A Frame of Reference for

Visual Perception
COLLEENM.SCHNECK

V isual perception is the total process responsible for the reception and cognition of visual stimuli (Zaba, 1984).
Some consider vision to be the most influential sense in humans. In fact, 70% of sensory receptors are allocated
to vision, thus leaving 30% to the other senses. Vision is one of the distant senses that allow a person to understand
what is occurring outside of his or her body or in extrapersonal space. Vision is a sensory receptor that feeds
information to the individual, which allows us to plan and adapt to the world. It is important for learning and
contributes to planning movement, as vision is needed as a guide until a motor plan is formed. ‘‘Seeing’’ involves
input from all the other senses. Vision does not work in isolation but rather as a dynamic system of intersensory
interactions. It is a process that requires interaction between the individual and his or her environment (Figure 11.1).
Skeffington (1963) was the first to propose a model that describes the visual process as the meshing of audition,
proprioception, kinesthesia, and body sense with vision. He proposed that visual perception is not obtained by vision
alone. It comes from combining visual skills with all other sensory modalities, including the proprioceptive and
vestibular systems. Through extension of Skeffington’s model, vision can be viewed as a dynamic blending of sensory
information in which new visual and motor input are combined with previously stored data and then used to guide a
reaction. Research demonstrates an expansive interconnectivity of sensory systems (Damasio, 1989; Thelen & Smith,
1994). Evidence of full brain activity when visualizing supports the concept that vision should be viewed within the
totality of all sensory systems.
In a recent study, visual deficits were found in 68% of typical seventh grade participants (Goldstand, Koslowe,
& Parush, 2005). Participants who passed a visual screening performed significantly better in visual perception than
those who failed, thus supporting the need to include a vision assessment for those experiencing visual perceptual
problems. In this study, the nonproficient readers had significantly poorer academic performance and vision screening
scores than proficient readers, again emphasizing the need to attend to vision (Goldstand, Koslowe, & Parush).
Because these visual perceptual problems can have serious ramification in limiting occupational participation well
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349

FIGURE 11.1 Infant using vision and touch to explore and learn about his toy.

beyond the school years (Brody, 1993; McLaughlin & Wehman, 1992), the importance of providing support services
and intervention for children who are experiencing academic difficulties cannot be overstated. Occupational
therapists (OTs) are often responsible for assessing and treating children to facilitate their learning at school when
visual perceptual problems are interfering with their academic learning.
Perceptual function is the interpretation of visual sensory information. If a problem exists in this area, it can
affect the child’s performance in areas of occupation (Lee, 2006). One important occupation of the child is being a
student. Students spend 30% to 60% of their school day on sustained reading, writing, and other desktop tasks
utilizing vision (McHale & Cermak, 1992; Ritty, Solan, & Cool, 1993). Information processing in the visual
perceptual domain has been identified as one of the major factors that can predict readiness for the first grade.
Perceptual and perceptual motor skills are important aspects of academic performance such as reading and writing
(Moore, 1979).
There are many other implications of visual perceptual problems on the occupations and life activities of children
in addition to education, which include activities of daily living (ADL), work, play, leisure, and social participation.
Functional problems that may result from visual perceptual issues in these areas include difficulties with eating,
dressing, locating objects in their desk, batting a ball and driving, to name a few. Therefore, it is important for OTs
to have a frame of reference to guide assessment and treatment in this area of practice.
THEORETICAL BASE

OTs have been influenced by cognitive and developmental psychology (Bandura, 1977; Gibson, 1969;
Gibson, 1966; Piaget, 1952, 1964; Massaro & Cowan, 1993; Miller, 1988), education (Frostig & Horne,
 Chapter11• AFrameofReferenceforVisualPerception 3
1973;
Kephart, 1971), neurology (Luria, 1980), and optometry (Getman, 1965; Scheiman, 2002; Skeffington,
1963) in developing a theoretical basis for understanding visual perceptual problems in children.
Developmental and acquisitional theories can be used in guiding change by OTs for children with visual
perception problems.
There are five basic assumptions made within the theoretical base of this frame of reference. These
assumptions are believed to be true and are not tested. They are as follows:
• Visual perception is a developmental process.
• Visual perceptual processing is learned and increases with development, experience,and practice, and
through stimulation from the environment (Figure 11.2).
• Children can learn by interacting with and observing adults and other children.
• Learning does not necessarily follow a developmental sequence. A deficit in one areadoes not predict
a deficit or problem in another area.
• Difficulty with visual perception can interfere with daily occupations including thedevelopment of
reading and writing skills.

FIGURE 11.2 Baby exploring and learning about his environment.

Developmental Theories
Developmental theories view the development of skills as occurring along a continuum. Skill
development is age dependent. See Table 11.1 for the developmental ages of visual perceptual skills.
 Chapter11• AFrameofReferenceforVisualPerception 4
Warren (1993a) presented a developmental hierarchy of visual perceptual skills using a bottom-up
approach to evaluation and treatment (Figure 11.3). She suggests that with knowledge of where the
deficit is located in the visual system, the therapist

Object (form)

Attention Exhibits longer visual attention span to complete school assignments by

11–12 yr

Visual memory Babies show significant visual memory ability by 6–7 mo (Rose, Feldman, &
Jankowski, 2001).
By 11–12 yr, expanded memory enables improved long-term recall

Form constancy Three-year-olds can sort objects on the basis of one dimension such as
shape, size, or color
Dramatic improvement in the children aged 6 and 7 yr; less improvement
from 8 to 9 yr of age (Williams, 1983)

Visual closure At 4 mo, an infant is able to perceive partially hidden objects as unitary
entities

Figure ground Improves between 3 and 5 yr of age; growth stabilizes at 6–7 yr of age
(Williams, 1983)

Spatial

Position in space Develops vertical to horizontal (3–4 yr) to oblique and diagonal (6 yr)
(Cratty, 1986)
Distinguish reversals (6 yr)
Left–right concept: own body (6–7 yr) (Cratty)
Directionality (8 yr)
Development complete (7–9 yr) (Williams, 1983)

Spatial relations Reaches accurately at 4–8 mo

Understanding of basic size by 3 yr
Understands concepts of space and time by 7 yr
Improves to approximately 10 yr of age (Williams, 1983)

Depth perception Evident at 2 mo, developed by 4–8 mo

Shows fear of falling off high places like changing table

Topographic orientation Improves to approximately 10 yr of age

 Chapter11• AFrameofReferenceforVisualPerception 5

Adaption
through vision

Visuocognition

Visual memory

Pattern recognition

Scanning

Attention = Alert and attending

Oculomotor control Visual fields Visual acuity

FIGURE 11.3 Hierarchy of visual perceptual skill development (Warren, 1993a).

could design appropriate evaluation and treatment strategies to remediate basic problems and improve perceptual
function. To do this, it is necessary for the OT to have an understanding of the visual system, including both the
visual receptive components and visual-cognitive components. Although Warren’s model presents a hierarchy of
skill development that is used to guide evaluation and treatment of visual perceptual dysfunction in adults with
acquired brain injuries, it is useful for children with visual perceptual deficits as well. These levels develop not only
with age but also in a hierarchy of influence. A hierarchy of visual perceptual skill development in the central nervous
system (CNS) is presented in Figure 11.3. The definitions of components of each level are provided in the following
list and are used in later descriptions of intervention.
Three primary visual skills, oculomotor control, visual fields, and visual acuity, form the foundation for all visual
functions.

