Vision in OT Practice

Housekeeping while people arrive.

Materials to have ready:

• Participation & Reflection Guide (printed or on screen)

• A current student on your caseload to think with

• Pen and paper, or the reflection boxes in this player

• One recent evaluation report you wrote

Housekeeping:

• Modules are self-paced; your place is saved as you go.

• Polls, reflections, and self-checks are participation supports — they do not affect your quiz score.

• Take a stretch break between modules; sustained near work is the topic, not the goal.

• The post-course exam and evaluation unlock after the last module.

Read the filed learning objectives verbatim — this is the AOTA-approved wording.

Objectives:

• Differentiate the levels of a structured visual performance framework and explain how each level influences occupational performance across pediatric and adult practice settings.

• Analyze the relationship between visual performance deficits and occupational challenges by applying a structured clinical reasoning framework to case scenarios.

• Integrate occupation-based assessment findings, clinical observations, and standardized measures to identify visual performance factors affecting participation in meaningful occupations.

• Develop occupation-centered intervention plans that incorporate evidence-informed strategies, environmental modifications, interdisciplinary collaboration, and client-centered goals based on the identified level of visual performance.

• Apply structured clinical reasoning to support documentation and outcome measurement that promotes occupational participation, health, and functional independence.

Explain how the session runs.

Schedule:

• Seven modules, 3.0 contact hours total

• Each module: teach → show → reflect → self-check

• Post-course exam (80% to pass, unlimited retakes)

• Course evaluation, then certificate

How they participate:

• Opening poll in every module

• Think / Process / Share reflection prompts

• Case vignettes with clinical reasoning prompts

• One knowledge check per module

Transition: "OT Scope in Vision: What We Own, What We Refer."

Open here. "OT Scope in Vision." What we own, what we refer, and the language that keeps us inside our license.

Say why this section matters for their caseload, then advance.

Ask the poll: "When a teacher says "she can't track," what stops you from acting on it today?"

Options:

• I am not sure it is inside OT scope

• I do not have the language for the report

• I do not know what to measure

• I act on it already and want cleaner documentation

Take a show of hands or the on-screen tally, then name the pattern you see before advancing.

Frame the slide: "Vision is a client factor, not a specialty add-on."

Walk each point, one sentence each:

• OTPF-4 lists visual functions among sensory body functions that shape occupational performance.

• Our lens is performance: how vision enables or limits reading, writing, dressing, play, work, and driving.

• Describing visual performance during occupation requires no referral or supervision.

• Ocular health, refraction, and disease diagnosis stay with optometry and ophthalmology.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Contrast the two columns: OT owns (performance) versus Refer out (ocular/medical).

OT owns (performance):

• Observed gaze control during a reading task

• Near-work endurance and fatigue time course

• Copying accuracy, line loss, place-keeping

• Task grading, environment, and compensatory strategy

Refer out (ocular/medical):

• Pain, redness, sudden vision change

• Suspected pathology or unexplained acuity loss

• Refraction and lens prescription

• Diagnosis of a binocular vision disorder

Ask: "Which column is your student living in right now?"

Frame the slide: "Say this, not that."

Walk each point, one sentence each:

• "Loses place 6 times in a 2-minute passage" — not "has a tracking disorder."

• "Copying accuracy drops from 90% to 55% after 8 minutes" — not "convergence insufficiency."

• "Reports blur at 40 cm after sustained near work; referred for eye exam" — findings plus disposition.

• Every statement ties an observation to an occupation and a next action.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Frame the slide: "Prevalence and the case for OT screening."

Walk each point, one sentence each:

• An estimated 1 in 4 school-age children has an undiagnosed vision problem (Kleinstein et al., 2003, population-based cohort).

• CDC surveillance data show 6.8% of children carry a diagnosed eye/vision condition; roughly 3% meet criteria for blind or visually impaired (BVI).

• Classroom occupations are visually loaded — reading, copying, and board work all route through vision, so a visual client factor touches nearly every academic occupation (framing statement, not a prevalence figure).

• ADHD populations show visual/binocular dysfunction at roughly 16% co-occurrence (Bellato et al., 2023, systematic review) — co-occurrence only, not causation, and a common confound for "inattention."

• Dyslexia is associated with unstable eye dominance in a majority of observational samples (73% / 63%) — a correlate, not a cause. AAP/AAO/AAPOS hold that dyslexia is language-based and vision treatment does not treat it.

• Strabismus occurs in an estimated 1.8–8.3% of children with autism spectrum disorder (Holhoș et al., 2022, systematic review) — an association, above general-population rates, not a causal link.

• These numbers are the argument for universal, low-burden OT vision screening — not a license to diagnose.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Contrast the two columns: Term versus What it means in schoolwork.

Term:

• Convergence

• Accommodation

• Stereopsis

• Fixation

• Saccades

• Pursuits

What it means in schoolwork:

• Both eyes turning inward together to hold near print in single focus — unstable convergence shows up as double vision or fatigue on close work.

• The eye's lens changing shape to keep near print sharp — poor accommodation looks like blur that worsens the longer the task runs.

• Depth perception from combining two eyes' images — weak stereopsis affects catching, stairs, and judging space on a busy page.

• Holding gaze steady on a target — an unstable fixation shows up as losing the word or the math problem being copied.

