Clinical Toolkit

Treatment Plan Templates

Goal-writing scaffolds and intervention menus mapped directly to VPA™ results. Adapt to your student, your setting, and your scope.

← Scope & Limitations Clinician's Manual

Age band

Swaps goal subject, functional context, dose cadence, and adds age-specific interventions. Skills and levels are unchanged.

Setting context: School-based OT

Use within scope. These templates are examples for licensed OTs and TVIs. Adapt goals to your student's baseline, IEP framework, and site policy. Refer out first when red flags are present.

Protocol library (FITT-P dosing · VPA™ outcome tracking)

Skill-by-skill graded protocols with FITT-P dosing (Frequency · Intensity · Time · Type · Progression), evidence tier per line, precautions/contraindications, and objective progression, regression, and discharge criteria — with outcomes tracked by the VPA™ rescore, the written COAST objective, and any outside assessment scores you entered.

Specialized population branches: post-concussion / mTBI, CVI (Roman-Lantzy-informed), low-vision, and complex learner (ADHD / DCD / ASD) each have their own triggers, intake add-ons, dosing rules, and discharge criteria.

Open specialized protocols →

Abbreviation & outcome-measure guide

What each term means and how to use it clinically

Outcome measures

COPMCanadian Occupational Performance Measure

A semi-structured interview that identifies the occupations a child or family values most and rates current performance and satisfaction.

Use: Administer at baseline, mid-point, and discharge. A change of ≥ 2 points on performance or satisfaction is considered clinically meaningful.

Use child/adolescent or caregiver-proxy version as appropriate. Purchase and use per publisher guidelines.

GASGoal Attainment Scaling

A standardized way to score how much a child achieves on individually written goals, from much worse than expected (−2) to much better than expected (+2).

Use: Write 1–3 goals, set baseline at −1 or −2, expected outcome at 0, and above/below outcomes at +1/−1 or +2/−2. Convert raw scores to a T-score at discharge.

Works well for IEP-aligned goals and small-N clinical progress monitoring.

CISS-15Convergence Insufficiency Symptom Survey — 15 items

A 15-item questionnaire about near-work symptoms such as headache, blur, double vision, tired eyes, and loss of concentration.

Use: Give to the child (usually age 8+) or as a parent proxy. Each item is scored 0–4. Total ≥ 16 for children or ≥ 21 for adults indicates a symptomatic near-work load. Re-administer to track change.

Built into the VPA clinical intake. It is a symptom screen, not a diagnosis by itself.

VSS-SchoolVisual Symptom Survey — School version

A 12-item school-based symptom log for teachers, parents, or students that captures observable near-work signs (rubbing eyes, losing place, head tilt, avoidance, etc.).

Use: Score each item 0–3. A total ≥ 8 or any single item ≥ 2 indicates a functional near-visual endurance concern that warrants follow-up.

Useful for triangulating with the CISS-15, VOMS, and classroom observation.

DEMDevelopmental Eye Movement test

A normed test of saccadic/pursuit-like scanning using vertical and horizontal arrays of numbers.

Use: Administer per the publisher’s manual. Compare horizontal and vertical times and errors. Use as a screening or progress measure, not a diagnostic vision test.

Often co-administered or reviewed with developmental optometry.

King-DevickKing-Devick rapid number-naming test

A timed test of saccadic efficiency and cognitive processing speed; commonly used in concussion management.

Use: Have the student read numbers across a series of cards as quickly and accurately as possible. Compare to a personal baseline or age norms.

Sideline and clinical versions exist; OT can use it to track return-to-learn recovery.

NSUCONortheastern State University College of Optometry Oculomotor Test

A clinical rating scale of fixation, pursuits, and saccades in children.

Use: Use a standardized target and rate the quality of each movement on the publisher’s scale. Often administered by optometrists; OTs may observe or co-measure.

Training is recommended to maintain reliability. Not a substitute for a full optometric exam.

Beery VMIBeery-Buktenica Developmental Test of Visual-Motor Integration

A norm-referenced test of visual-motor integration using shape and form copying.

Use: Administer per publisher instructions. Use the standard score and associated visual and motor subtests to describe VMI status and track change over time.

OT- or OD-collected; coordinate with the IEP team on re-eval intervals.

CDTClock Drawing Test

A brief drawing task that samples visual-spatial planning, executive function, and construction.

Use: Ask the child to draw a clock face and set the hands to a specific time. Score against a standard rubric and use as a serial probe, not a diagnostic screen.

In older students, marked failure should prompt neuropsychology or medical referral.

CVI RangeCVI Range / CVI Complexity Sequences (Roman-Lantzy)

A framework for assessing and describing visual functioning in children with cortical/cerebral visual impairment.

Use: Typically administered by the TVI; OT contributes functional observations about how the child uses vision during daily occupations.

Guides environmental complexity, preferred field, color, and movement supports.

Post-Concussion Vision Symptom ScalePost-Concussion Vision Symptom Scale

A symptom inventory tracking vision-related complaints after concussion (e.g., headache, light sensitivity, motion sensitivity, reading difficulty, screen intolerance).

Use: Administer at baseline and weekly during rehab. A score ≥ 20, or photophobia / motion sensitivity, supports opening the concussion protocol branch. Use alongside CISS-15 and VOMS.

Often used alongside the CISS-15 and VSS-School. Track change, not just absolute score.

CISS-15Convergence Insufficiency Symptom Survey — 15 items

A 15-item questionnaire about near-work symptoms such as headache, blur, double vision, tired eyes, and loss of concentration.

Use: Give to the child (usually age 8+) or as a parent proxy. Each item is scored 0–4. Total ≥ 16 for children or ≥ 21 for adults indicates a symptomatic near-work load. In concussion, pair with the Post-Concussion Vision Symptom Scale to separate near-work load from post-trauma symptom load.

Built into the VPA clinical intake. It is a symptom screen, not a diagnosis by itself.

Tools & clinical probes

NPCNear Point of Convergence

The closest point at which the eyes can maintain a single, fused image without double vision.

Use: Move a small target (penlight or accommodative target) along the midline toward the nose. Record the break point (when the image doubles) and the recovery point (when it single again). Co-measure with developmental optometry when possible.

A break point receded beyond 6 cm, or recovery beyond 10 cm, often supports convergence-insufficiency concerns.

Harmon working distanceHarmon distance (also called Harmon working distance)

The ergonomic near-working distance from the sternum to the elbow — roughly the distance from the child’s chin/chest to the knuckles when the elbow is bent at a right angle.

Use: Teach the child to place the page or screen at that distance, which reduces accommodative and convergence load while keeping posture upright.

Sometimes misspoken as “Harmen distance.” OT scope: training and accommodation; not a medical prescription.

Hart ChartHart chart / columnar saccade chart

A chart with columns of letters or numbers used to train and measure saccadic scanning.

Use: Have the student read each column top-to-bottom, then move left-to-right across columns. Time the run and count errors. Increase density as performance improves.

Curriculum-neutral; can be made with simple paper or purchased from vision-therapy suppliers.

Marsden ballMarsden ball (ball on a string)

A ball on a string used to train pursuits, fixation, and gaze stability.

Use: Swing the ball in horizontal, vertical, and circular planes while the child keeps the eyes on the ball and minimizes head movement. Progress from slow to fast and from single to dual planes.

Stop if dizziness, nausea, or headache occur.