• Oculomotor control is the efficient eye movement, which ensures that the scan path is accomplished.
• Visual fields register the complete visual scene.
• Visual acuity ensures that the visual information sent to the CNS is accurate.
The next level on the hierarchy is visual attention, followed by scanning, pattern recognition, visual
memory and lastly, visual cognition, with each building on the previous. Each level is listed below as
they are represented in the hierarchy:
• Visual attention is the thoroughness of the scan path that depends on visual attention.
 Chapter11• AFrameofReferenceforVisualPerception 6
• Pattern recognition is the ability to store information in memory requiring pattern detection and
recognition. This is the identification of the salient features of an object, including the configurable
aspects (i.e., shape, contour, and general features) and the specific features of an object (i.e., details
of color, shading, and texture).
• Scanning is pattern recognition dependent on organized, thorough scanning of the visual environment.
The retina must record all of the detail of the scene systematically through the use of a scan path.
• Visual memory is the mental manipulation of visual information needed for visual cognition and
requires the ability to retain the information in memory for immediate recall or to store for later
retrieval.
• Visual cognition is the ability to mentally manipulate visual information and integrate it with other
sensory information to solve problems, formulate plans, and make decisions.
Warren’s model provides a framework for assessing vision alone without consideration of the other
sensory systems. Sensory processing problems seem to be related to, but are not necessarily the cause
of, visual perception problems (Henderson, Pehoski, & Murray, 2002). For additional information
related to sensory processing problems, refer to Chapter 6.

Acquisitional Theories
Acquisitional theories focus on the learning of specific skills or subskills to function optimally within
the environment (Figure 11.4). The developmental level of the child is not emphasized in acquisitional
theories. The mastery of skills is the primary goal of this frame of reference. Behaviors are broken down
into smaller subskills and built upon each other, resulting in complex skill development (Royeen &
Duncan, 1999).
Age differences are expected within each age-group because of the maturational process as well as
schooling influences. Visual perceptual performance is also influenced by our cultural and
environmental experiences (Levine, 1987; Zimbardo, 1992). Some visual cognitive capacities are
present at birth, and other higher level visual cognitive tasks are not fully developed until adolescence
(Table 11.1). This development occurs through perceptual learning, the process of extracting information
from the environment. Gibson (1969) noted, ‘‘Perceptual learning is defined as an increase in the ability
of an organism to get information from its environments, as a result of practice with an array of
stimulation provided by the environment’’ (p. 77). This increases with experience and practice and
through stimulation from the environment. The child is active in investigating the world, and any
environment may encourage perceptual development (Piaget, 1964). Behavior is viewed as a response
to the environment either positively or negatively. Perceptual learning can be explained by the
information processing model.
 Chapter11• AFrameofReferenceforVisualPerception 7
FIGURE 11.4 Environmental experiences help a baby to
develop visual cognitive skills.

The term ‘‘visual information analysis,’’ using an information processing approach, defines the ability to extract
and organize information from the visual environment and to integrate it with other sensory information, previous
experience, and higher cognitive functions (Scheiman, 2002; Tsurumi & Todd, 1998). The information processing
model emphasizes the development of cognitive skills, particularly those related to attention, memory, thinking skills,
and problem-solving abilities (Massaro & Cowan, 1993). It explains the flow of visual information processing
through reception (input), organization and assimilation of visual information (processing) (Abreu & Toglia, 1987),
and output (Figure 11.5). This model focuses on how the learner attends to, recognizes, transforms, stores, and
retrieves information. The flow of information begins with the sensory input. Processing requires that the sensory
input be attended to, compared with previously stored information, transformed into a cognitive/mental
representation, and assigned meaning or acted upon. Output is the observable behavior that reflects whether learning
has occurred, or it can be cognitive/mental information that is stored. Feedback to the system comes from the output,
reinforcing observable behavior, and providing new input.
 Chapter11• AFrameofReferenceforVisualPerception 8

FIGURE 11.5 Visual processing model.

Input from the environment can be classified into form and space stimuli. Form stimuli include
objects, two-dimensional pictures, and symbols (i.e., letters and numbers). Spatial stimuli include events
and three-dimensional space. Input stimuli can be either sequential or simultaneous in nature (Levine,
1987). Sequential processing involves the integration of separate elements into groups wherein essential
nature is temporal. Each element leads to another, enabling the child to perceive an ordered series of
events. The order in which pieces of information are processed is critical to understanding. The
information is usually language based. An example of sequential processing is the directions for building
a model with Legos, a child following step-by-step pictures or a written direction. Simultaneous
processing is when the visual information comes at one time. This type of information is usually visual
and the concept of the whole is more important than the parts. For example, viewing a new toy at the
store and then recalling it later to tell a friend.
Visual information processing can be conceptualized on a continuum from simple to complex
(Abreu & Toglia, 1987). Simple visual processing involves little effort on the analytic ability to recognize
objects, colors, and shapes and to make gross discriminations of size, position, and direction. Object
processing, a subcategory of simple visual processing skills, is the ability to apprehend the meaning of
objects through vision. Complex visual processing requires concentration, effort, and much analysis. It
is the ability to accurately perceive detailed visual scenes, make subtle discrimination, and grasp the
interrelationships among simultaneously presented visual stimuli.
 Chapter11• AFrameofReferenceforVisualPerception 9
Major Concepts
Visual perception involves a receptive component and a cognitive component. The visual receptive
component is the process of extracting and organizing information from the environment. A person needs
to have a good receptive component for the cognitive component to work efficiently. The oculomotor
system enables the reception of visual stimuli and we need to consider the basic aspects of vision. The
visual cognitive component is the ability to interpret and use what is seen.