• Quick jumps between points, as in reading line to line — inefficient saccades look like skipped words or re-reading.

• Smooth following of a moving target, as in tracking a ball or a moving finger — poor pursuits show up as losing a thrown object or a moving demonstration.

Ask: "Which column is your student living in right now?"

Frame the slide: "Diagnoses OTs should recognize but never assign."

Walk each point, one sentence each:

• Cerebral/cortical visual impairment (CVI) — a brain-based visual processing impairment, not an eye finding.

• Optic nerve hypoplasia (ONH) — underdeveloped optic nerve affecting acuity and visual field.

• Strabismus and amblyopia — eye misalignment and reduced acuity from disuse.

• Albinism — reduced pigment associated with nystagmus, photophobia, and reduced acuity.

• Nystagmus — involuntary, rhythmic eye movement affecting fixation stability.

• Retinopathy of prematurity (ROP) — retinal vascular condition in infants born preterm.

• Retinitis pigmentosa (RP) — progressive peripheral vision and night-vision loss.

• Congenital cataract — clouding of the lens present from birth or early infancy.

• Our job: recognize the signs, make the referral to medical eye care, and adapt the occupation while the family waits for that appointment.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Read the quote verbatim, then pause.

"A child can pass a 20/20 acuity screen and still be unable to read a page." — Why the acuity floor is only the first of five levels

Then say what it means for practice in one sentence.

Frame the slide: "Vision work already lives in your school day."

Walk each point, one sentence each:

• Board-to-desk copying, worksheet completion, and sustained silent reading.

• Handwriting legibility under speed, volume, and page-layout demand.

• Cafeteria, hallway, stairs, and PE — mobility and clutter tolerance.

• Dressing, fasteners, and tool use in life-skills and transition programming.

Close with: "If you only take one of these back, take the first one."

Frame the slide: "Same-day referral triggers."

Walk each point, one sentence each:

• Eye pain, redness, discharge, or photophobia.

• Sudden or unexplained change in vision, including new double vision.

• Head tilt or eye turn not previously documented.

• Acuity loss that does not resolve with habitual correction worn.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Read the scenario aloud, slowly:

A Grade 4 student squints at the board, holds worksheets at 15 cm, and reports headaches after the second reading block.

Then put these questions to the room:

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

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

Give 60 seconds of think time before you take answers. Model answers are in the panel beside this script.

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Describe what belongs here: Screenshot of a de-identified present-level statement written in performance language..

Describe what belongs here: Photo showing habitual working distance, head tilt, or lighting conditions..

Contrast the two columns: Diagnosed and managed → OT addresses the functional limitation versus Undiagnosed, unverified, or changing → refer.

Diagnosed and managed → OT addresses the functional limitation:

• Low acuity: magnification, enlarged print, working distance, seating, decluttered materials.

• Reduced contrast: high-contrast materials, bold-line paper, reverse polarity, glare and lighting control.

• Field loss: systematic scanning, anchoring, line tracking, intact-field placement, O&M collaboration.

• These are Level 1 OT interventions — adaptation is intervention, not a holding pattern.

Undiagnosed, unverified, or changing → refer:

• No comprehensive exam on file, or correction not worn, outgrown, or unconfirmed.

• A functional loss nobody has evaluated, or one that does not match the documented diagnosis.

• Any red flag: new eye turn, new double vision, new field complaint, pain, sudden change.

• Write the referral and put the modification in place the same day.

Ask: "Which column is your student living in right now?"

Talk over the visual: "Two lanes, one student."

Say the caption in your own words: Medical eye care owns diagnosis and the optical correction; OT owns performance inside real occupations. The referral and the task modification run in parallel, on the same day.

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Land the "so what": If you stop treating while you wait on an eye-care report, the student loses weeks of instruction for a decision you were never going to make.

Explain the mechanism plainly: Diagnosis belongs to eye care; occupational performance under a known visual condition belongs to OT. Those two lines run in parallel, not in sequence.

Then give them the moves — say each one as something they can do Monday:

• Write performance language: what the student did, at what distance, for how long.

• Send the referral the same week you observe the sign — do not wait for the next IEP date.

• Keep the intervention plan running while the referral is out.

Tell them what success looks like: A report that names a diagnosis you did not make — that is the sentence to rewrite before it goes in the file.

Ask: "Who has a student this describes right now?" Take one answer, then move.

Two-minute case. Read it aloud:

A Grade 2 teacher tells you a student "definitely has convergence insufficiency — she sees double when she reads." Nothing in the file supports a diagnosis and there is no eye-care report.

Put the question to them: "What do you write, and what do you do first?" Give 60 seconds, no talking.

Model answer (reveal after they commit): Document the observation, not the label: "During 10 minutes of near reading, the student reported intermittent doubling and stopped reading twice." Refer to eye care that week for the undiagnosed report of diplopia, notify the family, and continue OT for the near-work endurance demand while the referral is out.

Close with the rule: Address the diagnosed, refer the undiagnosed, and never pause treatment while you wait.

Reflection prompt: "Recall one referral that arrived with a visual complaint. Which part of it did you own as OT, and which part needed eye care?"

Cues:

• Name the occupation that was breaking down.

• Name the one sentence you would send to the family today.

Offer the sentence starter: "I own the occupational observation that... I defer to eye care the question of whether..."

