The Visual Performance Assessment

Suggested citation. Foster, J. (2026). The Visual Performance Assessment: Technical Manual, Version 1.0. Visual Minds Learning, LLC. Retrieved from https://www.visualmindslearning.com/vpa/technical-manual

Author. Jeff Foster, MS, OTR/L, EdD(ABD). Graduate degree in vision rehabilitation; occupational therapist since 2000; MOT & OTA faculty at CBD College; doctoral candidate at Valdosta State University (EdD).

Instrument classification. The VPA™ is a criterion-referenced, clinician-administered framework of tasks and observations designed to describe an individual's visual performance across five clinically meaningful levels. It is not a norm-referenced psychometric test. Pilot-stage live norms are reported alongside criterion anchors; interpretation is criterion-first.

Intended user. Licensed occupational therapists (OT/OTR/L) and occupational therapy assistants (COTA) practicing within their state scope, plus OT/OTA faculty using the framework in coursework and fieldwork.

The VPA™ was developed to answer a question OTs face daily and cannot resolve with any single existing instrument: how is this person's visual system supporting — or interfering with — their occupational performance? Standardized visual-perceptual tests (e.g., TVPS-4, MVPT-4, Beery VMI) sample discrete skills well but do not describe integrated performance, and optometric screenings answer a different question (structural and refractive integrity).

The VPA™ occupies the space between: it is a functional profile that maps observed behavior to the OTPF-4 client factor Visual functions (b210–b229), and organizes findings into five performance levels that correspond to clinical decisions (monitor, support, remediate, refer).

Appropriate uses.

• Baseline profile at intake for school-based, outpatient, and clinic-based OT.
• Goal setting anchored to occupational performance rather than isolated subskills.
• Progress monitoring across an intervention block (typically 6–12 weeks).
• Framing OT recommendations to teachers, families, and OD colleagues.

Inappropriate uses.

• Diagnosis of ocular pathology, binocular vision disorder, or refractive error.
• Sole basis for eligibility determination where norm-referenced testing is required.
• Replacement for a comprehensive optometric or ophthalmologic examination when indicated.

The VPA™ construct is organized as five domains × five performance levels. Domains draw on Warren's hierarchical model of visual perception (1993), Scheiman & Rouse's clinical taxonomy of vision problems (2006), and the OTPF-4 categorization of visual functions.

Domains

1. Visual Access — near visual acuity, contrast sensitivity, and ocular health screening. Findings drive accommodations (print enlargement, contrast enhancement, lighting) and referral to developmental optometry when correction is indicated.
2. Visual Efficiency — oculomotor control (fixation, pursuits, saccades), accommodation, vergence, and visual endurance under sustained near demand.
3. Visual Processing — attention, discrimination, figure-ground, visual memory, form constancy, spatial relations, visual closure.
4. Visual-Motor Integration & Handwriting Readiness — copying, bilateral integration under visual load, in-hand manipulation with visual guidance, and legibility factors under a visual (not motor) lens.
5. Functional Integration — how the above show up in reading fluency, copying from a board, navigating novel environments, self-care, and age-appropriate IADLs.

Neural substrate: magnocellular, parvocellular, and the two visual streams

The five-domain model is behavioral, but the tasks are chosen to sample two parallel retinocortical pathways described in the primate and human visual neuroscience literature (Livingstone & Hubel, 1988; Merigan & Maunsell, 1993; Milner & Goodale, 1995/2006). The magnocellular pathway(M-cells → LGN magno layers → V1 layer 4Cα → dorsal stream / posterior parietal cortex) is fast, low-resolution, color-blind, and highly sensitive to motion, low-contrast, and peripheral information. It is the "where / how" system that supports gaze stability, saccadic accuracy, smooth pursuits, vergence control, figure-ground under motion, and the visuospatial guidance of action — the skills clustered in Domain 2 (Visual Efficiency) and the spatial elements of Domain 3.

The parvocellular pathway (P-cells → LGN parvo layers → V1 layer 4Cβ → ventral stream / inferotemporal cortex) is slower, high-resolution, color-sensitive, and specialized for sustained high-contrast detail. It is the "what" system that supports form discrimination, form constancy, visual closure, visual memory, and letter/word identification — the skills clustered in the object-recognition side of Domain 3 (Visual Processing) and the perceptual foundation of Domain 4 (Visual-Motor Integration).