Visual Receptive Functions

Visual receptive functions include acuity, accommodation, binocular fusion, convergence, oculomotor
control including fixation pursuit and saccadic eye movements, stereopsis, and visual fields.
• Acuity is the ability to discriminate the fine details of objects in the visual field. A vision measurement
of 20/20 means that a person can perceive at 20 ft.
• Accommodation is the ability of each eye to compensate for a blurred image. Accommodation refers
to the process used to obtain clear vision (i.e., to focus on an object at varying distances). This occurs
when the ocular muscle (the ciliary muscle) contracts and causes a change in the crystalline lens of
the eye to adjust for objects at different distances. Focusing must take place efficiently at all distances,
and the eyes must be able to make the transition from focusing at near point (a book or a piece of
paper) to far point (the teacher and the blackboard) and vice versa. It should take only a split second
for this process of accommodation to occur and this results in altering the focal distance of the eyes.
• Binocular fusion is the mental ability to combine the images from the two eyes into a single percept.
There are two prerequisites for binocular fusion. First, the two eyes must be aligned on the object of
regard; this is called ‘‘motor fusion,’’ and it requires coordination of six extraocular muscles of each
eye and precision between the two eyes. Second, the size and clarity of the two images must be
compatible; this is known as ‘‘sensory fusion.’’ Only when these two prerequisites have been met can
the brain combine what the two eyes see into a single percept (Figure 11.6).
• Convergence is the turning of the eyes inward as the object of regard moves toward the observer.
• Oculomotor skills are efficient eye movements that ensure that the scan path is accomplished. There
are three aspects to oculomotor skills: fixation, pursuit or tracking, and saccadic eye movement or
scanning. Fixation is the coordinated aiming of the eyes while shifting rapidly from one object to
another. This occurs when visual focus is on a stationary object. Pursuit or tracking refers to the
continued fixation on a moving object. Saccadic eye movements or scanning is the rapid change of
fixation from one point in the visual field to another.
 Chapter11• AFrameofReferenceforVisualPerception 10

FIGURE 11.6 Newborns initially attend to faces, using the visual receptive skills that they have developed.

• Stereopsis refers to the monocular or binocular depth perception or three-dimensional vision.

• Visual field refers to the extent of physical space visible to an eye in a given position. Its average
extent is approximately 65 degrees upward, 75 degrees downward, 60 degrees inward, and 95 degrees
outward.

Visual Cognitive Functions

Visual cognitive functions include visual attention, visual memory, and visual discrimination.
• Visual attention is the ability to attend to visual stimuli. It involves alertness, selective attention, vigilance, and
divided attention. A child develops long-term memory production that can be automatically executed without
active attention, through practice and learning.
• Visual memory involves integrating visual processing information with past experience (both long term and short
term). In short-term memory, the child uses a very small portion of his/her total knowledge base to recall visual
information (Baddeley, 1986; Cowan, 1988). There are two general types of visual memory: domain-specific and
procedural knowledge. Domain specific refers to memory of images, events, and facts. Procedural knowledge is a
memory store for ‘‘how to’’ and includes strategies for accomplishing a task (Glover, Ronning, & Bruning, 1990).
Encoding is the process of placing knowledge into memory.
• Visual discrimination is the ability to detect distinctive features of a visual stimulus and to distinguish whether the
stimulus is different from or same as others. Visual discrimination involves recognition, matching, and sorting.
There are two main types of visual perception: object perception and spatial perception. Object perception is
concerned with what things are. Object perception takes place in the temporal lobe of the brain. Object perception
consists of form constancy, visual closure, and figure-ground perception. Spatial perception will be discussed after
object perception.
 Chapter11• AFrameofReferenceforVisualPerception 11
• Form constancy is the recognition that forms and objects remain the same in various environments, positions, and
sizes. It is the ability to see a form and being able to find it, even though the form may be smaller, larger, rotated,
reversed, or hidden (Gardner, 1996). Form constancy helps a person develop stability and consistency in the visual
world. It enables the person to recognize objects despite differences in orientation in detail. Form constancy enables
a person to make assumptions regarding the size of an object, even though visual stimuli may vary under different
circumstances. The visual image of an object in the distance is much smaller than the image of same object at close
range, yet the person knows that the actual sizes are equivalent. For example, a school-aged child can identify the
letter A whether it is typed, written in manuscript, written in cursive, written in upper or lower case letters, or
italicized.
• Visual closure refers to the identification of forms or objects from incomplete presentations. This enables the child
to recognize quickly objects, shapes, and forms by mentally completing the image or by matching it to information
previously stored in memory. This allows the child to make assumptions regarding what the object is without
having to see the complete presentation. For example, a child at his or her desk is able to distinguish a pencil from
a pen, even though both are partly hidden under some papers.
• Figure-ground perception is the ability to perceive a form visually, and to find this form hidden in a conglomerated
ground or model (Gardner, 1996); the differentiation between foreground or background, forms and objects. It is
the ability to separate essential data from distracting surrounding information and the ability to attend to one aspect
of a visual field while perceiving it in relation to the rest of the field. It is the ability to visually attend to what is
important. For example, a child is visually able to find a favorite toy in a box filled with toys (Figure 11.7).
Spatial perception is being able to identify where things are in space. Spatial perception processing takes place in the
parietal lobe. It involves position in space, spatial relations, depth perception, and topographic orientation (Figure
11.8).
• Position in space is the determination of the spatial relationship of figures and objects to oneself or other forms
and objects. This provides the awareness of an object’s position in relation to the observer or the perception of the
direction in which it is turned. It is the discrimination of reversals and the rotations of figures (Hammill, Pearson,
& Voress, 1993). The perceptual ability is important to understanding directional language concepts such as in,
out, up, down, in front of, behind, between, left, and right. In addition, position in space perception provides the
ability to differentiate
 Chapter11• AFrameofReferenceforVisualPerception 12
FIGURE 11.7 Toddler using figure-ground perception to find a toy in a toy box.
 Chapter11• AFrameofReferenceforVisualPerception 13
among letters and sequences of letters in a word or a sentence (Frostig, Lefever, & Whittlesey, 1966). For example,
the child knows how to place letters equal spaces apart and touching the line; he or she is able to recognize letters
that extend below the line, such as p, g, q, or y. Another aspect of spatial perception, now referred to as ‘‘object-
focused spatial abilities,’’ focuses on the spatial relations of objects irrespective of the individual (Voyer, Voyer,
& Bryden, 1995). This includes skills evaluated by many formal assessments; however, poor performance of a
formal test may or may not be linked to functional behavior.
• Spatial relations is the analysis of forms and patterns in relation to one’s body and space and helps judge distances.
There are two types: categorical which includes concepts of above/below, right/left, on/off and coordinate which
specifies location in a way that can be used to guide precise movements.
• Depth perception refers to the determination of relative distance between objects, figures, or landmarks and the
observer and changes in planes of surfaces. It is crucial to the child’s ability to locate objects in the visual
environment, to have accurate hand movements under visual guidance, and to function safely with tasks such as
using

FIGURE 11.8 Teen using spatial perception to maneuver the soccer ball around opponents.

stairs or driving. This perceptual ability provides an awareness of how far something is, and it also helps move in
space (e.g., walk down stairs).
• Topographic orientation is the determination and connection of the location of objects and settings and the route
to the location. The ability to find one’s way depends on a cognitive map of the environment. These maps include
information about the destination, spatial information, instruction for execution of travel plans, recognition of
places, keeping track of where one is while moving about, and anticipation of features. These are important means
of monitoring one’s movement from place to place (Dutton, 2002; Garling, Book, & Lindberg, 1984). In addition,
the images that a person sees in the environment must be recognized and remembered if he or she is to make sense
of what is viewed and if the individual is to find his or her way around (Dutton, 2002). For example, the child is
able to leave the classroom for drinking water from the water fountain down the hall and return to his or her desk.
 Chapter11• AFrameofReferenceforVisualPerception 14
Visual Imagery/Visualization
Visual imagery/visualization is the necessary visual cognitive component that allows us to picture people, ideas, and
objects in the mind’s eye. It is important to reading comprehension and in planning, problem-solving, and
organizational skills (Levine, 1994).

