Why Visual Performance Matters: Foundations for Occupational Therapy Practice

Transition: "Module 4."

Open here. "Comorbidity Patterns." Autism, ADHD, dyslexia, and dysgraphia — visual performance signs, not causation.

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

Ask the poll: "In your practice, when a student has a diagnosis like ADHD or dyslexia, how often is a visual contribution also checked?"

Options:

• Always

• Usually

• Rarely

• Never

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

Frame the slide: "Association is not causation."

Walk each point, one sentence each:

• These four conditions frequently co-occur with visual performance differences — the visual finding does not cause the diagnosis.

• OT describes the visual sign and its occupational impact; OT does not attribute a diagnosis to a visual cause.

• About 1 in 4 school-age children may have an undiagnosed vision problem affecting academics (Kleinstein et al., 2003, CLEERE).

• These patterns raise suspicion for a referral — they do not replace one.

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: What is reported versus Occupational impact.

What is reported:

• Reduced eye contact or difficulty sustaining visual focus

• Difficulty tracking moving objects

• Visual hypersensitivity; avoids visually busy settings

• Figure-ground difficulty in cluttered environments

Occupational impact:

• Face recognition and disorganization with visual materials

• Reduced reading of expressions and nonverbal cues

• Strabismus reported at 1.8–8.3% in autism (Holhoș et al., 2022) — association only

• Magnocellular associations reported; mechanism unsettled

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

Contrast the two columns: What is reported versus Occupational impact.

What is reported:

• Difficulty sustaining focus on visual tasks; easily distracted

• Struggles tracking words across a page; frequent place loss

• Trouble filtering important visual details from background clutter

Occupational impact:

• Difficulty recalling visual details; needs repetition to interpret visual information

• Impulsive, rushed visual task completion with disorganized output

• ~16% report an unspecified vision problem (Bellato et al., 2023, systematic review); higher reported likelihood of convergence issues (Koscinski, 2022, narrative review) — co-occurrence only, not causation

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

Contrast the two columns: What is reported versus Reported associations.

What is reported:

• Letter or number reversals; misaligned text or math columns

• Difficulty focusing on relevant text amid a page (figure-ground)

• Difficulty following lines of text; challenges with saccadic movement

• Struggles recalling letter order or spelling from visual memory

Reported associations:

• 73% show deficits in at least one visual-processing domain (reported in the dyslexia visual-processing literature; observational samples, not a population prevalence)

• 63% show unstable eye dominance (same observational literature)

• Significant magnocellular correlation reported (Greatrex et al., observational)

• AAP / AAO / AAPOS joint statement: dyslexia is a language-based disorder; visual findings are correlates, not causes, and vision treatment is not a treatment for dyslexia

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

Frame the slide: "Visual performance signs associated with dysgraphia."

Walk each point, one sentence each:

• Illegible handwriting; struggles with letter formation, alignment, and spacing.

• Difficulty sustaining visual attention on writing tasks, producing incomplete or messy work.

• Frustration on precision visual-motor tasks such as drawing shapes or copying diagrams.

• This is a Level 4 visual-motor integration signature in a structured visual performance framework, treatable directly in OT — the framework that defines these levels is taught in Course 1.

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: "The numbers behind the urgency."

Walk each point, one sentence each:

• 1 in 4 school-age children are estimated to have an undiagnosed vision problem affecting academics (Kleinstein et al., 2003, population-based cohort).

• 6.8% of children under 18 have a diagnosed visual condition; 3% are blind or visually impaired (CDC surveillance data). These are co-occurrence figures, not causal claims.

• A visual performance sign inside any of these four diagnoses is a prompt for OT documentation and referral — not for OT diagnosis of the visual disorder.

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 5th-grade student with an ADHD diagnosis is referred for "poor handwriting and inattention." During your session he loses his place three times in one paragraph and cannot locate his pencil among other items on the desk.

Then put these questions to the room:

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

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

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?"

Set up the contrast: "A visual-motor signature on the page — and what changed it."

Point at the before panel first. Same student, same words, no external spatial structure.

Then the after panel. The visual boundary is supplied by the page instead of held in the head.

Say the rule out loud: This is a spacing, alignment, and formation problem — a visual-motor integration signature — not a motivation or handwriting-instruction problem. Document what you observed, modify the page today, and refer if no eye exam is on file.

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

Land the "so what": Autism, ADHD, dyslexia, and dysgraphia all produce behavior that overlaps with visual-performance findings. Treating one and ignoring the other stalls the student.

Explain the mechanism plainly: Overlapping presentations share observable behavior but differ in the conditions that change performance.

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

• Manipulate one visual condition and see whether performance moves.

• Keep both hypotheses alive in your documentation instead of choosing early.

• Coordinate with the SLP, teacher, and psychologist on what each of you is testing.

Tell them what success looks like: Performance that changes with a visual manipulation but not with an attention support, or the reverse.

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

Set up the contrast: "Task layout: dense page versus spaced page."

Point at the before panel first. Small print, tight leading, items packed edge to edge.

Then the after panel. Larger print, wide line spacing, fewer items per page, clear margin cue.

Say the rule out loud: Spacing is not an accommodation for content; the reading or math demand is unchanged. Only the visual-efficiency load moved.

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

Two-minute case. Read it aloud:

A Grade 4 student with an ADHD diagnosis loses his place while reading, skips lines, and finishes about half the passage. Medication is stable and he sustains attention well in a listening task.

Put the question to them: "How do you decide whether the reading breakdown is visual?" Give 60 seconds, no talking.

Model answer (reveal after they commit): Manipulate the visual variable, not the attention variable: same passage with a line guide, larger print, and fewer lines per page. If place-losing and completion improve without any attention support changing, you have a visual-efficiency contribution to document alongside the ADHD.

Close with the rule: Co-occurring diagnoses do not cancel each other. Change one condition at a time and let performance answer.

Reflection prompt: "Think about a student with a comorbid diagnosis. What one visual performance question would you add to the evaluation or IEP meeting?"

Offer the sentence starter: "I will ask: "When [student] does [occupation], what visual demand is hardest to meet?""

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

Knowledge check: "Which statement about dyslexia and vision is supported by evidence?"

Options:

• Dyslexia is caused by visual tracking problems and can be cured with eye exercises.

• Dyslexia is language-based; some students may also have co-occurring visual efficiency problems that need separate care.

• Colored overlays are the first-line treatment for dyslexia.

• OTs should not address visual-motor issues in students with dyslexia.

Correct answer: option 2. Rationale: Major pediatric and ophthalmology organizations agree that dyslexia is language-based. Some students may also have visual efficiency concerns, and those should be addressed by the appropriate provider while reading intervention targets the language deficit.