Think for one minute, write, then take two shares.

Knowledge check: "A student works at 15 cm from the page, squints during board copy, and reports headaches. Which statement belongs in your OT report?"

Options:

• Student demonstrates convergence insufficiency affecting near work.

• Student sustained near work at a 15 cm working distance and reported headache after 10 minutes of reading; eye examination recommended.

• Student requires vision therapy to normalize binocular function.

• Student needs reading glasses for classroom tasks.

Correct answer: option 2. Rationale: Objective performance under a stated condition, plus a referral. Diagnosis, optical recommendations, and therapy prescriptions belong to the eye care provider.

Transition: "A Structured, Level-Based Visual Performance Framework for Clinical Reasoning."

Open here. "The Five-Level Visual Performance Framework." A developmental hierarchy that organizes observation, assessment, and intervention.

Say why this section matters for their caseload, then advance.

Ask the poll: "Which framework levels do your current goals most often target?"

Options:

• Level 1 — acuity and sensory access

• Level 2 — visual efficiency

• Level 3 — visual processing

• Level 4 — visual-motor integration

• Level 5 — functional integration

Take a show of hands or the on-screen tally, then name the pattern you see before advancing.

Talk over the visual: "Beyond 20/20 — the Visual Performance System™."

Say the caption in your own words: Level 1 Visual Access → Level 2 Visual Efficiency → Level 3 Visual Processing → Level 4 Visual-Motor Integration → Level 5 Functional Integration.

Frame the slide: "Visual development milestones OTs should know."

Walk each point, one sentence each:

• Basic eye movement control (fixation, following) is commonly described as established by 2–3 months of age.

• Coordinated eye movement control is commonly described as expected by about 2 years.

• Complex visual-motor and visual-perceptual control is commonly described as continuing to mature until roughly 9 years — the age by which most school-readiness visual skills are expected to be reliable.

• Visual acuity is commonly described as progressing rapidly in infancy and approaching adult levels well before school entry, while efficiency and processing skills mature much later.

• Eye dominance (sighting preference) is commonly described as emerging and stabilizing in stages — around ages 4, 7, and 12 — with instability past those windows worth noting, not diagnosing.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Contrast the two columns: Ventral / parvocellular ("what" pathway) versus Dorsal / magnocellular ("where" pathway).

Ventral / parvocellular ("what" pathway):

• Carries fine detail, color, and form for object and letter identification

• Classroom sign: confuses similar letters/numbers (b/d, 6/9)

• Classroom sign: struggles to identify an object embedded in a busy picture

• Classroom sign: slow, effortful sight-word recognition despite adequate acuity

Dorsal / magnocellular ("where" pathway):

• Carries motion, spatial location, and visual guidance of movement

• Classroom sign: misjudges distance when reaching, stepping, or catching

• Classroom sign: loses place moving between lines or from board to desk

• Classroom sign: difficulty with maps, block designs, or spatial math layout

Ask: "Which column is your student living in right now?"

Talk over the visual: "Vision's two highways in the school day."

Say the caption in your own words: Ventral "what" signs versus dorsal "where" signs, side by side with the classroom behaviors each one produces.

Frame the slide: "How the Five-Level Framework was built."

Walk each point, one sentence each:

• OTPF-4 names visual functions as client factors — the framework simply organizes them by the order they have to be stable in.

• The developmental sequence of visual skill sets the floor order: sensory access, then efficiency, then processing, then visual-motor control, then occupation.

• Dual-stream neuroscience explains why two students fail the same worksheet for opposite reasons, so each level carries its own probe.

• School caseload data shaped the level definitions around what can actually be measured in a 30-minute session and written into an IEP.

• The clinical rule holds at every floor: an unstable higher level is never trusted until the levels beneath it are confirmed stable.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Talk over the visual: "One example per level."

Say the caption in your own words: What you see, the probe that confirms it, and the OT move that follows — for all five levels.

Run the five levels bottom-up.

Name each level, then say which one you assess first and why.

Contrast the two columns: Functional signs versus OT direction — adapt and refer.

Functional signs:

• Print held very close or pushed away; head tilt

• Fails photocopied/low-contrast packets, fine on crisp ones

• Performance drops in window glare or late in the day

• Misses curb edges, thresholds, food on the plate

OT direction — adapt and refer:

• Raise contrast; enlarge by task, not globally

• Kill glare; control clutter and spacing

• Set working distance where performance is best

• Write the eye-exam referral in parallel, not after

Ask: "Which column is your student living in right now?"

Talk over the visual: "Access, before and after."

Say the caption in your own words: The same worksheet at photocopy contrast and at full contrast with larger print — the gain came from the page, not the student.

Contrast the two columns: Functional signs versus OT direction — remediate + support.

Functional signs:

• Loses place, re-reads, finger-tracks past expected age

• Accurate early, degrades by minute 8–10

• Blur, doubling, headache, "words move" after near work

• Reads as inattention in the last block of the day

OT direction — remediate + support:

• Graded scanning and cancellation on real class text

• Near–far transitions tied to board-to-desk copying

• Fade support: finger → card → typoscope → none

• Keep a compensatory tool while stamina is built

Ask: "Which column is your student living in right now?"

Talk over the visual: "Line loss and the stamina curve."

