral would run in parallel?

Model: "During calendar-time instruction at approximately 2 m, [student] located the named target on 2 of 6 trials and contacted peers 3 times during transitions across a patterned carpet; a comprehensive eye examination is recommended and classroom visual supports are being trialed now." The referral is to comprehensive eye care (optometry or ophthalmology), because a passed screening does not rule out binocular, accommodative, or field problems. Emphasize the parallel: the modification starts today; you do not wait for the exam.

Examples to read aloud

• Reflection model answer (Module 1): "I own the occupational observation that he sustains near copy for four minutes before accuracy drops by half. I defer to eye care the question of whether an accommodative or binocular problem explains it."
• Mini-exercise model answer: "OT identifies how vision is limiting a person’s participation in daily occupations and changes the task, the environment, and the strategy so participation improves."
• Action-prompt coaching: if their written observation contains any condition name, have them rewrite it with a condition, a task, and a number.

Watch-outs

• Someone will say "the nurse already screened him." Reframe: an acuity screening tests one thing at one distance. It is not a comprehensive exam.
• Someone will want to write "convergence insufficiency." Redirect to the observable: working distance, place loss count, time to fatigue.

Presenter cues

• Teach the streams as two questions the brain asks, not as anatomy to memorize: "What is it?" and "Where is it, and where am I relative to it?"
• Use the handwriting before/after immediately after the stream teaching — it is the cleanest live demonstration that a "where" demand can be supplied by the page.
• Insist that participants never write stream language in a school document.

Answer key

Which stream does this description sound more consistent with, and what would you probe next to confirm it?

A dorsal / "where" pattern: word identification is intact, spatial localization and re-finding are not. Probes: (1) re-find a target line after a controlled look-away, counted over 10 trials; (2) locate a named object in a sparse array versus a cluttered array; (3) copy a simple spatial diagram versus copy a word list; (4) same reading passage on plain paper versus with a line guide. If performance jumps when spatial structure is supplied, you have your answer. Note out loud that this is patterning, not localization of a lesion.

How would you phrase this finding for a teacher without naming a "dorsal stream deficit"?

Model: "She reads the words accurately. What she loses is her place and her ability to find things on a busy surface. With a line guide and a decluttered desk she re-finds her line in about 2 seconds instead of 15, so those two supports should stay in place while we get an eye exam scheduled."

Examples to read aloud

• Reflection model answer (Module 2): "A ‘what’ problem looks like hesitating on visually similar letters even when the print is large. A ‘where’ problem looks like skipping a line every time she looks up at the board."
• Mini-exercise model answer: "During 10-minute board-copy tasks, the student re-finds her place an average of 15 seconds after each look-away and completes 40% of assigned lines; with a line guide she completes 80%."

Watch-outs

• Participants will try to assign a student to one stream. Say plainly that most real students show mixed patterns, and the value is in the probe, not the label.

Presenter cues

• Say the frame before the condition list: these are the mechanisms other people diagnose, and knowing them tells you what ceiling you are working under.
• The red-flag slide is the safety slide of this course. Slow down and read it.
• End on the standing rule: diagnosed and managed = address it; undiagnosed, unclear, or changing = refer it, and keep working either way.

Answer key

Which underlying conditions could plausibly produce this picture, and which of them would a passed acuity screen fail to detect?

Plausible: intermittent strabismus or a decompensating phoria (head tilt, intermittent diplopia), convergence or accommodative insufficiency, an uncorrected refractive error including astigmatism, photophobia from an anterior-segment or albinism-spectrum condition, or a superior oblique palsy driving the tilt. A distance acuity screening detects none of them: it does not test binocular alignment, fusion, near function, accommodation, contrast sensitivity, or light sensitivity. Also flag urgency — new or worsening diplopia, or a new head tilt, is a prompt-referral item, not a wait-and-watch item.

Write the one sentence of documentation that names the functional limitation you will treat, without naming a diagnosis.

Model: "During sustained near reading, [student] maintains a right head tilt, reports intermittent blur and doubling after approximately five minutes, and loses place on 6 of 10 lines; near-work endurance and place-keeping are the OT targets while a comprehensive eye examination is pending." No condition is named, urgency is implied, and the OT target is explicit.

Examples to read aloud

• Reflection model answer (Module 3): "During a 15-minute writing task, Marcus closed his left eye for most of the session and moved to 12 cm from the page; this matters because he completes half the written work of his peers in the same time."
• Mini-exercise model answer: three commonly missed on a school screen — (1) convergence insufficiency, because the screen tests distance, not near; (2) CVI, because acuity can be normal while visual processing is not; (3) contrast-sensitivity loss, because high-contrast charts do not test it.

Watch-outs

• Participants will want to "rule out" CVI. OT observation cannot rule any condition in or out. Describe the behaviors and route it.
• Someone will ask whether ONH means the child is autistic. It does not. Autistic-like behaviors — light gazing, stereotypies, atypical social gaze — are frequently reported in ONH, and they are described functionally, never diagnosed by OT.

Presenter cues

• Say "association is not causation" out loud at least three times in this module. It is the legal and ethical spine of the content.
• Give participants the exact phrase for a team meeting: "I am not saying vision causes this. I am saying there is an unanswered visual question, and here is the observation behind it."

Answer key

Which findings are visual-performance signs worth documenting separately from the ADHD diagnosis?