Brock stringBrock string convergence trainer

A string with colored beads used to teach awareness of convergence and single vision at near.

Use: Hold one end to the nose, place beads at various distances, and ask the child to look at one bead so it appears single and the other beads split into two images. Use under optometric direction.

Stop if diplopia or headache persists. OT-scope only; does not replace office-based vision therapy.

cpmCycles per minute

A rate measure used most often for accommodative facility (lens flipper tasks).

Use: Count how many times the child can clear a plus lens and then a minus lens in one minute while looking at a near target. Compare to optometrist target or age expectation.

Administered by optometry; OT may track the result.

VOMSVestibular/Ocular Motor Screening

A brief, validated clinical screen of smooth pursuits, saccades, convergence, and vestibular-ocular reflex (VOR) used in concussion and mild TBI assessment.

Use: Use as a documented rule-out screen within the first 90 days after injury. OTs may administer the oculomotor components (pursuits, saccades, convergence) within scope; vestibular components are typically administered or reviewed with the medical concussion team, PT, or neuro-optometrist. A positive finding supports opening the post-concussion vision protocol.

VOMS is a screening tool, not a diagnostic test. Positive results should be triangulated with the Post-Concussion Vision Symptom Scale, CISS-15, and clinical observation.

Interventions & protocols

20/20/20 rule20/20/20 near-work break rule

A self-management habit: every 20 minutes, look at something 20 feet away for at least 20 seconds.

Use: Embed into classroom routines, visual timers, or student checklists. Start with shorter intervals for students with poor near endurance.

Reduces accommodative and vergence fatigue; does not replace optometric treatment.

CITTConvergence Insufficiency Treatment Trial

A large multisite randomized controlled trial that established office-based vergence therapy as the most effective treatment for convergence insufficiency.

Use: Cite as evidence when referring a child to optometric vision therapy. OT’s role is functional generalization, accommodation, and habit training — not delivery of the CITT protocol itself.

The full CITT protocol is optometry-led.

VTVision therapy / optometric vision therapy

A supervised, office-based rehabilitation program for accommodative, vergence, oculomotor, and visual-perceptual problems.

Use: OT can supplement VT with functional home programs, school accommodations, and endurance generalization, but OT does not replace office-based VT.

Refer to developmental optometry when VT is indicated.

Team members

ODOptometrist (Doctor of Optometry)

A primary-eye-care provider who evaluates refractive, accommodative, vergence, ocular-health, and developmental vision concerns.

Use: “OD-directed” in a protocol means the optometrist leads the medical/vision-therapy component; OT supports carryover, accommodations, and occupational performance.

OT does not prescribe, diagnose, or modify refractive management independently.

TVITeacher of Students with Visual Impairments

An educator who specializes in vision-related accommodations, braille, assistive technology, and Expanded Core Curriculum.

Use: Partner with the TVI for students with CVI, low vision, or blindness. OT focuses on occupational performance; TVI focuses on vision-specific instruction and access to curriculum.

COMSCertified Orientation and Mobility Specialist

A specialist who teaches safe, independent travel to children with visual impairment.

Use: Coordinate with COMS when low vision or field loss affects safe mobility in school or community.

Conditions

VORVestibulo-Ocular Reflex

The reflex that keeps images stable on the retina while the head moves.

Use: “VOR × 1” exercise: the child keeps the eyes fixed on a target while moving the head side-to-side or up-down. Used in post-concussion vision-vestibular rehab.

Stop if dizziness or nausea worsens; coordinate with PT/physician when indicated.

mTBImild Traumatic Brain Injury (concussion)

A mild traumatic brain injury, commonly called concussion, that can disrupt visual, oculomotor, and vestibular function.

Use: Use symptom-guided dosing and return-to-learn staging. OT operates within scope on occupational participation; physician clearance is required for return-to-play.

HIEHypoxic-Ischemic Encephalopathy

Brain injury caused by insufficient oxygen and blood flow around birth.

Use: One of several medical conditions associated with CVI risk. Document history; do not attribute current functional vision solely to HIE without medical input.

PVLPeriventricular Leukomalacia

Brain injury affecting white matter near the ventricles, a common CVI-associated diagnosis.

Use: Note in the medical history and coordinate with medical, TVI, and early-intervention teams.

Scope note: Outcome measures should be administered and interpreted per their publisher manuals. OTs do not independently diagnose, prescribe, or deliver optometric vision-therapy protocols; coordinate with developmental optometry when indicated.

Visual Access — Near Acuity

Protocol · near acuity

3 lines

Long-term goal (9 wk)

Within 9 weeks, wearing best-corrected prescription as prescribed by the treating eye care provider, during grade-level near work in the classroom, [Student] will complete a 20-minute reading and worksheet block using established visual access accommodations (print size/enlargement, magnification or assistive technology, contrast, task lighting, working distance) with setup cues only, on 4 of 5 opportunities, to support classroom participation.

Short-term objectives

Within 4 weeks, wearing best-corrected prescription, during a seated near task at 40 cm, [Student] will complete 5 minutes of grade-level near work with the identified print-size, lighting, and magnification supports in place with one verbal cue, on 3 of 4 trials.
Within 6 weeks, during a 10-minute near-work task, [Student] will maintain the Harmon working distance (elbow-to-page) with intermittent verbal cues, for 90% of the task across 3 consecutive sessions.
Within 8 weeks, before beginning classroom near work, [Student] will set up their own accommodations (task lighting, enlarged or digital text, contrast, seating/position, magnifier or device zoom) independently, on 4 of 5 opportunities.

Progression criteria

Two consecutive sessions of stable Harmon distance with supports in place and no new symptom report → increase duration by 25%.
Independent application of accommodations across 3 sessions → fade cues.

Regression criteria

Return of squint / tilt / working-distance drift for 2 sessions → reduce duration and reintroduce environmental modifications.
New spontaneous complaints of blur or headache → pause, re-coordinate with optometry.

Discharge criteria

Meets LTG for 3 consecutive weeks with generalization across ≥ 2 school settings (classroom + one other).
Teacher / caregiver report of independent management for 4 weeks.
VPA™ rescore of the target skill within the expected range for the age band, with the supports in place.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
Teacher observation checklist for classroom participation

Precautions: Work from best-corrected acuity only. OT does not prescribe, modify, or set goals to change refractive correction, clarity, or blur. Coordinate with developmental optometry — OT does not prescribe or modify refractive correction. Rule out uncorrected refractive error before addressing performance components; a change in reported blur is a referral trigger, not an OT goal area.

Contraindications: Active photophobia or acute post-concussion visual symptoms — defer intensive near-work until cleared.

Intervention lines

Magnification & accessible-format access

Evidence II

Trial and train the access route that makes the detail resolvable at best-corrected vision: print enlargement to the student's measured comfortable size, digital text with adjustable zoom, stand/handheld magnifier for spot tasks (labels, rulers, maps), photograph-the-board capture, and audio/text-to-speech for high-volume reading. OT trains use and fit to the occupation; the eye care provider prescribes optical devices.

AOTA Practice Guidelines: Low Vision, 2020; AOTA AT position paper, 2016

Frequency: Daily use; 1× / week training during trial phase
Intensity: Low — training and setup
Time: 15–20 min training sessions
Type: Assistive technology / adaptive equipment training
Progression: Advance from adult-set magnification to student-selected access route across ≥ 2 settings; fade training once independent for 3 consecutive weeks.

