4.1 — Module 4
TransitionSay this
Transition: "Module 4."
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Presenter study handout
Why Visual Performance Matters: Foundations for Occupational Therapy Practice
3 contact hours · 0.3 AOTA CEUs · Module 4 · 17 slides
Presenter-side material. Each block shows the slide as the audience sees it, the talk track, and space for your own notes. Model answers appear here — do not hand this version to learners.
Module 4
4.2 — Comorbidity Patterns
Title- Autism, ADHD, dyslexia, and dysgraphia — visual performance signs, not causation.
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Open here. "Comorbidity Patterns." Autism, ADHD, dyslexia, and dysgraphia — visual performance signs, not causation.
Say why this section matters for their caseload, then advance.
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4.3 — Comorbidity reality
Poll- In your practice, when a student has a diagnosis like ADHD or dyslexia, how often is a visual contribution also checked?
- – Always
- – Usually
- – Rarely
- – Never
Say this
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
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4.4 — Association is not causation
Teaching slide- 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.
Say this
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.
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4.5 — Visual performance signs associated with autism
Comparison- 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
Say this
Contrast the two columns: What is reported versus Occupational impact.
What is reported:
• Reduced eye contact or difficulty sustaining visual focus
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4.6 — Visual performance signs associated with ADHD
Comparison- 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
Say this
Contrast the two columns: What is reported versus Occupational impact.
What is reported:
• Difficulty sustaining focus on visual tasks; easily distracted
My notes
4.7 — Visual performance signs associated with dyslexia
Comparison- 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
Say this
Contrast the two columns: What is reported versus Reported associations.
What is reported:
• Letter or number reversals; misaligned text or math columns
My notes
4.8 — Visual performance signs associated with dysgraphia
Teaching slide- 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.
Say this
Frame the slide: "Visual performance signs associated with dysgraphia."
Walk each point, one sentence each:
• Illegible handwriting; struggles with letter formation, alignment, and spacing.
My notes
4.9 — The numbers behind the urgency
Teaching slide- 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.
Say this
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).
My notes
4.10 — A comorbidity pattern in a real referral
Case- 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.
- Q1. Which findings are visual-performance signs worth documenting separately from the ADHD diagnosis?
- Q2. What would your present-level sentence say, and what referral (if any) would accompany it?
Say this
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:
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4.11 — Module 4 video — comorbidity patterns and OT documentation
Video- Walkthrough of the four comorbidity profiles and scope-safe phrasing.
Say this
Set up the clip in one sentence, play it, then debrief with "what did you notice?"
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4.12 — A visual-motor signature on the page — and what changed it
Before / afterA visual-motor signature on the page — and what changed it
Same student, same words, no external spatial structure.
- • Letter size drifts word to word; no consistent body height.
- • Spacing between words is inconsistent and the line drifts downward.
- • Letter formation breaks down as the line goes on (endurance, not knowledge).
The visual boundary is supplied by the page instead of held in the head.
- • Size becomes consistent because the target is visible.
- • Baseline and descenders land where they belong.
- • Output improves without any change to the writing prompt itself.
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.
- Unlined paper: Same student, same words, no external spatial structure. · Letter size drifts word to word; no consistent body height. · Spacing between words is inconsistent and the line drifts downward. · Letter formation breaks down as the line goes on (endurance, not knowledge).
- Two-line paper with a defined body space: The visual boundary is supplied by the page instead of held in the head. · Size becomes consistent because the target is visible. · Baseline and descenders land where they belong. · Output improves without any change to the writing prompt itself.
- Takeaway: 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.
Say this
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.
My notes
4.13 — So what? Co-occurrence is the norm, not the exception
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.
- Because: Overlapping presentations share observable behavior but differ in the conditions that change performance.
- Move: Manipulate one visual condition and see whether performance moves.
- Move: Keep both hypotheses alive in your documentation instead of choosing early.
- Move: Coordinate with the SLP, teacher, and psychologist on what each of you is testing.
- Watch for: Performance that changes with a visual manipulation but not with an attention support, or the reverse.
Say this
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:
My notes
4.14 — Task layout: dense page versus spaced page
Before / afterTask layout: dense page versus spaced page
Small print, tight leading, items packed edge to edge.
- • Return sweeps land on the wrong line
- • Skipped and repeated items look like carelessness
Larger print, wide line spacing, fewer items per page, clear margin cue.
- • Line-finding demand drops without lowering the academic demand
- • Accuracy rises before speed does — expect that order
Spacing is not an accommodation for content; the reading or math demand is unchanged. Only the visual-efficiency load moved.
- Before — dense layout: Small print, tight leading, items packed edge to edge. · Return sweeps land on the wrong line · Skipped and repeated items look like carelessness
- After — spaced layout: Larger print, wide line spacing, fewer items per page, clear margin cue. · Line-finding demand drops without lowering the academic demand · Accuracy rises before speed does — expect that order
- Takeaway: Spacing is not an accommodation for content; the reading or math demand is unchanged. Only the visual-efficiency load moved.
Say this
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.
My notes
4.15 — Two-minute case: vision, attention, or both?
Mini case- 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.
- Question: How do you decide whether the reading breakdown is visual?
- Model answer: 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.
- Teaching point: Co-occurring diagnoses do not cancel each other. Change one condition at a time and let performance answer.
Say this
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.
My notes
4.16 — Reflect and share
Reflection- Think about a student with a comorbid diagnosis. What one visual performance question would you add to the evaluation or IEP meeting?
- Starter: I will ask: "When [student] does [occupation], what visual demand is hardest to meet?"
Say this
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.
My notes
4.17 — Knowledge check — comorbidity
Self-check- Which statement about dyslexia and vision is supported by evidence?
- – 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.
- 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.
Say this
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.
My notes