Eye–hand Coordination (Visual Motor Integration)

Eye–hand coordination (also called visual motor integration [VMI]) is the discrete motor skill that enables the
coordination of the visual stimulus with the corresponding motor action (Law, Baum, & Dunn, 2005). Visual motor
speed also depends on visual perception (Figure 11.9).

FIGURE 11.9 Toddle coloring using eye–hand coordination.

Dynamic Theory
Learning theories (Bandura, 1977; Rogers, 1951, 1957; Vygotsky, 1931) emphasize a child’s
development of visual analysis skills. The therapist provides a systematic method for identifying the
pertinent, concrete features for form and spatial patterns, thereby enabling the child to recognize how
new information relates to previously acquired knowledge based on similar and different attributes. The
child learns to generalize to different tasks and therefore increasing occupational performance.
Perceptual training programs use learning theories to remediate deficits.
In this frame of reference, the therapist uses the teaching–learning process and activity analysis and
synthesis. The therapist first analyzes the skills that the child needs to learn. Then, the therapist models
and shapes these behaviors through reinforcement until the child achieves mastery. Mastery of the skill
provides its own reinforcement that allows the child to generalize that skill.
Task parameters should be considered which include environment, familiarity, directions, number
of objects included, spatial arrangements, and response rate per object (Toglia, 1989). Parameters should
initially be kept simple and then developed so that the child can handle multiple complex parameters.
 Chapter11• AFrameofReferenceforVisualPerception 15
Task
grading should also be considered through activity analysis. The environment can be structured in such
a way as to provide the learner with the greatest likelihood of success. Practicing tasks in multiple
environments helps increase generalization of the skill.
Modeling is the demonstration of a behavior or a skill (Figure 11.10). It is effective in promoting
learning if the child is reinforced when the modeled behavior is imitated.
FIGURE 11.10 Children attending to a therapist
modeling cutting shapes in play dough.

Modeling is used when the desired behavior or skill does not exist or when a complex skill does not yet exist in its
entirety. From observing others, the child will form his or her idea of how response components must be combined
and sequenced to the behavior. Later, this stored information will serve as the guideline for action. Modeling can
have influence on learning primarily through formative function. Practicing the new behaviors can also help as a
memory tool.
Learning can also be achieved through reinforcement. It serves as information and motivation in the learning
process. Reinforcement for learning is essential and refers to the environmental stimulus that rewards or does not
reward behavior. Reinforcement takes place through the environment, which includes the social and cultural context.
It is used to encourage development of behaviors and skills and to shape them so that they will occur more frequently.
Reinforcement that is given immediately following the desired behavior is a powerful method that can shape behavior
automatically and unconsciously. It provides an effective means of regulating behaviors that have already been
learned. The therapist can use words of praise or encouragement to foster skill development. Shaping means
 Chapter11• AFrameofReferenceforVisualPerception 16
rewarding close approximations of a desired skill and is used when the skill does not exist. The therapist uses
systematic cuing (Toglia, 1989) to guide the child during the teaching–learning process.
Three theoretical postulates underlie the dynamic theory of this frame of reference. They are as
follows:
• Primary visual receptive skills form the foundation of all visual cognitive functions.
• Acquisition of skills is a result of reinforcement that results in learning.
• Behaviors result from environmental interaction.

FUNCTION–DYSFUNCTION CONTINUA

There are seven function–dysfunction continua found in this frame of reference.

Visual Reception Skills

Avoidance of visual work such as reading and visual fatigue are common problems seen when children
have visual reception problems. When the child spends a lot of energy for visual motor activities, he or
she may have little energy remaining for the visual cognitive piece of the activity. Visual reception skills
are made up of two functions–dysfunction continua, oculomotor and visual reception skills. See Tables
11.2 and 11.3 for the function–dysfunction continua for oculomotor and visual reception skills.

Visual Attention
For visual perceptual skills, good visual attention is necessary so that the correct information can be
attended to and then acted upon or stored in memory (Figure 11.11). Difficulty with attention can cause
problems with spelling and letter formation. See Table 11.4 for indicators of visual attention dysfunction.

TABLE 11.2 Function–Dysfunction Continuum for Oculomotor Skills

ProficientOculomotorSkills IneffectiveOculomotorSkills
FUNCTION: Efficient eye movements that ensure that the DYSFUNCTION: Inefficient eye movements
scan path is accomplished
Indicators of Function Indicators of Dysfunction
Coordinated aiming of the eyes while shifting rapidly from Decreased ability to control and direct
one object to another (fixation) gaze
Able to visualize or focus on a stationary object (fixation)
Visually fixate on a moving object (pursuit or tracking) Turns head while reading across the page
Loses place during reading
Omits words
Able to change point of visualfixation fromonepoint Overshoots or undershoots target
inthe visual field to another rapidly (saccadic eye Needs finger or marker to keep place
movements or scanning)
 Chapter11• AFrameofReferenceforVisualPerception 17

TABLE 11.3 Function–Dysfunction Continuum for Visual Reception

FUNCTION: Able to use vision accurately in terms DYSFUNCTION: Unable to use vision accurately in
of acuity, accommodation, binocularity, terms of acuity, accommodation, binocularity,
convergence, stereopsis, and visual field convergence, stereopsis, and visual field
Indicators of Function Indicators of Dysfunction
Discriminates the fine details of objects in the visual Words blurry
field (acuity) Holds book too closely
Blinks frequently when engaging in visual work
Squints to see chalkboard
Able to focus on an object at varying distances Words blurry
(accommodation) Lose place, missing important information
Combines the images from the two eyes into a Complains of seeing double
single percept (binocularity) Repeats letters within words
Omits letters, numbers, or phrases
Misaligns digits in number columns
Squints, closes, or covers one eye
Tilts head extremely while working at a desk
Consistently show postural deviations at desk
activities
Turns eyes inward as the object of regard moves Excess—a condition in which the eyes have a
toward the observer (convergence) tendency to turn inward rather than outward
Insufficiency—a condition in which the eyes have
a tendency to drift outward when being used for
near work; the eyes work well at a far distance
Eyestrain and discomfort
Monocular or binocular depth perception Difficulty with three-dimensional space
(stereopsis)
Awareness of visual physical space (visual field) Runs into objects when walking
Does not see a visual stimulus approaching

Visual Memory
Children with poor visual memory exhibit difficulty with spelling, mechanics of grammar, punctuation,
capitalization, and the formulation of a sequential flow of ideas necessary for written communication.
To write spontaneously one must be able to revisualize letters and words without visual cues; if visual
memory problems exist, the child may have difficulty recalling the shape and formation of letters and
numbers. There may be small and capital letters missing within a sentence, the same letter may be written
in different ways on the same page, he or she may demonstrate the inability to print the alphabet from
memory, legibility may be poor, and the child may need a model to write. Visual sequential memory
 Chapter11• AFrameofReferenceforVisualPerception 18

was found to be one of the best predictors for handwriting speed and for children with handwriting
dysfunction (Tseng & Chow, 2000). See Table 11.5 for indicators of function and dysfunction.
FIGURE 11.11 Toddler
demonstrating good visual attention
toward a picture book so that
information can be stored in
memory.