Home program: One-page guide to the student's access route (print size, device zoom settings, magnifier use) for homework.

Environmental & task modification

Evidence II

Harmon working distance, task lighting, matte paper, high-contrast copies, print enlargement, slant board, scheduled micro-breaks (20/20/20 rule).

AOTA Practice Guidelines: Low Vision, 2020; Warren, 1993

Frequency: Daily (embedded in classroom routine)
Intensity: Passive — student maintains setup
Time: All near-work tasks
Type: Environmental / ergonomic
Progression: Fade cues as student independently sets up workstation across ≥ 3 settings.

Home program: Parent letter with 20/20/20 rule diagram, workstation photo, and 2-minute setup routine.

Client / caregiver / teacher education

Evidence II

Explicit teaching of near-work signs of fatigue, blur, and posture drift; when to prompt breaks; and how to advocate for accommodations.

AOTA OTPF-4; Feder & Majnemer, 2007

Frequency: 1× / week during consult
Intensity: Low — didactic
Time: 10–15 min
Type: Consultation / caregiver training
Progression: Fade to as-needed check-ins once teacher/caregiver independently identifies and responds to symptoms.

Visual Access — Contrast Sensitivity

Protocol · contrast

2 lines

Long-term goal (9 wk)

Within 9 weeks, wearing best-corrected prescription, during classroom instruction using low-contrast materials (photocopies, whiteboards, projected slides), [Student] will access and complete assigned work using their contrast accommodations (high-contrast print, bold writing tools, contrast/tint screen settings, task lighting, glare control) independently, on 4 of 5 opportunities, to support participation across the school day.

Short-term objectives

Within 4 weeks, wearing best-corrected prescription, when handed a faded copy or glare-affected board task, [Student] will identify the contrast barrier and request a modified format with one verbal cue, on 3 of 4 opportunities, to support classroom access.
Within 6 weeks, during classroom written work, [Student] will apply a personal contrast toolkit (dark pencil or bold marker, highlighter tape, contrast overlay, glare block, device contrast settings) independently, on 4 of 5 opportunities.

Progression criteria

Independent toolkit use in 3 consecutive sessions → fade prompts.

Regression criteria

Emergence of avoidance or refusal of low-contrast tasks → return to environmental modifications first.

Discharge criteria

Teacher confirms independent management across school day for 4 weeks.
Written COAST objective met on the identified contrast-loaded occupation.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
Teacher observation of participation in whiteboard / projected-slide tasks

Precautions: Work from best-corrected vision only. OT does not set goals to improve contrast sensitivity itself — goals target accommodations and access (high-contrast materials, bold tools, lighting, glare control, device contrast/tint settings). Coordinate with optometry — persistent or changing contrast difficulty warrants medical work-up.

Contraindications: Photophobia — introduce tints only after optometric clearance.

Intervention lines

Contrast enhancement toolkit

Evidence III

Bolder pencils / markers, highlighter tape for whiteboards, print-on-cream, tinted overlays (trial for individual preference), matte-finish laminate.

AOTA Low Vision Practice Guidelines, 2020

Frequency: Daily
Intensity: Passive
Time: All contrast-loaded tasks
Type: Environmental / adaptive equipment
Progression: Fade prompts as student self-initiates toolkit use.

Assistive-technology consultation

Evidence II

Screen-reader color inversion, digital contrast settings, tablet apps for capture-and-enlarge of whiteboard content.

AOTA AT position paper, 2016

Frequency: 1× / week during consult phase
Intensity: Low
Time: 20–30 min
Type: Consultation + training
Progression: Fade once student independently accesses AT for 3 consecutive weeks.

Visual Access — Stereopsis / Binocular Integration

Protocol · stereopsis

2 lines

Long-term goal (9 wk)

Within 9 weeks, wearing best-corrected prescription and following the treating optometrist's current recommendations, during near work and school mobility routines (stairs, playground, hallways), [Student] will complete assigned near work and move through the building using the agreed depth and alignment supports (seating, materials placement, handrail use, pacing), reporting double or blurred print to an adult when it occurs with supervision only, on 4 of 5 observations, to support academic participation and safety.

Short-term objectives

Within 4 weeks, during an optometrist-cleared carryover activity assigned by the treating optometrist, [Student] will complete 5 minutes of the assigned activity and log any symptoms with setup cues only, on 3 of 4 trials.
Within 8 weeks, during recess and building transitions, [Student] will navigate stairs and playground equipment without hesitation or excessive head tilt with supervision only, on 4 of 5 observations.

Progression criteria

Sustained diplopia-free anaglyph work at 5 min → advance to 10 min with cognitive load.

Regression criteria

Emergence of diplopia, headache, or suppression → stop, notify optometry, return to environmental / postural work.

Discharge criteria

Meets LTG; optometry documents stable binocular status.
VPA™ rescore stable or improved and the written objective met across 3 consecutive weeks.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
CISS-15 rescore
Optometric stereo-acuity follow-up

Precautions: Sensory fusion / anaglyph work only after developmental optometry has cleared ocular alignment and ruled out contraindicated strabismus subtypes. Anaglyph tasks are not a substitute for prescribed optometric vision therapy.

Contraindications: Active manifest strabismus without optometric oversight. Photosensitive epilepsy — avoid strobing anaglyph stimuli.

Intervention lines

Sensory-fusion (anaglyph) protocol — post-optometric clearance

Evidence II

Graded red/green anaglyph activities: gross localization → simple discrimination → sustained near-work with anaglyph text. Curriculum-neutral, OT-scope, after optometric clearance.

Cooper & Duckman, 1978; Scheiman & Wick, 2020

Frequency: 3× / week
Intensity: Moderate — stop at first symptom
Time: 5–15 min per session
Type: Sensory-fusion / anaglyph
Progression: Duration and complexity ↑ 25% every 2 symptom-free weeks.

Home program: 5-min daily anaglyph card + parent symptom log.

Environmental & postural support

Evidence II

Lighting, contrast, seating with lumbar support, stable working distance, and pre-mobility scanning routines for stairs / playground.

Warren, 1993

Frequency: Daily
Intensity: Passive
Time: All near-work + mobility
Type: Environmental
Progression: Fade cues as independence emerges.

Visual Efficiency — Convergence

Protocol · convergence

3 lines

Long-term goal (9 wk)

Within 9 weeks, wearing best-corrected prescription and following the treating optometrist's current recommendations, during grade-level near work in the classroom, [Student] will sustain a 20-minute near-work block using the agreed near-work supports (working distance, break schedule, task chunking), reporting no more than one symptom of near-work stress (blur, diplopia, headache, print swim) with setup cues only, on 4 of 5 school days, to support academic participation.

Short-term objectives

Within 4 weeks, during a 10-minute classroom near-work block, [Student] will complete the assigned work with the prescribed break schedule in place and report symptoms using the classroom symptom log with one verbal cue, on 3 of 4 opportunities.
Within 6 weeks, on the CISS-15 symptom survey, [Student] will report a symptom score at least 5 points below baseline with self-report support, ≥ 5-point decrease from baseline, to support near-work participation.
Within 8 weeks, during self-directed near work, [Student] will apply the 20/20/20 break rule independently, on 4 of 5 opportunities.

Progression criteria

3 consecutive symptom-free sessions at current dose → advance duration by 25% OR add cognitive load.
NPC break improves by ≥ 2 cm on repeat testing → advance target size / complexity.