Say the caption in your own words: Place-keeping errors across a 2-minute passage, and accuracy decaying past minute 8 — an efficiency signature, not inattention.

Talk over the visual: "Oculomotor control — the movement systems."

Say the caption in your own words: Fixation, smooth pursuits, and saccades carry reading and copying. When they fatigue, accuracy decays on a predictable curve — the classroom signs and the OT directions, side by side.

Contrast the two columns: Functional signs versus OT direction — load, then strategy.

Functional signs:

• Cannot find the item on a busy page or crowded hook rack

• b/d/p/q confusion past the developmental window

• Many glances per copied word; model does not hold

• Reverses place value; struggles with maps and diagrams

OT direction — load, then strategy:

• Cut visual load: fewer items, boxed work, stable layout

• Teach a narratable search pattern and self-cue

• Chunk the model; preview the page for landmarks

• Outcome = independent strategy, not worksheet score

Ask: "Which column is your student living in right now?"

Talk over the visual: "Visual load on the page."

Say the caption in your own words: Same target item on a crowded page and a de-loaded page with a taught search pattern: 41 seconds with prompts vs. 7 seconds without.

Talk over the visual: "Perception — and what it looks like in handwriting."

Say the caption in your own words: Discrimination, visual memory, spatial relations, and figure-ground — and how each one surfaces on the page as placement, orientation, sizing, and spacing errors.

Contrast the two columns: Functional signs versus OT direction — isolate, then treat.

Functional signs:

• Legible in isolation, degrades under speed or volume

• Drifting baselines, sizing, spacing, margin overruns

• Copying, diagrams, and cutting on a line are hard

• Keyboarding accuracy and fastener tasks lag

OT direction — isolate, then treat:

• Compare trace vs. copy vs. dictation before planning

• Clean dictation + poor copy = treat upstream levels

• Shrinking model, part-to-whole, spatial scaffolds

• Pair with access: reduced copy volume, notes, tech

Ask: "Which column is your student living in right now?"

Talk over the visual: "Trace vs. copy vs. dictation."

Say the caption in your own words: Three writing samples of the same sentence. Clean dictation with a poor copy points upstream — treat Levels 1–3 before drilling the hand.

Talk over the visual: "When the eyes and hand stop agreeing."

Say the caption in your own words: The trace–copy–dictation comparison at a glance, with the functional signs and the clinical rule that keeps you from drilling the hand for an eye problem.

Contrast the two columns: Functional signs versus OT direction — measure the occupation.

Functional signs:

• Reading rate and endurance below expectation

• Written output far below spoken capability

• Incomplete work, avoidance, late-period fatigue

• Multi-step visual tasks fail in class and community

OT direction — measure the occupation:

• Goal = sustained minutes, accuracy, output, independence

• Intervention sits on whichever floor is unstable

• Document the chain: occupation → level → dose → probe

• Re-probe with the identical baseline task

Ask: "Which column is your student living in right now?"

Talk over the visual: "Where the goal line sits."

Say the caption in your own words: Baseline and 9-week re-probe on the occupations themselves: sustained reading minutes, sentences copied, written output, and work completion.

Frame the slide: "Two rules for choosing where to start."

Walk each point, one sentence each:

• Bottom-up to stabilize: adapt or fix the lowest unstable floor first.

• Top-down for meaning: pick the occupation, then find the floor holding it up.

• Run both threads at once — remediation on the floor, compensation on the occupation.

• If you cannot tie the session to the student's day, you picked the wrong level.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Talk over the visual: "The Active OT Remediation Pathway."

Say the caption in your own words: Medical clearance is the floor; the five levels climb from Visual Access through Functional Integration. Remediate the unstable floor on one side, compensate on the occupation on the other.

Frame the slide: "The same four-part shape, every level."

Walk each point, one sentence each:

• 1 — Baseline probe: re-measure the same task before you treat.

• 2 — 6–10 min graded work on the unstable floor.

• 3 — 3–5 min of that skill inside the student's real classroom material.

• 4 — One-sentence hand-off to the teacher naming the support to keep.

Close with: "If you only take one of these back, take the first one."

Contrast the two columns: Level 1 — Access versus Level 2 — Efficiency.

Level 1 — Access:

• Contrast and print-size trials, not drills

• Record the best condition; paste it into accommodations

• Glare control and setup taught as self-advocacy

• Eye-exam referral sent the same day

Level 2 — Efficiency:

• Fixation hold → saccadic accuracy → pursuit path

• Near–far transitions tied to board-to-desk copying

• Timed re-probe of the passage you opened with

• Fade support in writing: finger → card → typoscope → none

Ask: "Which column is your student living in right now?"

Contrast the two columns: Levels 3–4 versus Level 5.

Levels 3–4:

• Stress one processing skill inside a real page

• Outcome = the strategy the student narrates unprompted

• L4: trace vs. copy vs. dictate before you plan

• Pair every remedial block with an access change

Level 5:

• End every session inside the occupation itself

• Sustained reading minutes, full copy task, timed writing

• This probe is the goal line — nothing else belongs there

• Document occupation → level → dose → probe

Ask: "Which column is your student living in right now?"

Contrast the two columns: Levels 1–2 versus Levels 3–5.