Visual Discrimination
There is a finite set of visual operations or routines used to extract shape properties and spatial
relationships. Children usually orient to the top or bottom of an object to recognize it. Visual recognition
is a breakdown of the active feature-by-feature analysis necessary for interpretation of a visual image.
If a child demonstrates poor recognition of letters or numbers, then he or she may show poor letter
formation in handwriting. Decoding ability, which utilizes form constancy, is the single best predictor
of reading comprehension (Tui, Thompson, & Lewis, 2003). Reversals of letters and numbers occurring
after age 7 often indicate poor visual discrimination especially in form constancy. An object recognition
problem may indicate that the child is fixated on one portion of an object and not seeing the whole. For
example, because of the difficulty in shifting visual attention to another aspect of the object or
 Chapter11• AFrameofReferenceforVisualPerception 19

environmental scene, the child may miss essential features. In adults, visual agnosia is a disorder of
recognition. The individual can identify objects by touch, but is unable to recognize objects visually
TABLE 11.4 Function–Dysfunction Continuum for Visual Attention

FUNCTION: Visually attentive DYSFUNCTION: Poor visual attention

Indicators of Function Indicators of Dysfunction
Visually attentive to people and objects Focus may be on irrelevant information
Easily confused
Difficulty screening out unimportant or
irrelevant information
Cannot see, recognize, or isolate salient features
andthereforedoesnotknowhowtofocusattention
Explores and selects relevant visual information Overattentiveness
Screens out irrelevant information • Easily distracted
• Does not attend long enough for memory
• Overly focused on irrelevant information
Underattention
• Difficulty orienting to visual stimuli
• May habituate quickly to a visual stimulus
• Fatigues easily
• Poor sustained attention
Concentrates on a visual stimulus (vigilance) Reduced persistence at a task
Difficulty maintaining visual attention
Focuses on two different stimuli at the same time Can focus only on one task at a time
(divided attention)
 Chapter11• AFrameofReferenceforVisualPerception 20

TABLE 11.5
Function–
Dysfunction Continuum for Visual Memory

RemembersVisualInformation DifficultyRememberingVisualInformation
FUNCTION:Abilitytoretainandusevisual DYSFUNCTION: Difficulty retaining and retrieving visual
information information
Indicators of Function Indicators of Dysfunction
Mentally manipulates visual information Fails to attend adequately, which is needed for storage
of visual memory
Retains information in memory for Poor or reduced ability to recognize, match, or retrieve
immediate recall or to store for later visual information
retrieval Poor handwriting
Prolonged response time
Inconsistent recall abilities
Letter reversals
Good memory for ‘‘how to’’ (domainspecific Poor memory of images, events, and facts
memory)
Good memory of images, events, and facts Poor memory for ‘‘how to’’
(procedural memory) Poor strategies for accomplishing a task
Proficient visual sequential memory Decreased handwriting speed
Stores visual information into memory Trouble storing visual information into memory
(encoding) Poor ability to use mnemonic strategies for storage
 Chapter11• AFrameofReferenceforVisualPerception 21

TABLE 11.6 Function–Dysfunction Continuum for Object (Form) Discrimination

FUNCTION: Ability toDYSFUNCTION: Unable to percieve what things are
percieve what things are
Indicators of Function Indicators of Dysfunction
Form constancy Difficulty recognizing letter or words in different print, sizes, or in different
environments
May have difficulty copying from a different type of print or handwriting
May not recognize errors in own handwriting and is not able to make
corrections
Letter and number reversals
Visual closure May be unable to identify a form or object if an incomplete presentation is
made
Figure ground Difficulty perceiving an object that is not well defined, such as an object in a
purse or drawer or visually confusing environments such as supermarkets
May overattend to details and miss the big picture
Overlook details and miss information
Trouble attending to a word on a printed page because of inabilily to block
out the other words
Poor visual search strategies
Difficulty finding the sleeve on an all white shirt

despite normal visual acuity. This can occur in children as well. See Table 11.6 for indicators of
function/dysfunction.

Visual Spatial
These skills are used to interact with and organize the environment. Visual spatial skills develop from
an awareness of one’s body concepts such as right/left, up/down, and front/back. The understanding of
left/right is called ‘‘laterality,’’ and directionality is the understanding of an external objects position in
space in relation to himself or herself. This understanding allows the child to handle spatial phenomena
in a visual manner. See Table 11.7 for the function–dysfunction continuum of visual spatial skills.

Visual Motor Integration

Motor skills of posture, mobility, and coordination may be affected by poor visual skills. Process skills
of knowledge, temporal organization, organization of space and objects, and adaptation all can be
affected by visual perception thus affecting VMI. Visual perceptual difficulties also affect the child’s
ability to use tools and relate materials to one another. The child may show problems with cutting with
scissors, coloring, constructing with blocks or other construction toys, doing puzzles, using fasteners in
dressing, and tying shoes (Figure 11.12). Of the seven subtests of the Test of Visual Perceptual Skills
(TVPS), a common test used by OTs, deficits on the subtest of visual memory and visual spatial
 Chapter11• AFrameofReferenceforVisualPerception 22

relationships seem to be most likely related to visual motor difficulties (O’Brien, Cermak, & Murray,
1988; Parush et al., 1998).
TABLE 11.7 Function–Dysfunction Continuum for Visual Spatial Skills
FUNCTION: Uses visual skills to interact DYSFUNCTION: Does not use visual skills efficiently to
with and organize the environment interact with and organize the environment
Indicators of Function Indicators of Dysfunction
Position in space Reversal of letters and numbers after 9 yr of age
Reversal error in order of words and numbers
Trouble discriminating among objects because of their
placement in space
Difficulty planning actions in relation to objects
Letter reversals
Writing and spacing letters and words on a page
Difficult understanding directional language
Spatial relations Left to right progression or writing words and sentences
Overspacing or underspacing, trouble keeping in the
margins
Inconsistency in letter size and placement of letters on a
line Inability to adapt letter sized to the space provided on
the paper or worksheet
Trouble orienting in the environment
Depth perception Difficulty moving in space
Difficulty recognizing the surface plane has changed
Difficulty catching a ball
Sorting and organizing personal belongings
Topographic orientation Difficulty finding one’s way in the environment
Easily lost
Difficulty determining the location of objects and settings
 Chapter11• AFrameofReferenceforVisualPerception 23