Regression criteria

NPC break recedes ≥ 3 cm from baseline → step down to previous level and coordinate with optometry.
CISS-15 rises ≥ 5 points → pause and reassess.

Discharge criteria

NPC ≤ 6/10 cm sustained across 3 sessions AND CISS-15 in sub-threshold range for 4 weeks.
Written COAST objective met on the identified near-work occupation.
Optometry concurs with discharge or transitions to maintenance.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
CISS-15 (pre / post / q6wk)
NPC serial measurement

Precautions: OT-scope convergence work supplements — does not replace — optometric office-based vision therapy where indicated. Stop any exercise that produces sustained diplopia, headache, or nausea.

Contraindications: Active post-concussion with worsening vergence symptoms — coordinate with medical team first.

Intervention lines

Office-based vergence therapy referral + OT co-treatment

Evidence I

CITT/RCT-level office-based vergence therapy administered by developmental optometry; OT co-treats via near-work endurance, posture, and generalization to occupation.

CITT Study Group, 2008 (Arch Ophthalmol); Scheiman et al., 2011

Frequency: OD-directed (typically 1×/wk office); OT co-treat 1–2×/wk
Intensity: Moderate
Time: 45–60 min OD; 20–30 min OT
Type: Combined office-based VT + OT functional generalization
Progression: Per optometry; OT scales occupational demand as vergence measures improve.

OT-scope vergence supports (Brock string, pencil push-ups, near-far shift)

Evidence II

Curriculum-neutral vergence supports embedded into functional near-work sessions. Not a substitute for optometric VT when indicated.

Scheiman & Wick, 2020; Rouse et al., 2009

Frequency: 3–5× / week
Intensity: Low–moderate — stop at first sustained symptom
Time: 5–10 min warm-up + 15–20 min functional task
Type: Neuromuscular + functional near-work
Progression: ↑ duration or add reading load every 2 symptom-free weeks.

Home program: 5-min daily Brock string OR pencil push-ups + 20/20/20 rule reminder + symptom log.

Environmental / ergonomic + client education

Evidence II

Harmon distance, lighting, seating, and explicit teaching of symptom recognition and the 20/20/20 rule to student, caregiver, and teacher.

Feder & Majnemer, 2007; Warren, 1993

Frequency: Daily
Intensity: Passive
Time: All near-work
Type: Environmental / education
Progression: Fade cues as student self-manages.

Visual Efficiency — Accommodation

Protocol · accommodation

2 lines

Long-term goal (9 wk)

Within 9 weeks, wearing best-corrected prescription and following the treating optometrist's current recommendations, during sustained classroom near work, [Student] will complete a 20-minute work block with the agreed near-work supports in place, reporting no more than one symptom of near-work stress (blur, print swim, headache) with setup cues only, on 4 of 5 opportunities, to support classroom endurance.

Short-term objectives

Within 6 weeks, during a sustained 15-minute copying or reading task, [Student] will maintain the recommended working distance and complete the task without requesting an unscheduled break with intermittent verbal cues, on 3 of 4 opportunities.
Within 8 weeks, during self-directed near work, [Student] will initiate 20/20/20 breaks independently, on 4 of 5 opportunities.

Progression criteria

3 consecutive symptom-free sessions → ↑ duration or add task load.

Regression criteria

CISS-15 or symptom log worsens ≥ 5 pts → step down and re-coordinate.

Discharge criteria

Meets LTG for 3 consecutive weeks; optometrist confirms stable accommodative facility.
VPA™ rescore stable or improved and the written objective met across 3 consecutive weeks.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
CISS-15
Optometrist accommodative-facility retest (cpm)

Precautions: Accommodative rehabilitation is optometry-led; OT contribution is functional generalization and habits. Discontinue any exercise that produces sustained blur, headache, or nausea.

Contraindications: Recent uncorrected refractive change — defer until optometry updates prescription.

Intervention lines

Optometric accommodative therapy referral

Evidence I

Developmental optometry directs accommodative rehab (lens flippers, plus/minus loose lenses, monocular/binocular facility work).

Scheiman & Wick, 2020; Marran et al., 2006

Frequency: Per optometry
Intensity: OD-directed
Time: OD-directed
Type: Office-based accommodative therapy
Progression: Per optometry.

OT-scope near-far transfer + task rotation

Evidence II

Structured near ↔ intermediate ↔ far task rotation embedded in classroom-relevant occupations to prevent accommodative fatigue.

Scheiman & Wick, 2020

Frequency: Daily
Intensity: Low
Time: Every 20 min of near-work → 20 sec at ≥ 20 ft
Type: Habit / routine
Progression: Fade prompts as student self-initiates.

Visual Efficiency — Place Keeping & Visual Search

Protocol · saccades

1 line

Long-term goal (9 wk)

Within 9 weeks, when reading a grade-level paragraph aloud in class, [Student] will track across text lines with no more than 2 regressions per 100 words with setup cues only, on 4 of 5 opportunities, to support classroom reading fluency.

Short-term objectives

Within 4 weeks, during a Hart Chart or column-scan task, [Student] will complete the scan at the target rate with fewer than 2 regressions with one verbal cue, on 3 consecutive sessions.
Within 6 weeks, on a DEM or King-Devick-style scan co-measured with optometry, [Student] will complete the scan with improved timing with examiner cueing per protocol, ≥ 15% improvement from baseline, to support classroom reading.

Progression criteria

Baseline error rate halved on 3 sessions → progress to next stimulus density.

Regression criteria

Regression rate ↑ 25% for 2 sessions → step down.

Discharge criteria

Meets LTG; teacher reports fluent oral reading; the written COAST objective met.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
Timed oral reading fluency
DEM / King-Devick (OD-collected)

Precautions: Coordinate with optometry when place-keeping breakdown occurs alongside vergence or near-focus symptoms.

Contraindications: Active post-concussion with worsening oculomotor symptoms.

Intervention lines

Place keeping and visual search ladder — column scan → dense text → worksheet navigation

Evidence II

Graded reading and search density (large columns → text density → cluttered worksheet) with generalization into classroom reading and copying.

Scheiman & Wick, 2020; Ayton et al., 2009

Frequency: 3× / week
Intensity: Moderate
Time: 15–20 min
Type: Reading navigation + visual search generalization
Progression: ↑ stimulus density every 2 sessions of criterion performance.

Home program: 3-min daily column-scan card.

Visual Efficiency — Pursuits

Protocol · pursuits

1 line

Long-term goal (9 wk)

Within 9 weeks, during NSUCO-format pursuit observation in horizontal, vertical, and circular planes, [Student] will follow the target without head substitution with setup cues only, on 3 consecutive administrations, to support playground safety and reading progression.

Short-term objectives

Within 4 weeks, during a 60-second Marsden ball or moving-target pursuit task, [Student] will follow the target with no more than one loss of fixation with one verbal cue, on 3 consecutive sessions.

Progression criteria

3 criterion sessions → add cognitive load (naming task during pursuit).

Regression criteria

Return of head-dominant tracking → step down to gentler plane.

Discharge criteria

NSUCO pursuit rating ≥ 4 across planes for 4 weeks; the written COAST objective met.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
NSUCO ratings (serial)

Precautions: Coordinate with optometry for suspected cranial-nerve or neuro-visual involvement.

Contraindications: Active post-concussion with symptom exacerbation.

Intervention lines

Pursuit training ladder — Marsden ball → figure-8 → metronome-paced

Evidence II

Graded pursuit training from evaluator-paced large targets to metronome-paced dual-task figure-8.