Levels 1–2:

• L1: Fast Screener acuity/contrast; VPA ladders at 60 cm and 40 cm; printable cards in the Worksheet Print Hub

• L2: Follow the Ball, Dynamic Pursuit, Tracking Patterns, Arrow Zigzag, Saccade Sweep, Letter Hunt, Jumping Words, Convergence Zoom, Z-Pattern Scan Grid

• L2: Red/Green anaglyph screening + intervention packets

Levels 3–5:

• L3: Hidden Treasure Hunt, Figure Ground, Form Constancy Contrast Challenge, Memory Grid, Visual Closure — each with a matched worksheet

• L4: Visual Motor Skills, grid/spatial-planning sheets, curriculum-neutral handwriting-readiness packets

• L5: grade-banded reading and writing probes, Treatment Templates (9-week LTG/STO), generated clinical report

Ask: "Which column is your student living in right now?"

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Describe what belongs here: Your own framework graphic, if you want it in place of the built-in ladder slide..

Describe what belongs here: Interactive activity or worksheet that demonstrates work at one specific level..

Land the "so what": Most "visual processing" referrals resolve one or two levels lower — the signal was not getting in, or the eyes were not staying on the work long enough to process anything.

Explain the mechanism plainly: The five levels are ordered by dependency: acuity and sensory input, efficiency, processing, visual-motor integration, functional integration.

Then give them the moves — say each one as something they can do Monday:

• Before you buy a processing program, confirm Level 1 and Level 2 are accounted for.

• State the level you are targeting in the goal so the team can see the reasoning.

• Re-check the lower level when progress stalls instead of adding more of the same activity.

Tell them what success looks like: Fast gains once the lower level is addressed — that is confirmation you had the level wrong, not luck.

Ask: "Who has a student this describes right now?" Take one answer, then move.

Two-minute case. Read it aloud:

A Grade 3 student reverses letters, loses his place, and rubs his eyes after five minutes of reading. The teacher asks for "visual perceptual therapy."

Put the question to them: "Which level do you investigate first, and what does that change on Monday?" Give 60 seconds, no talking.

Model answer (reveal after they commit): Level 2 (visual efficiency) comes first: place-losing plus eye rubbing after a short latency points to fixation and near endurance, not discrimination. Check habitual correction is worn (Level 1), then trial a spaced page and a line marker before any processing program.

Close with the rule: Symptoms that appear with time on task are efficiency findings until proven otherwise.

Reflection prompt: "Take one student. Which level is the lowest one showing a breakdown, and what observable behavior tells you that?"

Cues:

• Start at the bottom of the ladder, not at the complaint.

Offer the sentence starter: "The lowest level showing a breakdown is... The behavior that tells me is..."

Think for one minute, write, then take two shares.

Knowledge check: "A student copies inaccurately from the board and loses his place mid-line. Where should intervention planning begin?"

Options:

• Level 4, because the written output is inaccurate

• Level 5, because the classroom task is the problem

• The lowest level showing a breakdown, verified before working upward

• Whichever level the teacher reports first

Correct answer: option 3. Rationale: The framework is a hierarchy. Treating an upper level while a lower one is unstable produces gains that do not carry into occupation.

Transition: "Screening vs. Assessment: The OT's Two-Step Workflow."

Open here. "Screening vs. Assessment." The OT two-step workflow: rule in the need, then measure it.

Say why this section matters for their caseload, then advance.

Ask the poll: "What happens in your setting after a vision screen flags a concern?"

Options:

• We move straight to intervention

• We refer out and wait

• We refer out and run an occupation-based assessment in parallel

• It varies by building or by teacher

Take a show of hands or the on-screen tally, then name the pattern you see before advancing.

Contrast the two columns: Screening versus Assessment.

Screening:

• Fast, caseload-scale, pass/flag

• Answers: is a closer look warranted?

• Fast Screener and Mini VPA™

• Never the basis for a plan of care

Assessment:

• Level-by-level performance measurement

• Answers: where does performance break down?

• Full VPA™ — 15 skills across 5 domains

• Feeds goals, dosage, and disposition

Ask: "Which column is your student living in right now?"

Frame the slide: "The two-step in practice."

Walk each point, one sentence each:

• Step 1 — Screen: brief probes at each of the five levels; record flags, not diagnoses.

• Step 2 — Assess: run the Full VPA™ on flagged domains and adjacent levels.

• Interpret bottom-up: clear the floor before attributing failure to processing.

• Disposition every finding: OT plan, refer, monitor, or no action.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Talk over the visual: "Fast Screener mid-administration."

Say the caption in your own words: Evaluator script, PASS/FLAG rubric, referral triggers, and the on-screen worksheet in a single view.

Frame the slide: "What VML gives you at the screening step."

Walk each point, one sentence each:

• Fast Screener — brief acuity, contrast, efficiency, and a functional writing sample.

• Pre-K Quick Screen (ages 3–4) — refer or simple activities, no scoring burden.

• Mini VPA™ — one probe at each of Levels 1–5 to flag the domains to measure.

• Free Vision Concern Quiz for teachers and families to start the referral conversation.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Frame the slide: "What turns a flag into a Full VPA™."

Walk each point, one sentence each:

• Any probe failed at or below the expected level for the age band.

• A probe passed only with degraded rate, endurance, or heavy strategy use.

• Teacher or caregiver report that conflicts with a passed probe.

• Any red-flag ocular symptom — refer regardless of the screen result.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Contrast the two columns: Measure it versus Record it.