FIGURE 11.12 Preschooler showing oral motor overflow while using a tool in a visual motor task.
TABLE 11.8 Function–Dysfunction Continuum for Visual Motor Integration
FUNCTION: Able to use vision to accurately DYSFUNCTION: Unable to use vision to perform
perform motor tasks motor tasks
Indicators of Function Indicators of Dysfunction
Legible handwriting Inability to copy letters and forms legibly
Skillfully build with blocks and Legos Difficulty building with blocks and Legos
Adequate speed for visual motor activities Decreased speed in visual motor activities

Handwriting is a VMI skill used by school-aged children. Factors associated with handwriting
legibility are visual perception, eye–hand coordination, and VMI. Visual sequential memory was a
significant predictor of handwriting speed (Feder et al., 2005). See Table 11.8 for indicators of
function/dysfunction in VMI.
Visual perceptual problems can affect all aspects of the child’s life and occupations. For instance,
in ADL the child may have difficulty obtaining the supplies needed for grooming, such as using a brush
and mirror to style hair, applying toothpaste to the toothbrush, fasteners, and matching clothes to name
a few. Playing games with other children can be difficult because of the visual perception skills needed.
Helping with the chores such as sorting and folding clothes may be impossible.
 Chapter11• AFrameofReferenceforVisualPerception 24

GUIDE
FOR EVALUATION

To identify visual perceptual factors that limit occupational performance and participation, OTs often
ask and observe how visual perceptual difficulties affect daily occupations (Chan & Chow, 2005), thus
utilizing a top-down approach. Through the evaluation process, OTs try to determine the possible causes
and types of visual perceptual dysfunction so that an effective intervention plan can be developed. It is
helpful to start the evaluation process with a screening to determine the primary problem areas. Because
of the complexity of visual perception, it is important to use various methods in the evaluation process
including observation, review of history, and standardized tests.
One of the first steps in the screening process would be to review the child’s medical history. It
would be useful to determine if an ophthalmic or ophthalmologic evaluation has been done on the child
and if there are any medical conditions that could affect performance in this area. Although a screening
performed by the OT is not a substitute for a comprehensive examination by a vision professional, it can
help establish the need for such an examination and also help the therapist to plan his or her therapy
program, taking vision into consideration. Furthermore, if and when visual deficits have been properly
diagnosed, the therapist could develop supportive, compensatory, and/or instructional strategies to help
improve the child’s performance within his visual capacities (Scheiman, 1997). Assessments that are
used by OTs to assess visual reception skills are presented in Table 11.9.
Understanding the child’s academic performance might provide some insight into the possibility of
visual perceptual problems. Performing clinical observations of the

Erhardt Development Fetal—6 mo Reflexive visual patterns; Good interrater reliability;

Vision Assessment voluntary eye movements of no test–retest reliability,
(Erhardt, 1989) localization, fixation, ocular construct and
pursuit, and gaze shift discriminate validity
found

Visual Skills Appraisal 5–9 yr Pursuit, scanning, alignment, Information on reliability

(Richards & and locating movements; or validity not found
Oppenheim, 1987) hand–eye coordination;
fixation unity

Pediatric Clinical Vision School age Accommodation, acuity, Information on reliability

Screening for binocular vision, ocular or validity not found
Occupational motility, refraction, visual
Therapists field, visual information
(Scheiman, 2002) processing
 Chapter11• AFrameofReferenceforVisualPerception 25

TABLE
11.9
Crane–Wick Test K-12 grades Accommodation Information on reliability
Instruments
(Crane & Wick, 1987) Saccadic eye movement or validity not found
to Assess
Near point of convergence
Visual
Eye teaming
Reception
Pursuit of movement
Visual processing
Functional hearing

child’s visual perceptual skills would also be useful. This can be done by watching a child engage in carefully selected
play activities or functional tasks, such as creating block and pegboard designs, playing with Legos, drawing and
writing, dressing activities, playing computer games, looking for hidden pictures in a confusing background, playing
ball, and doing puzzles (Mulligan, 2003). Observations of procedural knowledge (strategies for accomplishing a
task) and verbal-kinesthetic strategy (verbal, tactile, and motor strategies for accomplishing a task), to name a few,
can also be observed (Figure 11.13). Cultural influences should always be considered in the evaluation process
(Josman, Abdallah, & Engle-Yeger, 2006). It would also be helpful to observe the child in some academic tasks
within a classroom setting, especially if the referral indicated that academic performance is a problem area.
Interviews can also be used to determine where perceived problems are, or to find out how visual problems may be
interfering with functional performance. Interviews should include the parents and/or care providers, and classroom
teachers.
The second step in the evaluation process is to generate and test hypotheses to determine factors that support or
hinder the child’s ability to engage successfully in valued occupations (Mulligan, 2003). As the therapist proceeds
with the evaluation process, a bottom-up approach following the developmental hierarchy of visual perception can
be used to determine the types of deficits that are contributing to problems in occupations. Some norm-referenced
tests are usually used in addition to interviews
26
PartII• FramesofReference

FIGURE 11.13 Observation of a child doing puzzles to assess procedural knowledge for accomplishing the task.

and clinical observations. There are various assessments developed to assist the OT. The visual
perceptual instruments most frequently used by OTs are briefly reviewed in Table 11.10. This table
provides assessments, the age ranges that they are appropriate for, and the specific areas assessed, so
that the therapist can choose the most appropriate tool for use with the child.

Visual Spatial Assessment

Many of the instruments reviewed earlier also assess visual spatial skills. The assessments reviewed
here only measure aspects of visual spatial skills. The Jordon Left–Right Reversal Test, Revised (Jordon,
1980) is a standardized test that can be administered individually or in a group. It is untimed and takes
approximately 20 minutes to administer and score. The Reversals Frequency Test is a simple, easy-to-
administer test devised to determine whether a child exhibits an abnormal number of letter or number
reversals. See Table 11.11 for instruments to assess visual spatial skills.