Two: (1) place loss — three times in one paragraph, which is a countable, condition-bound observation; (2) figure-ground search failure — cannot locate a pencil in a cluttered field, which you can test again with a decluttered field. Both are documented as performance under a stated condition, separate from the ADHD diagnosis and without claiming vision explains the ADHD. Handwriting quality itself is a visual-motor output observation and belongs in the OT plan regardless.

What would your present-level sentence say, and what referral (if any) would accompany it?

Model: "During 10-minute paragraph copy, [student] loses place 3 times and requires 2 adult prompts to resume; he locates a target item in a cluttered field on 1 of 5 trials and 5 of 5 trials when the field is reduced to three items. Reduced-clutter materials and a line guide are in place. Referral: comprehensive eye examination if none is on file within the past year." Referral is warranted here because near-work place loss has not been evaluated — not because ADHD requires one.

Examples to read aloud

• Reflection model answer (Module 4): "I will ask: when he does sustained written work, what visual demand is hardest to meet — finding the target, holding the place, or holding the endurance?"
• Mini-exercise model answer: "Reading decoding difficulty is being addressed as a language-based skill by the reading specialist. Separately, OT observes near-work place loss and reduced copy endurance under 10-minute conditions. These are documented as distinct concerns; a comprehensive eye examination has been recommended to answer the visual-efficiency question. OT does not attribute the reading difficulty to vision."

Watch-outs

• A participant will bring up colored overlays for dyslexia. Answer: dyslexia is language-based; overlays are not a treatment for it. If a student prefers a tint, trial it as a comfort/contrast variable with a measured outcome, and keep reading intervention where it belongs.
• Someone will say vision therapy fixes dyslexia. That is contradicted by the AAP/AAO/AACO joint statement. Do not let it stand unaddressed in a live room.

Presenter cues

• Anchor the module: adaptation is intervention. You do not wait for the eye exam to make the task usable.
• Walk the four levels with one occupation the whole way through — reading a worksheet works well — so the levels stay concrete.
• Hold up an actual worksheet next to the contrast reference slide. That moment changes more practice than the slide does.

Answer key

Which three modifications from this module serve both profiles at once?

Best three: (1) contrast enhancement — bold-line or highlighted paper and high-contrast print serves low acuity and reduces figure-ground search cost; (2) decluttering and array reduction — fewer items per page, one task per page, cleared desk and walls; (3) lighting and glare control — task light on the working side, matte surfaces, window beside or behind, which raises effective contrast without changing the material. Accept line isolation (typoscope) as a fourth. Point out these rarely conflict, which is why one plan can serve both profiles.

What would you measure before and after the modifications to show they worked?

Pick countable, condition-bound measures and keep the task identical: lines completed in a fixed 10 minutes; place losses per passage; time to locate a named target in the array; adult prompts required; and student-reported comfort or fatigue at a fixed time point. Change one variable at a time so you know which modification carried the effect, and record the condition ("with highlighted two-line paper, task light on") in the same sentence as the number.

Examples to read aloud

• Reflection model answer (Module 5), occupation = reading a worksheet: "Increasing visibility means enlarging print to 18 pt on matte paper with a task light. Enhancing the signal means a stand magnifier or pinch-to-zoom on a tablet. Augmenting means text-to-speech running alongside the print. Substitution means the full audio version when the visual channel cannot carry the task."
• Mini-exercise model answer: "Given high-contrast, enlarged (18 pt) worksheets and a glare-free seat, [student] will complete written classwork within the time allotted to peers on 4 of 5 opportunities."

Watch-outs

• Participants will ask which magnifier to order. Redirect: trial what the student already carries — the tablet — before ordering anything, and remember device selection sits with the low-vision provider.
• Someone will treat low vision as a Level 5 problem. It is a Level 1 access problem; Level 5 change is the downstream result.

Presenter cues

• Do not let this module become a sales pitch. It is a synthesis module; the course sequence is the last two minutes.
• Make the room actually write the three sentences. Give them four silent minutes; the silence is the intervention.
• Close on the honest limitation: observation is real skill, and unordered observation is hard to defend. That is what structure fixes.

Answer key

Write the functional description in one sentence, in occupational terms.

Coach the shape: [condition] + [occupation] + [observable result with a number]. Model: "During 10-minute near writing at a standard desk, [student] completes 3 of 8 assigned lines and repositions to 12 cm from the page four times." Reject anything containing a condition name or the words "poor," "weak," or "difficulty with" unmodified.

Write the referral decision and rationale in one sentence.

Two acceptable shapes. Refer: "Referring for a comprehensive eye examination because no exam is on file and the near-work breakdown has not been medically evaluated." Do not refer: "No referral at this time; a comprehensive exam six months ago documented corrected acuity and correction is worn consistently, so the observed breakdown is being addressed as an occupational performance target." The rationale, not the decision, is what you are grading.

Write the modification you will make Monday and the single observable indicator you will watch.

Model: "Monday I will provide highlighted two-line paper and a task light for all near writing, and I will count lines completed in a fixed 10 minutes at baseline and again on Friday." One modification, one number, one time frame. If they name three modifications, make them choose one — otherwise they cannot attribute the change.

Examples to read aloud

• Mini-exercise model answer: "A level-based structure tells me which finding to address first and lets me state in writing why that target precedes the next one — my current notes list findings without ordering them."

Watch-outs

• Participants will want to change everything Monday. One modification, one indicator. Anything more and the data is uninterpretable.
• Someone will ask if the VPA™ replaces standardized testing. It is criterion-referenced, not norm-referenced; for most school questions it is sufficient, and outside standardized scores attach to it when a team or payer requires them.