VPA items are constructed so that low-contrast, motion, timing, and gaze-holding tasks preferentially load the magnocellular / dorsal stream (contrast sensitivity, fixation, pursuits, saccades, vergence facility, reading endurance under time pressure), while high-contrast form, memory, and discrimination tasks preferentially load the parvocellular / ventral stream (discrimination, form constancy, visual closure, visual memory, copying accuracy). This is not a localization claim about any individual student — the two streams are heavily cross-connected and functional performance always reflects both — but it gives the clinician a neurobiological rationale for why a student can pass 20/20 acuity and still fail low-contrast tracking, or pass tracking and still fail form-based copying. The framework thresholds and intervention groupings (Section 8) use this pathway lens to explain co-occurring flags and to guide dosage — magno-loaded skills respond to timing, contrast, and load manipulations; parvo-loaded skills respond to detail, complexity, and memory load manipulations.

Performance Levels (VPL)

Task selection followed a three-stage process modeled after standard scale- development practice (Boateng et al., 2018):

1. Construct sampling. A candidate pool of 74 tasks was drawn from the clinical literature (Scheiman, Warren, Borsting), the OTPF-4 visual functions taxonomy, and 26+ years of the author's school-based caseload notes.
2. Expert review. Tasks were reviewed by five clinicians (four OTR/L, one COVD-affiliated OD) for content relevance, ecological validity, and administrability without specialized optometric equipment. Tasks with fewer than four of five reviewers rating them "essential" or "important" were removed (n = 21 removed).
3. Field feasibility. Remaining tasks were piloted in school-based and outpatient settings; tasks requiring greater than 3 minutes to administer or yielding < 70% inter-observer agreement on a pilot subsample were revised or removed (n = 14 revised, 6 removed).

The retained item set for VPA™ v1.0 comprises 33 tasks across the five domains, each mapped to at least one OTPF-4 visual function code and at least one occupational performance context.

Full VPA™ administration is designed to complete in 40–55 minutes for children and 50–70 minutes for adolescents and adults, in a single session or split across two. The Mini VPA takes 15–20 minutes and samples one item per domain.

Environment

• Quiet room; illumination 300–500 lux at the working surface.
• Working distance ≈ Harmon distance (elbow to first knuckle).
• Habitual correction worn if prescribed; note any refusal.

Sequence

1. Case history and referral concern (5 min).
2. Domain 1: Visual Efficiency (12–18 min).
3. Domain 2: Visual Processing (10–14 min).
4. Domain 3: Visual-Motor Integration & Handwriting Readiness (8–12 min).
5. Domain 4: Functional Integration observation (5–10 min, often embedded in prior tasks).

Fidelity

Each task in the clinician's manual specifies: verbal script, target working distance, allowable prompts, stop criteria, and observation prompts. Deviations from the script must be noted in the record and may invalidate norm comparison for that item.

Each task is scored on a 1–5 anchored rubric aligned to the five VPLs. Anchors are behavior-specific rather than time-only; a "fast but inaccurate" performance and a "slow but accurate" performance can both fall at VPL 3 but with different narrative descriptors.

Generic anchor definitions

Domain VPL. Computed as the median of task VPLs within a domain, rounded down when the mean falls between two levels. Rationale: medians resist distortion by a single outlier task while remaining sensitive to broad domain weakness.

Composite VPL. Reported alongside the five domain VPLs but never as a single "score." The framework is deliberately profile-based; a composite is provided only to support caseload triage.

VPA™ v1.0 is criterion-referenced. The norms reported on /research and returned in scoring output are pilot-stage live normsintended to contextualize criterion decisions, not to replace them.

Sample (pilot)

• Recruitment: convenience sample of school-based OT caseloads and family referrals across MS, LA, UT.
• Age bands: 5–7, 8–10, 11–13, 14–17, 18–29, 30–59, 60+.
• Target n ≥ 30 per band for the pilot phase; achieved n varies by band and is displayed live on /research.
• Exclusion criteria: known ocular pathology, uncorrected refractive error, active concussion within 30 days, or IQ < 70 by prior record.

Reporting

Pilot norms are reported as domain-level means and interquartile ranges only. No standard scores or percentile ranks are published in v1.0. The v1.0 output states the pilot status on every scored report.

Roadmap to standardization

1. Complete pilot sampling to n ≥ 100 per age band (target 2027).
2. Stratified national sample with recruitment quotas by sex, ethnicity, region, and SES (target 2028).
3. Formal norming publication with confidence intervals, standard errors of measurement, and floor/ceiling analyses.

Reliability and validity work for v1.0 is in progress. This section documents the roadmap; findings will be posted to /research and versioned in this manual as they mature.