Visual Motor Integration Assessments

The Developmental Test of Visual Motor Integration (VMI, Beery, Buktenica, & Beery, 2004), the Wide
Range Assessment of Visual Motor Abilities (Adams & Sheslow, 1995), Test of Visual Motor Skills
(TVMS, Gardner, 1995), the Slosson Visual Motor Performance Test for Children and Adults (Slosson
& Nicholson, 1996), and the Test of Visual Analysis
TABLE 11.10 Instruments to Assess Visual Perception
 Chapter11• AFrameofReferenceforVisualPerception 27

Developmental Test 4–10 yr Eye–hand coordination Strong normative data

of Visual Perception, Visual spatial relations Internal consistency for three
Second Visual figure ground compositescaleswereabove0.93
Edition (DTVP-2, Hammill, Visual motor speed Test–retest reliability for a 2-wk
Pearson, & Voress, 1993) Copying interval 0.71–0.86 across
Position in space subtests, 0.89–0.94 for
Visual closure composite scores
Visual form constancy Interrater reliability coefficients
0.87–0.94 across subtests, 0.95–
0.97 for composite scores
Concurrent validity between
DTVP-2 motor items and VMI
(0.89)

Motor-Free Visual 4–11 yr Visual discrimination High test–retest reliability (r =

Perception Visual memory
0.81)andinternalvalidity(r=0.88)
Test-Third Visual spatial relations
Edition (MVPT-3, Visual figure ground Criterion validity determined
Colarusso & Visual closure relativetoacademicperformance
Hammill, 2003) (r = 0.38) and intelligence (r =
0.31)

Test of Visual Perceptual 4–12.11 yr Visual discrimination Test–retest reliability 0.33–0.78;

Skills-Revised (TVPS-R, Visual memory 0.81 for total test (Brown,
Gardner, 1997) Visual form constancy Rodger, & Davis, 2003)
Visual spatial relationships Content validity, test–retest
Visual sequential memory reliability (Chan & Chow, 2005)
Visual figure ground
Visual closure

Test of Visual Perceptual 12–18 yr Visual discrimination Cronbach’s α coefficients 0.81–

Skills Upper Limits (TVPS- Visual memory 0.89
UL, Gardner, 1997) Visual form constancy Reliability coefficient across all
Visual sequential memory age levels was 0.86
Visual figure ground Concurrent validity based on
Visual closure correlations with Bender Visual
Motor Gestalt (0.31–0.81),
DTVMI
(0.46–0.64), TVMS-R (0.70)
 Chapter11• AFrameofReferenceforVisualPerception 28

Test of Pictures, Forms, 5–8 yr Ability to perceive visual forms, Split-half reliability coefficients
Letters, Numbers, Spatial letters, and numbers in the (0.10)–(0.95)
Orientation and correct direction and sequence Item validity (rs= 0.14–0.27)
Sequencing Skills for
(Gardner, 1997) words
(continued)
TABLE 11.10 (Continued)

Sensory Integration and 4–8.11 yr Space visualization Interrater reliability (0.94–0.99)

Praxis Tests (Ayres, 1989) Figure ground Content validity
DesigncopyconstructionPraxis

Miller Assessment for 2.9–5.8 yr Figure ground Interrater reliability (0.98)

Preschoolers (MAP, Puzzle Test–retest reliability (0.81)
Miller, Eye–hand coordination
1988) Block design
Object memory
Draw a person
VMI, visual motor integration; TVMS-R, Test of Visual Motor Skills-Revised; DTVMI, Developmental Test of Visual Motor Integration.

Skills (Rosner & Fern, 1983) are used to assess VMI skills. These assessments will be briefly reviewed.
The Developmental Test of Visual Motor Integration, Fifth Edition, Revised (2004) (VMI) is a
norm-referenced design copy test for ages 2 to 18 (full form) and 2 to 7 (short form). There are two
additional optional subtests: (1) visual perception and (2) motor coordination. This test can be
administered individually or in groups.
The Wide Range Assessment of Visual Motor Abilities (Adams & Sheslow, 1995) is an individually
administered test taking approximately 15 to 25 minutes. Raw scores are converted to standard scores.
Test of Visual Motor Skills—Revised (TVMS, Gardner, 1995) is a norm-referenced design copy
test. It is quick and easy to administer. The test is unique in that the types of errors are classified and
scored to give qualitative information.
Test of Visual Analysis Skills (Rosner & Fern, 1983) is an untimed, individually administered,
criterion reference test. The purpose is to assess if the child is able to determine the relationships
necessary for integrating letter and word shapes. See Table 11.12 for age ranges, areas assessed, and
psychometric information of these assessments.
 Chapter11• AFrameofReferenceforVisualPerception 29

Jordon Left-Right 5–12 yr Reversals of letters, Test–retest reliability

ReversalTest,ThirdRevisedEdition numbers, and words (0.90)
(Jordon, 1980)

Reversals Frequency Test (Gardner, 5–15 yr Execution—write letters in Information on reliability

1978). lower case as dictated or validity not found
Recognition
Matching
TABLE 11.12 Instruments to Assess Visual Motor Integration

The Developmental Test of 2–18 yr Three subtests Test–retest (0.89),

Visual Motor Integration, Fifth interrater (0.92), and
Edition, Revised (VMI, Beery, internal (r= 0.92) reliability
Buktenica, & Beery, 2004)

Wide Range Assessment of Visual 3–17 yr Drawing Internal consistency (1.00–0.92)

Motor Abilities (Adams Matching Test–retest correlation (0.86)
& Sheslow, 1995) Pegboard

Test of Visual Motor Skills— 2–13 yr Design copy Reliability coefficients across all
Revised (TVMS-R, Gardner, age levels was 0.86
1995) Concurrent validity (0.23–0.48)

The Slosson Visual — Screening test for Internal consistency (0.93)

Motor Performance perceptual organization Test–retest reliability (0.97)
Test for Children and Adults and eye–hand Concurrent validity (0.59–0.64)
(Slosson & Nicholson, 1996) coordination

Test of Visual Analysis Skills 5–10 yr Copying simple to complex Validity (0.79–0.83)
(Rosner, 1983) geometric patterns

POSTULATES REGARDING CHANGE

There are three general postulates regarding change in this frame of reference:
1. The therapist will create an environment that will facilitate the development of visualperceptual skills
in accordance with the child’s age and abilities.
2. Visual cognitive skills are facilitated through the use of teaching learning principlesfor remediation.
 Chapter11• AFrameofReferenceforVisualPerception 30

3. The therapist creates an environment that fosters the development of component parts of skills or
specific skills.
There are six specific postulates regarding change for this frame of reference:
1. The development of visual receptive skills influences visual cognitive skills, which willresult in the
child’s improved ability to engage in meaningful occupations.
2. Visual cognitive skills improve in an environment where there is modeling of a desiredbehavior and
immediate reinforcement to the child regarding desired behavior.
3. The integration of lower level skills, such as visual attention, will develop higher levelskills in visual
reception and visual cognition, such as visual memory.
4. The integration of lower level skills, such as visual memory, will facilitate thedevelopment of higher
level skills, such as visual discrimination.
5. The development of visual discrimination facilitates the development of visual spatialskills and VMI.
 Chapter11• AFrameofReferenceforVisualPerception 31

6. The therapist creates an environment that allows the child to use compensatory skills and environmental
strategies to aid in visual cognitive skills and engaging in resulting occupations.

