The VPA™: Assessment & Clinical Reasoning

Transition: "Clinical reasoning walkthroughs: three student profiles from referral to interpretation."

Open here. "Clinical Reasoning Walkthroughs." Three student profiles from referral to disposition.

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

Ask the poll: "Where does your reasoning most often stall?"

Options:

• Turning scores into a hypothesis

• Deciding what to treat first

• Deciding what to refer

• Explaining it to the team

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

Read the scenario aloud, slowly:

Intake: passed a kindergarten vision screening, no eye examination since, no glasses, homework is "a battle." Band 5–7. Findings — L1: near acuity at criterion both eyes; intermediate acuity at 60 cm one line below criterion with a one-line difference between the eyes; Maya leans toward the card. L2: fixation and pursuits at criterion; NPC break 9 cm, recovery 13 cm, stable across three trials. L3: at criterion through Level 4. L4: form copying reaches Level 3, orientation errors on diagonal intersections. L5: reading at criterion for grade; writing sample shows b/d reversals and an inconsistent baseline.

Then put these questions to the room:

• The referral says "reversals." Does the data support a processing explanation?

• Which single finding carries the most clinical weight?

• What is the disposition?

Answer to Q1: No. Discrimination and form constancy are at criterion through Level 4 — that is exactly the skill set that would be weak if the reversals were perceptual. At age 7 with intact discrimination, b/d reversals sit inside ordinary developmental variation.

Answer to Q2: The intermediate acuity finding: one line below criterion at 60 cm, a one-line interocular difference, and a compensatory lean. That is Level 1, in a child who has never had a comprehensive eye examination — and 60 cm is exactly the distance the board-copying complaint lives at.

Answer to Q3: Refer for a comprehensive eye examination. Change the environment now — seating, contrast, and copy-from-desk instead of copy-from-board. Re-assess Levels 3 through 5 after the ocular question is settled, because a Level 1 finding makes everything above it provisional.

Read the scenario aloud, slowly:

Intake: glasses worn consistently, eye examination 8 months ago, headaches during silent reading, avoids reading homework. Band 8–11. Findings — L1: at criterion both distances. L2: fixation at criterion; saccades reach Level 3, with head movement on every horizontal shift at Levels 4 and 5 and two refixations per line; NPC break recedes across trials from 8 cm to 14 cm. L3: at criterion through Level 5. L4: at criterion through Level 4. L5: reading rate at criterion for the first two minutes then decays; line loss begins around four minutes; writing volume falls off in the final third.

Then put these questions to the room:

• What in this profile separates an efficiency finding from a processing finding?

• Which single observation is the strongest in the protocol?

• What is the disposition — and what does the teacher need to hear?

Answer to Q1: The time course. Everything is fine at the start and degrades over minutes — that is fatigue-sensitive machinery. A processing deficit is impaired from the very first item, not the fourth minute. Levels 3 and 4 are at criterion, which rules processing out directly.

Answer to Q2: The receding NPC across three trials — 8 cm to 14 cm. It corroborates both the reading decay and the headaches, and no other finding accounts for all three as plausibly.

Answer to Q3: Both paths at once. Refer for an eye examination specifically addressing near-point function — binocular diagnosis and any lens or optometric therapy decision is not ours — and start OT intervention on near-point endurance and saccadic accuracy inside real reading. Tell the teacher: "He can do it when he tries" is exactly what this finding looks like from the back of the room. The ability is real; the endurance is not.

Read the scenario aloud, slowly:

Intake: glasses, current examination, no discomfort reported, strong verbal performance, OT in elementary school discharged in grade 4. Band 12–16. Findings — L1 and L2 at criterion throughout. L3 at criterion through Level 5. L4: grid-pattern reproduction reaches Level 2; proportion and spatial organization break down as grid complexity increases; he rechecks the model repeatedly. L5: reading at criterion; writing sample shows adequate content, poor organization on the line, slow effortful production, visible frustration.