Maples, 1995 (NSUCO); Scheiman & Wick, 2020

Frequency: 3× / week
Intensity: Moderate
Time: 10–15 min
Type: Ocular-motor
Progression: ↑ speed / dual-task load every 2 criterion sessions.

Visual Efficiency — Fixation Stability

Protocol · fixation

1 line

Long-term goal (9 wk)

Within 9 weeks, during reading and copying tasks with typical classroom noise and movement, [Student] will hold fixation on the target for 30 seconds without drift independently, on 3 consecutive sessions, to support reading and copying accuracy.

Short-term objectives

Within 4 weeks, during a dual-task fixation activity with counting as the distractor, [Student] will sustain 20 seconds of fixation with no more than one refixation with one verbal cue, on 3 of 4 trials.

Progression criteria

3 criterion sessions → add complexity / postural challenge.

Regression criteria

Increase in refixations → remove cognitive load first.

Discharge criteria

Meets LTG; the written COAST objective met.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
NSUCO fixation subrating

Precautions: Photosensitive epilepsy — avoid strobing stimuli.

Contraindications: Nystagmus without optometric management plan.

Intervention lines

Graded fixation drills + postural challenge

Evidence II

Dot / Marsden ball fixation with progressive duration, cognitive load, and postural instability (balance disc).

Scheiman & Wick, 2020; Maples, 1995

Frequency: 3× / week
Intensity: Low–moderate
Time: 10 min
Type: Ocular-motor + postural
Progression: ↑ time or add balance component every 2 criterion sessions.

Visual Processing — Discrimination

Protocol · discrimination

1 line

Long-term goal (9 wk)

Within 9 weeks, during classroom decoding and math tasks, [Student] will discriminate confusable letters and numbers (b/d, p/q, 6/9) accurately independently, at ≥ 95% accuracy on 4 of 5 opportunities, to support reading and math accuracy.

Short-term objectives

Within 4 weeks, on a 10-item confusable letter-pair worksheet, [Student] will mark the target letters correctly with setup cues only, at ≥ 90% accuracy across 3 sessions, to support classroom accuracy.

Progression criteria

Criterion accuracy 3 sessions → generalize into decoding tasks.

Regression criteria

Error rate rises ≥ 20% → step down to matched-pair sort.

Discharge criteria

Meets LTG in classroom context; the written COAST objective met.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
Curriculum-based reading accuracy sample

Precautions: Rule out uncorrected refractive error before extended perceptual training.

Intervention lines

Graded discrimination ladder + tactile letter formation

Evidence II

Sorting/matching drills with progressive similarity, tactile letter formation (sand tray / rice bin / air-write) to strengthen visual-motor memory of letter forms.

Schneck, 2010; Feder & Majnemer, 2007

Frequency: 3× / week
Intensity: Low–moderate
Time: 15 min
Type: Perceptual + tactile
Progression: ↑ distractor similarity every 2 criterion sessions.

Home program: 5-min daily confusable-pair worksheet + tactile letter tray.

Visual Processing — Figure–Ground

Protocol · figure ground

1 line

Long-term goal (9 wk)

Within 9 weeks, on grade-level dense worksheets and textbook pages, [Student] will locate the target information independently, within 125% of peer time on 4 of 5 opportunities, to support independent classroom work completion.

Short-term objectives

Within 6 weeks, during a hidden-picture or embedded-figures task, [Student] will find all targets within age-expected time with setup cues only, on 3 consecutive sessions.

Progression criteria

Age-expected time on 3 sessions → advance density.

Regression criteria

Frustration / task refusal → reduce density and reintroduce color cueing.

Discharge criteria

Meets LTG; teacher observation confirms.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
Timed worksheet completion vs. peer norm

Intervention lines

Graded figure–ground ladder — color cue → grayscale → text density

Evidence II

Hidden-picture / letter-search / word-search tasks with progressive density and reduced color cueing.

Schneck, 2010

Frequency: 3× / week
Intensity: Low–moderate
Time: 10–15 min
Type: Perceptual
Progression: ↓ color cue every 2 criterion sessions.

Visual Processing — Closure

Protocol · visual closure

1 line

Long-term goal (9 wk)

Within 9 weeks, during grade-level reading and worksheet tasks, [Student] will recognize partially obscured words and shapes at grade-level speed independently, on 4 of 5 classroom tasks, to support reading efficiency.

Short-term objectives

Within 6 weeks, on partial-picture and partial-word closure tasks, [Student] will identify the whole item with setup cues only, at ≥ 90% accuracy across 3 sessions, to support classroom accuracy.

Progression criteria

Criterion accuracy → increase occlusion / decrease reveal.

Regression criteria

Guessing behavior → increase reveal and add strategy prompts.

Discharge criteria

Meets LTG; the written COAST objective met.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)

Intervention lines

Graded closure ladder — partial reveal → progressive occlusion

Evidence III

Partial-picture / partial-word / diagram-interpretation tasks.

Schneck, 2010; Martin, 2017 (TVPS-4)

Frequency: 3× / week
Intensity: Low
Time: 10 min
Type: Perceptual
Progression: ↑ occlusion every 2 criterion sessions.

Visual Processing — Memory

Protocol · visual memory

1 line

Long-term goal (9 wk)

Within 9 weeks, during board-to-paper copying and spelling tasks, [Student] will retain and reproduce 5-symbol or 5-word sequences from a 5-second exposure independently, at ≥ 90% accuracy on 4 of 5 opportunities, to support copying and written recall.

Short-term objectives

Within 6 weeks, on a sequential visual memory task, [Student] will recall the sequence in order with setup cues only, increasing span by ≥ 2 items from baseline, to support classroom copying.

Progression criteria

Criterion span 3 sessions → ↑ delay or interference.

Regression criteria

Span drops → reduce delay and reintroduce chunking cues.

Discharge criteria

Meets LTG; classroom copy speed improves.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
Board-to-paper timed copy sample

Intervention lines

Visual memory ladder — look-cover-write, memory matrix, delayed recall

Evidence II

Graded memory tasks with escalating span, delay, and interference; cross-modal auditory pairing to strengthen encoding.

Martin, 2017; Schneck, 2010

Frequency: 3× / week
Intensity: Low–moderate
Time: 10–15 min
Type: Perceptual + cognitive
Progression: ↑ span, delay, or interference every 2 criterion sessions.

Home program: 5-min daily flashcard chain + look-cover-write.

Visual Processing — Form Constancy

Protocol · form constancy

1 line

Long-term goal (9 wk)

Within 9 weeks, across classroom materials using varied fonts, sizes, and orientations, [Student] will identify letters and numbers correctly independently, at ≥ 95% accuracy on 4 of 5 classroom tasks, to support reading across materials.

Short-term objectives

Within 6 weeks, on a multi-font identity-sort worksheet, [Student] will sort the items correctly with setup cues only, at ≥ 90% accuracy across 3 sessions, to support classroom accuracy.

Progression criteria

Criterion accuracy → ↑ font / rotation variability.

Regression criteria

Reversal errors persist → reintroduce tactile letter formation.

Discharge criteria

Meets LTG; b/d/p/q errors resolve in written output.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
Handwriting sample reversal count

Intervention lines

Multi-font sort + tactile letter formation

Evidence II

Sorting letters/shapes by IDENTITY across fonts, sizes, rotations; paired with tactile letter tray and multisensory formation.