Measure it:

• Intermediate tasks at 60 cm, near tasks at 40 cm

• Even, glare-free lighting on the stimulus plane

• Feet supported, surface at elbow height

• Habitual correction worn — note if absent

Record it:

• Time of day and time on task

• Any deviation from the standard setup

• Prompts given beyond the single permitted repetition

• Observed strategy, not just pass/fail

Ask: "Which column is your student living in right now?"

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Describe what belongs here: Capture the Say/Do card, level ladder, and scoring panel together..

Describe what belongs here: Photo of measured working distance, lighting, and seating during a screen..

Land the "so what": A screening tells you where to send the student next. It never produces a score you can put in a present level.

Explain the mechanism plainly: Screening is sensitive by design and cannot separate a capacity limit from a demand mismatch. Assessment does that, under controlled setup.

Then give them the moves — say each one as something they can do Monday:

• Use the Fast Screen to decide: refer, assess, or monitor.

• Only move to Mini or Full VPA when you are prepared to change the plan based on the result.

• Say "screening indicated" in writing, never "the student has."

Tell them what success looks like: Anyone quoting a screening result as a score — correct it in the meeting, in one sentence.

Ask: "Who has a student this describes right now?" Take one answer, then move.

Set up the contrast: "Postural setup changes what you are measuring."

Point at the before panel first. Feet unsupported, trunk collapsed, page about 15 cm from the eyes.

Then the after panel. Feet supported, hips back, page raised toward a slant, working distance near Harmon distance.

Say the rule out loud: Fix posture and distance before you score anything. Otherwise you are documenting the setup, not the student.

Ask: "What did we change — the child, or the demand?"

Two-minute case. Read it aloud:

A Grade 5 student passed the school nurse vision screening in September. In November he holds his book at 12 cm, closes one eye during reading, and has fallen behind on written output.

Put the question to them: "What is your next step, and why is the passed screening not the answer?" Give 60 seconds, no talking.

Model answer (reveal after they commit): Refer to eye care for the new one-eye closure and near behavior, and run your own performance-based screen the same week. The nurse screening tested distance acuity only — it says nothing about near efficiency, binocular comfort, or endurance. Continue OT for the written-output demand meanwhile.

Close with the rule: A passed acuity screening rules out one thing at one distance. It does not clear the visual system.

Reflection prompt: "Write the decision rule you will use to move a student from screening to full assessment. Be specific enough that a colleague could apply it."

Offer the sentence starter: "I move to a full assessment when... The threshold is... The evidence I need is..."

Think for one minute, write, then take two shares.

Knowledge check: "What is the job of a screen?"

Options:

• To measure the size of the deficit

• To rule the concern in or out and decide the next step

• To establish a baseline for the IEP goal

• To document medical necessity for billing

Correct answer: option 2. Rationale: Screens sort; assessments measure. A screen that produces a goal has been asked to do a job it cannot do.

Transition: "IEPs, Medicaid, and Occupation-Based Documentation."

Open here. "IEPs, Medicaid, and Functional Documentation." Turning visual performance findings into defensible educational relevance.

Say why this section matters for their caseload, then advance.

Ask the poll: "What most often gets your vision-related goals pushed back?"

Options:

• Educational relevance is questioned

• The goal is not measurable as written

• It reads as a medical or optical recommendation

• My goals get approved without pushback

Take a show of hands or the on-screen tally, then name the pattern you see before advancing.

Frame the slide: "What a reviewer needs to see."

Walk each point, one sentence each:

• The occupation: what the student is expected to do in the school day.

• The observed performance gap, quantified (rate, accuracy, endurance, prompts).

• The conditions under which performance changes (distance, time on task, contrast, print size).

• The educational impact statement tying the gap to access and participation.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Frame the slide: "Occupation-based goals, not skill-drill goals."

Walk each point, one sentence each:

• Target the occupation: copying, sustained reading, worksheet completion, note-taking.

• Condition + behavior + criterion + timeframe, all measurable from your own data.

• Progress monitoring uses the same probe you used at baseline.

• Avoid goals that read as vision therapy protocols.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Read the scenario aloud, slowly:

Grade 3 student: near copying accuracy 92% for the first 3 minutes, dropping to 58% by minute 9, with 7 place-loss events. Acuity screen passed.

Then put these questions to the room:

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

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

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

Give 60 seconds of think time before you take answers. Model answers are in the panel beside this script.

Contrast the two columns: Reviewer accepts versus Reviewer questions.

Reviewer accepts:

• Copy accuracy falls 34% within one class period

• Requires 3 adult prompts to re-find place per page

• Completes 40% of assigned written work in allotted time

• Access improves 22% with 14-pt print and glare control

Reviewer questions:

• "Poor tracking skills"

• "Visual perceptual deficits noted"

• "Needs vision therapy exercises"

• "Below age level on perceptual testing"

Ask: "Which column is your student living in right now?"

Frame the slide: "What has to be in the note."

Walk each point, one sentence each:

• Skilled reasoning: why an OT was required for this session.

• Objective data tied to the goal, recorded the same way each time.

• Response to intervention and the grading decision you made.

• Plan for the next session, including dose and re-probe schedule.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Frame the slide: "Write accommodations from measured conditions."

Walk each point, one sentence each:

• Only list a modification you tested and recorded a change from.