Reliability studies planned

• Inter-rater reliability — pairs of trained OTs score the same video-recorded administrations. Target: κ ≥ 0.75 on domain VPL by 2027.
• Test–retest stability — same clinician re-administers at 4–6 weeks in a clinically stable subgroup. Target: ICC ≥ 0.80 on domain VPL.
• Internal consistency — Cronbach's α for tasks within each domain. Target: α ≥ 0.70.

Validity evidence planned

• Content validity — expert-panel content validity index (CVI) already gathered in item development (Section 3).
• Convergent validity — VPA™ Domain 2 with TVPS-4; Domain 3 with Beery VMI; Domain 1 with clinical NSUCO scores.
• Discriminant validity — group-difference studies with concussion, ADHD, and typically developing cohorts.
• Ecological / criterion validity — correlation of domain VPLs with teacher-rated classroom performance and Woodcock–Johnson reading fluency.

Interpretation is profile-first. A single domain VPL is a headline, not a conclusion. Clinicians are trained to:

1. Read the five domain VPLs as a shape before reading any number.
2. Identify the lowest-numbered domain and ask: does this pattern match the referral concern?
3. Check for a > 1-level gap between Visual Efficiency and Visual Processing — often the strongest signal for intervention priority.
4. Cross-reference Functional Integration observations against caregiver/teacher report.
5. Generate two or three testable hypotheses before writing goals.

A worked case walk-through is provided in the Clinician's Manual, and a growing case library is available at /cases (in development).

• Pilot-stage norms have not been standardized; standard scores and percentile ranks are not appropriate at v1.0.
• The VPA™ is administered by a single clinician; observer effects have not yet been quantified.
• The instrument is English-language and culturally bound to U.S. educational norms in its present form.
• Individuals with severe motor, cognitive, or communication impairments may not be validly assessed with the current item set.
• The VPA™ does not screen for or diagnose ocular disease. A clinician who suspects pathology (sudden vision change, unequal pupils, papilledema signs, new-onset diplopia) must refer for medical evaluation.

Semantic versioning: MAJOR.MINOR.PATCH.

Administration and interpretation of the VPA™ falls squarely within the scope of occupational therapy practice. Per the OTPF-4, Visual functions are categorized as client factors (body functions b210–b229) that OTs routinely evaluate and address as they impact occupational performance. Occupational therapists are independently licensed professionals with training in development, physiology, kinesiology, and the client factors that support occupation.

The VPA™ is not a diagnostic instrument for ocular disease or binocular vision disorders. OTs using this framework refer to developmental optometry when indicated by findings that fall outside OT scope, as they would for any other client factor.

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25. Scheiman, M., & Rouse, M. W. (2006). Optometric management of learning-related vision problems (2nd ed.). Mosby.
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Reliability and validity estimates below are pilot-stage, drawn from the internal calibration sample. Sample sizes are honestly disclosed; gaps are called out explicitly rather than concealed. All values will be republished in v1.1 with the external calibration cohort.

α = Cronbach's alpha across items within domain. ICC = intraclass correlation (two-way mixed, absolute agreement). κ = Cohen's kappa on ordinal VPL rating.

Expected VPL ranges below reflect the median ± IQR of the pilot sample. These are descriptive expected values, not standard scores. A student below the expected range warrants clinical hypothesis generation, not a diagnostic label.

Grounded in: Kulp & Schmidt (1996) for early literacy vision markers; Scheiman & Wick (2020) for binocular expectancies; Maples (2003) NSUCO norms; Beery (2010) VMI age equivalents; Case-Smith & O'Brien (2020) developmental frames.

Every skill has a fidelity checklist covering distance, lighting, occluder use, cadence, and scripting adherence. Clinicians new to the VPA™ should complete a calibration set of five recorded administrations reviewed against the rubric anchors before independent use.

• Distance verification: measure to nearest 1 cm (near) and 5 cm (intermediate) at each session.
• Lighting: 500–700 lux at the working plane; document if outside range.
• Occluder: opaque; no fenestrations; alternate ownership hand to prevent postural drift.
• Cadence: metronome at prescribed BPM for saccade/pursuit tasks; no verbal pacing.
• Scripting: read the on-screen prompt verbatim on first administration; paraphrase only on repeat trials.
• NSUCO scoring: 5-point ability, accuracy, head, and body movement scales; percent-agreement target ≥ 85%.
• Perceptual items: Cohen's κ target ≥ 0.70 for VPL rating between raters on the same recorded session.
• Re-test interval: 2 weeks minimum for stability; 6–12 weeks for treatment-effect re-measure.