Schneck, 2010; Feder & Majnemer, 2007

Frequency: 3× / week
Intensity: Low–moderate
Time: 10–15 min
Type: Perceptual + tactile
Progression: ↑ variability every 2 criterion sessions.

Visual Processing — Spatial Relations

Protocol · spatial relations

1 line

Long-term goal (9 wk)

Within 9 weeks, during math, directional worksheets, and map or diagram tasks, [Student] will align columns, follow directional cues, and interpret simple diagrams independently, at ≥ 90% accuracy on 4 of 5 classroom tasks, to support math accuracy and written organization.

Short-term objectives

Within 6 weeks, on rotation-match and block-design copy tasks, [Student] will reproduce the target arrangement with setup cues only, at ≥ 90% accuracy across 3 sessions, to support classroom accuracy.

Progression criteria

Criterion accuracy → ↑ rotation angle and design complexity.

Regression criteria

Loss of orientation → return to explicit directional-language cueing.

Discharge criteria

Meets LTG; math and map tasks completed independently.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
Curriculum-based math alignment sample

Intervention lines

Directional-language + block-design ladder

Evidence II

Explicit directional-language work paired with graded block-design copies, rotation-match, and map/graph tasks.

Cornhill & Case-Smith, 1996; Schneck, 2010

Frequency: 2–3× / week
Intensity: Low–moderate
Time: 15 min
Type: Perceptual + language
Progression: ↑ rotation / complexity every 2 criterion sessions.

Visual-Motor Integration & Handwriting Readiness

Protocol · visuomotor

2 lines

Long-term goal (9 wk)

Within 9 weeks, during a 5-minute grade-level writing task, [Student] will produce legible written output for size, spacing, and alignment independently, at ≥ 90% legibility on 4 of 5 opportunities, to support classroom written expression.

Short-term objectives

Within 4 weeks, on a curriculum-neutral shape-copy measure (or an optometry-collected Beery VMI parallel form), [Student] will copy the forms accurately with setup cues only, improving by ≥ 5 standard-score points or reaching ≥ 90% grade-level accuracy, to support classroom written output.
Within 6 weeks, during a 3-minute classroom copy task, [Student] will apply spacing, sizing, and alignment strategies independently, on 3 consecutive sessions.
Within 8 weeks, during board-to-paper (far-to-near) copying, [Student] will complete the copy task at classroom pace with setup cues only, reaching ≥ 80% of peer rate.

Progression criteria

≥ 90% shape-copy accuracy 3 sessions → advance to sentence copy.
≥ 90% legibility on 3-min sample → advance to 5-min sample.

Regression criteria

Legibility drops ≥ 20% for 2 sessions → step down and reintroduce vertical-surface warm-up.
Emergence of hand fatigue / grip changes → reassess grasp and posture.

Discharge criteria

Meets LTG for 3 consecutive weeks in classroom writing.
Teacher confirms independent legibility management for 4 weeks.
VPA™ rescore of visual-motor integration within the expected range and a scored handwriting sample showing the targeted change.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
Beery VMI (OT- or OD-collected)
Handwriting legibility sample (size / spacing / alignment scored)

Precautions: Curriculum-neutral: OT does not deliver proprietary handwriting programs beyond scope and licensing. Coordinate with classroom writing instruction. Rule out grasp / postural / core-strength contributors before attributing legibility issues purely to VMI.

Intervention lines

Graded shape / symbol copy ladder

Evidence II

Preschool shapes → elementary shape set → oblique/complex forms → sentence copy → board-to-paper transfer. Vertical-surface warm-ups (chalkboard/whiteboard) before near-paper tasks.

Beery & Beery, 2010; Daly, Kelley & Krauss, 2003; Cornhill & Case-Smith, 1996

Frequency: 2–3× / week
Intensity: Moderate
Time: 20–30 min
Type: Visual-motor + handwriting readiness
Progression: ↑ complexity every 2 criterion sessions.

Home program: 5-min daily shape / sentence copy + vertical warm-up on window / easel.

Postural + workstation foundation

Evidence II

Feet-flat seating, forearm support, paper angle, non-dominant stabilizer hand, Harmon working distance; pre-writing warm-up (proximal → distal).

Feder & Majnemer, 2007

Frequency: Daily
Intensity: Passive
Time: All writing tasks
Type: Environmental / ergonomic
Progression: Fade cues as student self-establishes.

Visual-Motor — Executive-Visuospatial Planning

Protocol · clock planning

1 line

Long-term goal (9 wk)

Within 9 weeks, during multi-step graphic tasks (organizers, diagrams, extended written responses), [Student] will plan and execute the task to completion independently, at ≥ 80% completion on 4 of 5 opportunities, to support written organization and work completion.

Short-term objectives

Within 6 weeks, on a graphic-organizer task, [Student] will use a plan-do-check strategy with one verbal cue, on 3 consecutive sessions, to support classroom work completion.

Progression criteria

Independent strategy use 3 sessions → fade cues.

Regression criteria

Loss of structure → reintroduce checklist / graphic scaffold.

Discharge criteria

Meets LTG; classroom teacher confirms.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
Serial CDT (documented, not diagnostic)

Precautions: Failure ≥ 4 of 5 CDT criteria in older students → coordinate with neuropsychology / medical team.

Intervention lines

Plan-Do-Check strategy training with graphic organizers

Evidence II

Explicit metacognitive strategy training embedded in classroom-relevant graphic tasks (organizers, timelines, essay maps).

Missiuna & Mandich, 2001 (CO-OP); Toglia, 2005

Frequency: 1–2× / week
Intensity: Moderate
Time: 20–30 min
Type: Cognitive strategy
Progression: Fade prompts as strategy internalizes.

Functional Integration — Reading + Writing Endurance

Protocol · reading endurance

1 line

Long-term goal (9 wk)

Within 9 weeks, during a grade-level near-work block combining reading and generative writing, [Student] will sustain 20 minutes of work reporting no more than one symptom episode with setup cues only, on 4 of 5 school days, to support academic participation.

Short-term objectives

Within 4 weeks, during a combined 5-minute reading and 2-minute writing block, [Student] will sustain the block symptom-free with setup cues only, on 3 consecutive sessions.
Within 8 weeks, during a combined 10-minute reading and 5-minute writing block, [Student] will sustain the block with no more than one symptom episode with setup cues only, on 3 consecutive sessions.

Progression criteria

Criterion duration 3 sessions → ↑ 25% duration.

Regression criteria

≥ 2 symptom episodes in a session → step down 25%.

Discharge criteria

Meets LTG for 3 consecutive weeks.
VPA™ rescore stable or improved with teacher-reported participation in the target academic task.
Teacher confirms independent management for 4 weeks.

Outcome measures

VPA™ rescore of the target skill (baseline / mid-cycle / 9 weeks)
Progress on the written COAST objective (met / partially met / not met)
CISS-15 / VSS-School (serial)
Sustained on-task time from classroom observation

Precautions: Address any Domain 1 / 2 underlying deficits concurrently — endurance work assumes stable access + efficiency.

Contraindications: Active post-concussion with symptom exacerbation — begin with sub-symptom-threshold pacing.

Intervention lines

Graded near-work endurance protocol

Evidence II

Time-based near-work ladders pairing sustained reading with age-matched functional writing; posture setup, prescribed micro-breaks (20/20/20), graded linguistic load.