• Name the condition: distance, print size, contrast, lighting, seating.

• Give the teacher one sentence, not a protocol.

• Re-test the accommodation at least annually.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Describe what belongs here: De-identified IEP text showing the present level and matching annual goal..

Describe what belongs here: Baseline vs. re-probe data used to document progress..

Land the "so what": If the present level does not name the occupation, the condition, and the measurable demand, the service does not get funded and the goal does not get taught.

Explain the mechanism plainly: IEP teams and Medicaid reviewers cannot act on "poor visual skills." They act on observable performance under stated conditions.

Then give them the moves — say each one as something they can do Monday:

• Write present levels as condition + behavior + criterion, in performance language.

• Tie every goal to a classroom occupation the team already recognizes.

• Keep the referral trail in the record so scope is visible to the reader.

Tell them what success looks like: A goal you cannot measure on a Tuesday with what you already have in the room — rewrite it.

Ask: "Who has a student this describes right now?" Take one answer, then move.

Set up the contrast: "Before / after: the same student, two present levels."

Point at the before panel first. Reads as a diagnosis, cannot be measured, names no occupation.

Then the after panel. Observation, condition, and measurable classroom demand.

Say the rule out loud: Same student, same session. Only the second version tells the team what to do and lets you show change.

Ask: "What did we change — the child, or the demand?"

Two-minute case. Read it aloud:

A draft IEP present level reads: "Student demonstrates poor visual tracking and visual perceptual weakness affecting academics."

Put the question to them: "Rewrite it in one sentence you could defend in a Medicaid audit." Give 60 seconds, no talking.

Model answer (reveal after they commit): "During 10 minutes of grade-level copying from a near model, the student lost place 9 times and completed 40 percent of the passage, compared with the class expectation of full completion." Add the condition (distance, duration, material) and the observable count; leave interpretation for the reasoning section.

Close with the rule: Condition, behavior, criterion. If a reader cannot repeat your observation, it is not a present level.

Reflection prompt: "Draft one goal now: name the occupation, the visual performance factor limiting it, the condition, and the criterion."

Cues:

• All four elements, one sentence.

• Use the student you brought with you today.

Offer the sentence starter: "In [occupation], [student] will [what] under [condition] to reach [criterion]."

Think for one minute, write, then take two shares.

Knowledge check: "Which element is missing? "Student will improve visual tracking to 80% accuracy.""

Options:

• The criterion

• The occupation and the condition

• The measurement period

• Nothing — this goal is complete

Correct answer: option 2. Rationale: There is no occupation and no condition, so the goal is not educationally relevant as written and cannot be observed in context.

Transition: "Case Walkthroughs: Three Common Occupational Performance Patterns."

Open here. "Case Walkthroughs." Four real student profiles, worked through together — then one on your own.

Say why this section matters for their caseload, then advance.

Ask the poll: "Which of these three presentations shows up most on your caseload?"

Options:

• Board copying breaks down, near work is fine

• Reading endurance collapses after a few minutes

• Handwriting is illegible with intact motor control

• All three, on different students

Take a show of hands or the on-screen tally, then name the pattern you see before advancing.

Read the scenario aloud, slowly:

Maya, age 8, has glasses worn consistently and a current eye exam. She copies the first two lines from her worksheet accurately, then loses her place, skips lines, and stops after 5 minutes. Her teacher says the first problems on a math page are always her best work.

Then put these questions to the room:

• What does the drop-off after 5 minutes tell you that a single accuracy score does not?

• Do you treat, refer, or both?

Answer to Q1: Accuracy is intact, so the skill exists — what fails is holding it over time. That points to efficiency and endurance (Levels 2–3), not to a missing skill.

Answer to Q2: Treat. Her eye exam is current and her correction is worn, so there is no undiagnosed finding to route out. Build endurance with timed near tasks and reduce the visual load on the page.

Read the scenario aloud, slowly:

Elijah, age 7, tracks smoothly, keeps his place while reading, and has 20/20 corrected acuity. His letters vary in size, drift above and below the line, and spacing collapses when he copies from the board.

Then put these questions to the room:

• Which level do you target first?

• How do you tell whether it is the visual part or the motor part?

Answer to Q1: Start at the lowest level that is unstable — here that is visual-motor integration (Level 4). Do not start at handwriting output itself; that is the symptom, not the floor.

Answer to Q2: Grade the task: have him copy from a paper model at his desk instead of the board. If near copying is clean and far copying is not, the breakdown is in the shifting and spatial demand, not in hand control.

Read the scenario aloud, slowly:

Aiden, age 10, scores low on every task you present. He was up late, has no eye exam on file, and his teacher reports he "gives up on everything," not just visual work.

Then put these questions to the room:

• What do you check before you interpret any of these scores?

• What is your obligation about the missing eye exam?

Answer to Q1: Rule out validity threats first: sleep and state, effort, task setup and lighting, and whether he even has correction. Flat-low profiles are usually a testing condition problem before they are a vision problem.

Answer to Q2: Refer. There is no diagnosed acuity or contrast finding here — it is undiagnosed. Route to eye care first; you do not build vision-specific goals on an unexamined visual system.

Read the scenario aloud, slowly:

Sofia, age 14, reads at grade rate with clean acuity and efficiency. She cannot find a labeled part on a diagram, loses items in a full locker, and misreads graphs in science.