An interpretive-cautions reminder is printed on every clinical report: a VPL alone does not tell you the ocular status, the developmental trajectory, or the classroom experience. It anchors a clinical conversation; it does not replace one.

The VPA™ is intended for use by licensed occupational therapists within their state / jurisdictional scope of practice, or by supervised OT students, OT assistants, or clinicians with a comparable scope in the visual client factors. It is not intended for use by unlicensed personnel as a screening battery deployed at scale.

Contraindications:

• Acute (< 48 h) post-concussion — defer intensive oculomotor demand; use the concussion protocol branch.
• Undiagnosed photosensitive epilepsy — omit high-contrast flashing / anaglyph stimuli until cleared.
• Suspected but undiagnosed strabismus or CVI — administer for hypothesis generation only; do not report VPLs as diagnostic.
• Medical instability (post-surgical, severe illness) — defer.

Ethical use commitments:

• Results are educational assessment data — never labeled as diagnosis of a medical condition.
• Reports are shared only with the family, IEP team, and coordinated providers per informed consent.
• Item content is not shared with families in advance of administration.
• The instrument is republished when calibration or scoring changes; version numbers are stamped on every report.

Selected references with DOIs for the doctoral-grade evidence base underpinning the VPA™ and the specialized protocol branches. This list supplements §12.

1. American Academy of Optometry (2011). Care of the Patient with Accommodative and Vergence Dysfunction. Clinical Practice Guideline. https://www.aoa.org/
2. Birch, E. E. (2013). Amblyopia and binocular vision. Progress in Retinal and Eye Research, 33, 67–84. https://doi.org/10.1016/j.preteyeres.2012.11.001
3. CITT Study Group (2008). Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol, 126(10), 1336–1349. https://doi.org/10.1001/archopht.126.10.1336
4. Ciuffreda, K. J. et al. (2007). Occurrence of oculomotor dysfunctions in acquired brain injury: A retrospective analysis. Optometry, 78(4), 155–161. https://doi.org/10.1016/j.optm.2006.11.011
5. Ellis, M. J. et al. (2015). Vestibulo-ocular dysfunction in pediatric sports-related concussion. J Neurosurg Pediatr, 16(3), 248–255. https://doi.org/10.3171/2015.1.PEDS14524
6. Law, M. et al. (2005). Canadian Occupational Performance Measure (4th ed.). https://www.thecopm.ca/
7. Kiresuk, T. J. & Sherman, R. E. (1968). Goal Attainment Scaling. Community Mental Health Journal, 4(6), 443–453. https://doi.org/10.1007/BF01530764
8. Kulp, M. T. et al. (2016). Uncorrected hyperopia and preschool early literacy (VIP-HIP). Ophthalmology, 123(4), 681–689. https://doi.org/10.1016/j.ophtha.2015.11.023
9. Lueck, A. H. & Dutton, G. N. (2015). Vision and the Brain. APH Press.
10. Master, C. L. et al. (2016). Vision diagnoses common after sports concussion. Clin Pediatr, 55(3), 260–267. https://doi.org/10.1177/0009922815594367
11. Roman-Lantzy, C. (2018). Cortical Visual Impairment: An Approach to Assessment and Intervention (2nd ed.). AFB Press.
12. Rouse, M. W. et al. (2004). Validity of the convergence insufficiency symptom survey (CISS). Optom Vis Sci, 81(6), 384–390. https://doi.org/10.1097/01.opx.0000135092.34793.a5
13. Storey, E. P. et al. (2017). Vestibular/ocular motor screening (VOMS) is a valuable tool. Clin J Sport Med, 27(3), 226–231. https://doi.org/10.1097/JSM.0000000000000341
14. Turgeon, C. et al. (2019). School-based OT vision interventions: A scoping review. Can J Occup Ther, 86(3), 191–202. https://doi.org/10.1177/0008417419838904
15. Wong, A. M. F. (2015). New concepts in stereopsis. Ophthalmology, 122(1), 5–7. https://doi.org/10.1016/j.ophtha.2014.11.009

Four population-specific protocol branches sit alongside the standard intervention library. Each has its own entry triggers, intake add-ons, dosing rules, phase model, outcome measures, and discharge criteria. See the interactive protocol library at /vpa/protocols.

• Post-Concussion / mTBI — symptom-guided return-to-learn, VOR reintegration, driving-readiness pre-screen.
• CVI (Roman-Lantzy-informed) — Phase I/II/III complexity-controlled hierarchy, TVI co-management.
• Low-Vision — environment audit → device fluency → occupational integration.
• Complex Learner (ADHD / DCD / ASD) — regulation-first sequencing, shortened bouts, higher frequency.