Borsting et al., 2003 (CIRS); Scheiman & Rouse, 2006; Feder & Majnemer, 2007

Frequency: 3–5× / week
Intensity: Moderate — stop or step down at symptom threshold
Time: 10 min → 30 min over 9 weeks
Type: Functional integration
Progression: ↑ 25% duration every 2 symptom-free sessions.

Home program: Home reading log with symptom column; 5-min pre-reading warm-up.

Key abbreviations in the templates below

NPC = near point of convergence; Hart chart = saccade training chart; NSUCO = NSU College of Optometry oculomotor test; Harmon working distance = elbow-to-page distance; 20/20/20 rule = every 20 min, look 20 ft away for 20 sec. See the full Abbreviation & outcome-measure guide at the top of the page for administration and scoring details.

Level 1

Visual Access

Foundational input — acuity and contrast. Without access, all downstream skills over-report deficits.

Near Acuity (best corrected)

VPA finding: With best-corrected acuity known, student shows postural compensations, avoidance, or reduced output at 40 cm.

Long-term goal (9 wk)

Within 9 weeks, student will complete grade-level near-point occupational tasks (reading, writing, worksheet) for 15 continuous minutes using established access supports (print size, contrast, lighting, magnification, working distance), 4/5 trials.

Short-term objectives

Tolerate near-point tasks with prescribed correction and Harmon working distance for 5 minutes, 3/4 trials.
Independently select and set up the identified access supports (enlargement or magnification, lighting, contrast) before near work, 4/5 opportunities.
Demonstrate correct posture (feet flat, elbow flexion, 16" working distance) with cue in ≤1 verbal prompt across a 10-minute writing task.

Intervention menu

Refer to developmental optometry (highest priority).
Compensatory: relative size (print enlargement), relative distance, magnification, contrast enhancement.
Environmental: task lighting audit, glare control, matte paper.
Postural: Harmon distance training, seating / footrest setup.
Slant board trial for near-work.

Dose

1× / week direct OT + daily 5-min classroom accommodation trials.

Progress monitoring

Log support use and near-task output/avoidance; re-observe functional performance every 8 weeks. Acuity itself is re-measured by eye care, not OT.

Referral

Yes — developmental optometry before intensive intervention.

Scope

OT works from best-corrected acuity. Goals target compensatory access — enlargement, magnification, contrast, lighting, distance — never improved clarity or reduced blur.

Contrast Sensitivity

VPA finding: Fatigue or avoidance with faded print, whiteboards, low-contrast worksheets.

Long-term goal (9 wk)

Within 9 weeks, student will independently complete high- and standard-contrast classroom worksheets with equivalent accuracy (±10%) across 5 consecutive sessions.

Short-term objectives

Identify preferred contrast overlay and use independently in 4/5 sessions.
Tolerate whiteboard-to-paper copy task for 5 minutes with ≤2 loss-of-place errors.

Intervention menu

Refer to optometry / neuro-visual assessment.
Tinted overlay trial (yellow, blue, gray).
Matte paper, glare-control lighting, seating away from window glare.
High-contrast marker/pencil selection.

Dose

Environmental accommodations daily; OT consult 1× / 2 weeks.

Progress monitoring

Contrast preference log; teacher rating of fatigue on 5-point scale weekly.

Scope

OT modifies the task and environment (contrast enhancement, glare control, overlays) to support performance. OT does not set goals to change contrast sensitivity itself — that is measured and managed by eye care.

Level 2

Visual Efficiency

Ocular-motor mechanics — fixation, pursuits, saccades, convergence.

Fixation Stability

VPA finding: Drift, refixation, or head-dominant stabilization during attention-loaded near tasks.

Long-term goal (9 wk)

Within 9 weeks, student will maintain steady fixation on a near target for 30 seconds under mild cognitive load, 4/5 trials.

Short-term objectives

Maintain fixation on a 1-cm target at 40 cm for 20 seconds without loss, 3/4 trials.
Maintain fixation while performing a paired auditory task (counting), 3/4 trials.

Intervention menu

Marsden ball fixation drills.
Dot-target work with graded distraction.
Balance-plus-fixation (tandem stance, disc).
Progress to fixation under cognitive load.

Dose

2× / week direct OT × 5 min blocks; home program 3× / week.

Progress monitoring

Fixation duration in seconds, weekly.

Smooth Pursuits

VPA finding: Jerky pursuits, head movement dominance, loss of place while tracking.

Long-term goal (9 wk)

Within 9 weeks, student will demonstrate smooth pursuit tracking in H, V, and circular planes without head movement, 4/5 trials (NSUCO ≥ 4).

Short-term objectives

Track a slow-moving target 45° H without head turn in 3/4 trials.
Track text-scan target across a single line for 30 seconds without loss of place.

Intervention menu

Pursuit drills — H / V / circular planes.
Marsden ball, laser tag activities.
Metronome-paced progression from evaluator-set → 60 bpm.
Progress to text-scan targets.

Dose

2× / week direct OT × 5–8 min; classroom teacher does 1-min warm-up before reading.

Progress monitoring

NSUCO (NSU College of Optometry oculomotor test) pursuit score every 4 weeks; re-run VPA Pursuits section at 8 weeks.

Saccadic Tracking

VPA finding: Line-skipping, place-losing, finger-tracking during reading.

Long-term goal (9 wk)

Within 9 weeks, student will complete grade-level Hart chart (saccade training chart) at ≥ target rate for grade with ≤ 2 errors, 4/5 trials.

Short-term objectives

Complete large-target saccade drill (12" separation) accurately in 3/4 trials.
Read one grade-level paragraph without finger tracking, 3/5 trials.

Intervention menu

Hart chart (saccade training chart) columnar reading.
Metronome-paced text scans.
Progress: large targets → letter-density stimuli.
Line-guide fading protocol.

Dose

2× / week direct OT × 5 min; daily 2-min Hart chart (saccade training chart) in classroom.

Progress monitoring

Hart chart time & error count weekly.

Convergence (Screening Observation)

VPA finding: NPC (near point of convergence) screening break > 6 cm, near-work fatigue, blur or doubling reports, reading avoidance.

Long-term goal (9 wk)

Within 9 weeks, student will sustain 15 minutes of grade-level near work with no more than one fatigue or blur report and no drop in written output, 4/5 sessions.

Short-term objectives

Complete a 10-minute near reading block with ≤ 1 self-reported symptom, 3/4 trials.
Maintain legible written output across a 10-line copy task using taught pacing breaks, 3/4 trials.

Intervention menu

Refer to developmental optometry first; vergence remediation is optometry-led.
OT scope: graded near-work duration, 20/20/20 pacing, scheduled visual breaks.
Workstation, posture, lighting, and working-distance audit.
Print size, spacing, line guides, and reduced copying load in the classroom.
Support optometrist-prescribed home vergence work as carryover only, under written direction.

Dose

1× / week OT check-in + daily classroom pacing and adaptation trials.

Progress monitoring

Minutes of tolerated near work and symptom checklist weekly; re-screen NPC observation at 6 weeks.

Referral

Yes — developmental optometry.

Level 3

Visual Processing

Perceptual processing — discrimination, figure-ground, closure, spatial, memory, form constancy.

Visual Discrimination

VPA finding: Letter / number confusion (b/d, p/q, 6/9) beyond age 7.

Long-term goal (9 wk)

Within 9 weeks, student will discriminate confusable letter/number pairs with ≥ 90% accuracy in a 30-item timed task.