Then put these questions to the room:

• Levels 1, 2, and 3 are clean. What does that rule out?

• What does the repeated model-rechecking tell you?

• What does his age change about the plan?

Answer to Q1: Access, efficiency, and perceptual judgment. He sees it, holds it, and interprets it accurately — and still cannot produce a matching output. That isolates the limiter at Level 4.

Answer to Q2: It is the behavioral signature of intact perception paired with unreliable motor reproduction. He keeps going back to the model because his output does not match what he correctly perceives.

Answer to Q3: At 15, with a long-standing production problem and intact perception, remediation alone is not defensible. The plan needs an occupation-level compensation conversation — keyboarding, scribing, output-format accommodation — alongside any graded practice. And the refusal is not a separate behavior problem; it is a rational response to the finding, so it belongs in the occupational performance statement.

Read the scenario aloud, slowly:

Intake: no glasses, eye examination last year reported normal, no headaches, likes being read to and dislikes reading alone. Band 8–11. Findings — L1: at criterion both distances. L2: fixation at criterion; pursuits at criterion; saccades reach Level 4 with no head movement and no rate decay across the timed passage. L3: figure-ground reaches Level 2 — she cannot locate a target item on a dense page; discrimination and visual memory at criterion through Level 4. L4: at criterion through Level 4. L5: reading rate below criterion from the first minute and flat across eight minutes; she finds the line again quickly once she loses it.

Then put these questions to the room:

• Which level is the limiter, and what rules out the obvious answer?

• Write the one-sentence occupational performance statement.

• What would you change in the classroom on Monday?

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

Frame the slide: "The same four questions in every case."

Walk each point, one sentence each:

• What is the occupation named in the referral?

• Which level is the breakdown point, and what do the clean floors rule out?

• What condition changed performance — distance, time, contrast, noise?

• What is the disposition: treat, accommodate, refer, or monitor?

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 reports versus Route to eye care.

OT reports:

• Rate decay across a timed passage

• Place-loss counts and prompt counts

• Copy accuracy under speed and volume

• Condition-dependent change in performance

Route to eye care:

• Self-reported blur, doubling, or eye pain

• Unexplained acuity loss at either distance

• New head tilt or eye turn

• Symptoms persisting despite clean OT-side data

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: De-identified writing or copy sample belonging to one of the cases..

Describe what belongs here: Domain profile for the case you are walking through..

Land the "so what": What you are certified to do is connect a referral question to a scored profile to a defensible decision — that chain is what the team is buying.

Explain the mechanism plainly: A score with no reasoning trail cannot be defended, replicated, or built on by the next therapist.

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

• Write the referral question at the top of your reasoning and answer it explicitly.

• State the alternative explanations you ruled out and how.

• End every walkthrough with a disposition: treat, refer, monitor, or reassess.

Tell them what success looks like: A report that never returns to the original question — that is where teams stop reading.

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

Two-minute case. Read it aloud:

The referral question was "why can this student not finish written work?" Your report describes the profile in detail and recommends OT twice monthly.

Put the question to them: "What is missing?" Give 60 seconds, no talking.

Model answer (reveal after they commit): The direct answer. Add one sentence that answers the question posed: which domain and which condition account for the incomplete work, what was ruled out, and what changes for the student in the classroom starting now.

Close with the rule: Answer the question you were asked, in the words it was asked in.

Reflection prompt: "For the walkthrough we just finished, write the disposition you would document and the one thing you would tell the teacher tomorrow."

Offer the sentence starter: "Disposition:... One thing for the teacher:..."

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

Knowledge check: "Interpretation is complete. What determines the disposition?"

Options:

• The lowest score on the profile

• The level of breakdown, the validity of the data, and what the occupation requires

• The family preference

• Available service minutes

Correct answer: option 2. Rationale: Disposition is a reasoning product: what broke down, how much you trust the data, and what the occupation demands.