Then put these questions to the room:

• Before you write a goal on figure-ground, what must you confirm?

• How do you tie this to something the IEP team cares about?

Answer to Q1: Confirm it shows up in real tasks, not just in your testing — locker, diagram, graph. One low score alone is not a goal.

Answer to Q2: Write the goal at the occupation: locating labeled information on a science diagram or textbook page within a set time, with the figure-ground skill as the "why," not the goal itself.

Read the scenario aloud, slowly:

Noah, age 5, holds books about 4 inches from his face, squints at the whiteboard, and has a documented diagnosis of albinism with reduced acuity managed by his ophthalmologist. He engages well and works hard for 15 minutes at a time.

Then put these questions to the room:

• Is this a referral or something you address? Say why in one sentence.

• Name the first two supports you would put in place tomorrow.

Give 60 seconds of think time before you take answers. Model answers are in the panel beside this script.

Frame the slide: "How to read any profile in four steps."

Walk each point, one sentence each:

• Rule out validity threats: setup, state, effort, correction.

• Clear the floor: acuity and contrast at the measured distances.

• Find the lowest unstable level and stop there.

• Tie that level to the occupation in the referral question.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Contrast the two columns: OT acts versus OT routes out.

OT acts:

• Direct service on the unstable floor

• Accommodation and environmental change

• Teacher/caregiver hand-off with one support to keep

• Scheduled re-probe with the baseline task

OT routes out:

• Eye-care referral for any ocular trigger

• Adjunct standardized testing for depth in one skill

• Team referral when language or attention confounds

• Monitor with a defined re-check date

Ask: "Which column is your student living in right now?"

Set up the clip in one sentence, play it, then debrief with "what did you notice?"

Describe what belongs here: Profile chart from a completed VPA™ showing the shape you are discussing..

Describe what belongs here: De-identified handwriting or copy sample that illustrates the case..

Land the "so what": Three patterns cover most school referrals — near endurance, page navigation, and visual-motor output. Recognizing the pattern gets you to the right first probe in minutes.

Explain the mechanism plainly: Each pattern has a different latency signature: minutes to fatigue, loss across lines, or breakdown as motor precision rises.

Then give them the moves — say each one as something they can do Monday:

• Name the pattern out loud before you choose a tool.

• Match the first probe to the pattern rather than running the whole battery.

• Re-check the pattern at the 9-week mark; patterns shift as demand changes.

Tell them what success looks like: A student who fits two patterns — that is usually a Level 1 or Level 2 issue driving both.

Ask: "Who has a student this describes right now?" Take one answer, then move.

Two-minute case. Read it aloud:

A Grade 4 student starts written work strongly, then within six minutes his letter size grows, spacing collapses, and he asks to take a break.

Put the question to them: "Which pattern is this, and what is your first probe?" Give 60 seconds, no talking.

Model answer (reveal after they commit): Near endurance, not visual-motor capacity: performance was intact at the start and degraded with time on task. Probe sustained near work with a timed baseline, check working distance and posture, and compare a 3-minute and 10-minute sample before touching handwriting instruction.

Close with the rule: Degradation over time is endurance. Breakdown from the first line is capacity.

Reflection prompt: "For the vignette we just worked, what would you have done differently before today, and what will you do now?"

Offer the sentence starter: "Before today I would have... Now I will..."

Think for one minute, write, then take two shares.

Knowledge check: "Reading endurance collapses after four minutes but single-word accuracy is intact. What does that pattern point to first?"

Options:

• Visual processing (Level 3)

• Visual efficiency and near endurance (Level 2)

• Visual-motor integration (Level 4)

• Acuity (Level 1)

Correct answer: option 2. Rationale: Accuracy intact, endurance failing, is the signature of an efficiency and sustaining problem — not a processing one. Refer for eye examination in parallel.

Transition: "Evidence Base, Levels of Evidence, and Selecting Graded Intervention."

Open here. "Who Does What — Supports, Roles, and Collaboration." Turning one flagged level into a plan the whole team can carry, and saying honestly what it rests on.

Say why this section matters for their caseload, then advance.

Ask the poll: "When you choose a vision-related strategy, what usually decides it?"

Options:

• Published evidence for that strategy

• What is in the supply closet

• What the student will tolerate

• What I was taught in fieldwork

Take a show of hands or the on-screen tally, then name the pattern you see before advancing.

Frame the slide: "Vision is already inside the OT domain."

Walk each point, one sentence each:

• We describe vision as a client factor: acuity, field, eye-movement control, focusing, perception.

• We measure it as a performance skill: what the eyes actually do during reading, writing, dressing, play.

• We change it in context: light, glare, print size, contrast, seating, clutter.

• The eye itself — health, glasses, prism, patching — is not ours. That is a referral, every time.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."

Frame the slide: "Four tiers, four owners."

Walk each point, one sentence each:

• Prevention is classroom design — the teacher and team own it; we suggest and model it.

• Accommodation is written access for one student — the team writes it; we trial it and word it.

• Intervention is skill-building inside the real task — this is the OT-only tier.

• Eye health, lenses, prism, and patching belong to optometry or ophthalmology.

Point at the figure while you talk — name the parts before the labels.

Close with: "If you only take one of these back, take the first one."