Short-term objectives

Sort mixed b/d/p/q set with 100% accuracy on tactile-cued trials, 3/4 sessions.
Complete graded discrimination worksheet (similar shapes) with ≥ 80% accuracy.

Intervention menu

Graded sorting/matching drills.
Targeted letter-pair discrimination.
Tactile letter formation (sand tray, textured letters).
Font-variety exposure.

Dose

3× / week × 10 min integrated with handwriting block.

Progress monitoring

Timed discrimination probe every 4 weeks.

Figure–Ground

VPA finding: Overwhelm on cluttered worksheets, textbooks, word searches.

Long-term goal (9 wk)

Within 9 weeks, student will independently locate target items in age-appropriate cluttered arrays within grade-normed time, 4/5 trials.

Short-term objectives

Complete hidden-picture puzzle at graded density with ≤ 1 skip, 3/4 trials.
Use window / highlighter strategy independently in 3/5 classroom tasks.

Intervention menu

Hidden-picture puzzles (graded density).
Letter/shape searches on graded backgrounds.
Worksheet-density modification (chunk / mask).
Window template or highlighter strategy.

Dose

2× / week × 10 min direct + daily classroom accommodation.

Progress monitoring

Time-to-find on standardized array every 4 weeks.

Visual Closure

VPA finding: Slow word recognition, difficulty with partial forms and math symbols.

Long-term goal (9 wk)

Within 9 weeks, student will recognize partially-occluded age-appropriate words and forms with ≥ 85% accuracy.

Short-term objectives

Complete dot-to-dot with missing segments in 3/4 trials without cueing.
Read partially-covered grade-level sight words with 80% accuracy.

Intervention menu

Partial-picture completion tasks.
Occluded-word reading drills.
Progressive-reveal guessing games.
Sight-word recognition with graded occlusion.

Dose

2× / week × 8 min direct.

Progress monitoring

Occluded-word probe every 4 weeks.

Spatial Relations

VPA finding: Reversals, math column misalignment, difficulty with maps and multi-step directions.

Long-term goal (9 wk)

Within 9 weeks, student will accurately align multi-digit math and follow 3-step spatial directions with ≥ 90% accuracy.

Short-term objectives

Copy block designs at grade level with ≤ 1 rotation error, 3/4 trials.
Follow 3-step directional prompts (above/below/beside) with 100% accuracy.

Intervention menu

Directional-language work (left/right, above/below).
Block-design copies.
Rotation matching tasks.
Graph paper for math column alignment.

Dose

2× / week × 10 min direct.

Progress monitoring

Block design or column-math probe every 4 weeks.

Visual Memory

VPA finding: Poor sight-word retention, math fact recall, copying accuracy from board.

Long-term goal (9 wk)

Within 9 weeks, student will recall visual sequences of age-appropriate length (grade-normed) with ≥ 85% accuracy.

Short-term objectives

Recall a 4-shape sequence after 10-second delay, 4/5 trials.
Complete look-cover-write on 5 sight words with ≥ 80% accuracy.

Intervention menu

Look-cover-write drills.
Memory matrix tasks (2×2 → 4×4).
Flashcard chaining.
Auditory-visual cross-modal pairing.

Dose

3× / week × 8 min direct; daily 3-min classroom warm-up.

Progress monitoring

Sequence-length probe every 4 weeks.

Form Constancy

VPA finding: Reversals past age 7, difficulty generalizing shapes across fonts/sizes/rotations.

Long-term goal (9 wk)

Within 9 weeks, student will identify target letters/shapes across ≥ 3 fonts and ≥ 2 rotations with ≥ 90% accuracy.

Short-term objectives

Sort multi-font letter set with 100% accuracy, 3/4 sessions.
Match rotated shapes to canonical form with 90% accuracy.

Intervention menu

Multi-font letter sorting.
Rotated shape matching.
Mirror/reversal discrimination games.
Tactile letter formation.

Dose

2× / week × 10 min integrated with handwriting.

Progress monitoring

Form constancy probe every 4 weeks.

Level 4

Visual-Motor Integration

Eye-hand output — the visual foundation under handwriting, copying, and drawing.

Visual-Motor Integration & Handwriting Readiness

VPA finding: Poor alignment, spacing, sizing, board-to-paper copy errors, inefficient worksheet output.

Long-term goal (9 wk)

Within 9 weeks, student will produce a grade-level 5-sentence writing sample with ≥ 90% legibility for sizing, spacing, and alignment.

Short-term objectives

Copy pre-writing shape sequence with correct proportions in 3/4 trials.
Board-to-paper copy of 3-line passage with ≤ 2 errors, 4/5 trials.
Maintain spacing (finger-space or spacing frame) across 3 sentences.

Intervention menu

Curriculum-neutral graded copying (shapes → letters → words → sentences).
Spacing / sizing frames, rulered-grid copying.
Vertical-to-horizontal transfer drills (chalkboard → paper).
5-minute visual-motor warm-up before writing tasks.
Postural setup + Harmon working distance (elbow-to-page distance).

Dose

2× / week direct OT + daily 5-min warm-up in classroom.

Progress monitoring

Handwriting legibility probe (sizing/spacing/alignment rubric) every 4 weeks.

Visual-Spatial Planning (Clock Drawing)

VPA finding: Clock-drawing errors suggesting visual-spatial planning or executive limits.

Long-term goal (9 wk)

Within 9 weeks, student will complete a plan-do-check drawing task with all planning components present, 4/5 trials.

Short-term objectives

Verbalize a 3-step drawing plan before starting, 3/4 trials.
Self-check completed drawing against model with ≥ 90% accuracy.

Intervention menu

Guided sequencing drawing tasks.
Drawing to verbal instruction.
Plan-do-check executive coaching.
Chunking complex figures into sub-plans.

Dose

1–2× / week × 10 min direct.

Progress monitoring

Clock-drawing or complex-figure probe every 6 weeks.

Referral

Consider neuropsych consult if severe or progressive.

Level 5

Functional Integration

Real-world endurance — the load test that reveals whether efficient sub-skills survive under classroom demand.

Reading Endurance & Fluency

VPA finding: Teacher reports 'shuts down after 10 minutes' — sub-skills collapse under load.

Long-term goal (9 wk)

Within 9 weeks, student will sustain grade-level near-reading task for 20 continuous minutes with prescribed micro-breaks and ≤ 15% fluency drop across the interval.

Short-term objectives

Sustain 5 minutes of grade-level reading with no postural break-down, 4/5 sessions.
Use taught 20/20/20 micro-break routine independently in 3/5 sessions.
Complete 10-minute reading task with fluency drop ≤ 20% from minute-1 baseline.

Intervention menu

Timed near-task ladders (5 → 10 → 15 → 20 min).
Prescribed micro-breaks (20/20/20 rule: every 20 min, 20 ft, 20 sec).
Posture / ergonomic setup (Harmon working distance, footrest, lighting).
Graded increases in duration AND text density.
Environmental audit of reading location.

Dose

3× / week × task-appropriate duration; daily classroom protocol.

Progress monitoring

Reading endurance timed probe (words per minute across intervals) every 4 weeks; symptom checklist bi-weekly.

Author: Jeff Foster, MS, OTR/L, EdD(ABD). Templates are examples, not prescriptions. Clinician retains professional responsibility for goal selection, dose, and interpretation.