APPLICATION TO PRACTICE

Treatment planning requires an understanding of the underlying reasons for difficulty as well as a
delineation of the conditions that influence performance (Toglia, 1989). A remedial approach focuses on
the impairment underlying the vision problem, following the developmental process. An adaptive approach
facilitates improved function through compensation using cognition. Compensation is any practical
environmental adjustment such as assistance from others, training procedures that are activity or situation
specific, and strategies and environmental adaptations (Zoltan, 1996). This approach provides training in
the actual occupations meaningful to the child. Both approaches may be used in treatment.
Remediation, strategy use, and environmental adaptations are tools for treatment. With remediation,
the goal is to improve deficit skills. It can involve intervention of underlying causes, or structured practice
of specific skills so that these skills can develop and become more automatic (Gentile, 1997). Strategy use
overlaps with remediation because certain deficits may be because of ineffective strategy use. Strategies
for search, scanning, attention, monitoring work, and encoding information can be taught. While using
strategies, environmental changes can be made to assist the individual to improve performance or function.
Additionally, a therapist may change and make accommodations to the task so that success is possible.
Sometimes, the child’s performance is dependent on the environmental adaptations, and therefore the
child’s skills have not actually improved, as the accommodations are external to the child.
The child, his or her parents, teachers, and caregivers may need to be educated about the child’s deficits
and the intervention strategies. This can be very helpful throughout the intervention process. This education
helps make those involved with the child aware of his or her limitations and the functional implications of
the visual perceptual problems. Education also helps others to view the child in a different way. For
example, rather than insisting that the child is lazy, they would recognize the problem and then could aid
with cues or environmental adaptations.
Figure 11.5 earlier in the chapter presents the visual processing model and a guide to where these
treatment approaches (remediation, strategies, and environmental adaptations) can be used. The following
section presents treatment approaches following the visual processing model beginning with input.

Input: Environmental Adaptations

Visual input can be influenced by the context and the activity demands and should be considered in
designing treatment activities. For example, the lighting should be adequate, but should not cause a glare
on the workspace. When children are visually distracted in the classroom, one easy approach is to work
with the teacher to make the classroom less busy visually, thereby increasing visual attention. The therapist
might also suggest that child be positioned closer to the board so that objects on the sides of the classroom
are not in his or her direct visual field. If a child has visual memory issues, the therapist can suggest to the
teacher that drawers are labeled and that a cue card be made with directions for frequent tasks within the
classroom. When a child has problems with topographical orientation, the therapist can suggest the use of
landmarks to the child or suggest that signs with high color contrast be used in the environment.
Some suggestions for environmental adaptations to the activity demands include the following:
• Choosing activities that are motivating for the specific child
• Using manual activities that will encourage the child to view the movements; handmovements help
educate the eye about object qualities
• Progressing the activity from simple to complex
• Variation of the task parameters to encourage variability of practice (Lesensky &Kaplan, 2000)
• Random and variable practice
• Part practice is more efficient for complex tasks such as dressing
• Whole practice is important for integrated timing in tasks such as handwriting.
 Chapter11• AFrameofReferenceforVisualPerception 32

Processing: Remediation of Visual Reception

The developmental model proposed by Warren (1993a,b) suggests that higher level skills evolve from
integration of lower level skills. Remediation treatment would begin where the deficit is located lowest in
the hierarchy (Figure 11.3). The therapist would design treatment strategies to remediate basic problems to
improve perceptual function. If deficits occur at the foundational level, then activities to improve
oculomotor skills would be incorporated into the treatment. Optometry and occupational therapy could
collaborate on common goals related to the effects of vision on performance. Once oculomotor skills are
efficient, treatment should proceed from attention to memory to visual discrimination. For example, general
sensory stimulation or inhibition may be provided prior to visual activities to improve visual attention.

Processing: Remediation of Visual Cognition

The remedial approach utilizes repeated drills and exercises, in a teaching–learning environment, which
are aimed at specific cognitive processes. It also assumes that occupations are composed of subcomponents
which can be ‘‘remediated by a building block approach that emphasizes improvement in the hierarchical
subcomponents to allow the structure of occupational performance to be reconstructed’’ (Zemke, 1994, p.
25).
The therapist uses specific techniques to promote remediation. These include setting task parameters,
task grading, modeling, and reinforcement to encourage learning. Task parameters would involve using
familiar objects, ensuring that directions are clear and structuring the environment to minimize distractions.
The therapist can also consider limiting the number of objects used and the spatial arrangement of objects
to help the child focus on the tasks at hand. The therapist might also limit the response rate per object
(Toglia, 1989). The therapist would focus on simplifying the task until the child develops the skill to handle
multiple parameters. Once the child develops more skill, the therapist can use activity analysis to grade the
task to provide more challenges for the child. The environment for intervention should be structured to
promote the greatest chance of success for the child. Once this occurs then similar tasks can be practiced
in multiple environments to increase the potential for generalizing the skill.
Modeling and practice are remedial approaches that therapists use to develop visual cognition skills. Modeling
involves demonstrating a behavior or a skill that the child can then imitate. Once the child imitates the behavior or skills,
reinforcement will promote learning. This technique is used when a desired behavior or skill does not exist or when the
therapist is trying to build a more complex skill from a rudimentary skill. The child will develop the ability to respond
to various stimuli and situations based on the observation of therapist and other children who have already mastered
these skills. The child can learn to combine and sequence skills and behaviors. Repetition helps the child to learn and
store the information, so that it can be used later as a guide for action. Modeling provides the formative learning, whereas
practicing new behaviors can reinforce the behaviors and serve as a memory tool.
Positive reinforcement is important in the learning process of visual cognitive skills. Reinforcement provides the
child with feedback and serves as a motivation for the child. Positive reinforcement refers to the response that the
therapist or the environment provides to reward positive responses. Such reinforcement may be made by the therapist,
teacher, or vary depending on the social or cultural context. It encourages the development of behaviors and skills, and
can be used to shape behaviors so that they occur more frequently or in a more appropriate manner. Reinforcement may
be provided in various ways. If it is given immediately following the desired behavior, it can be very powerful and can
have an automatic or unconscious effect on resultant behaviors. Reinforcement can also be a very effective way of
regulating behaviors that have been previously learned. Words of praise can also foster skill development. Rewarding
close approximations of a desired skill is called ‘‘shaping.’’ This is also useful in developing skills and behaviors.
Additionally, the therapist might use systematic cuing (Toglia, 1989) to assist the child during teaching–learning
process. Different types of cues are presented in Table 11.13.
In the teaching–learning process, investigative questioning is another approach that can be used by the therapist to
develop visual cognitive skills. After a correct response is obtained by the child, investigative questioning is used by
the therapist to ask the child to explain his or her answer. The therapist should also consider when it is appropriate to
permit a second try, prompt, demonstrate, extend or remove time limits, impose time limits, and change instruction and
presentation (Gentile, 2005). Learning involves unobservable cognitive or mental processes such as memory and
attention. Learning can be facilitated by the use of a multisensory approach. The child can benefit from using tactile
input to learn shapes, letters, and numbers. By using textures, the child has additional sensory experiences. For example,
letters can be formed with clay, sandpaper, beads, or pipe cleaners.
 Chapter11• AFrameofReferenceforVisualPerception 33

Repetition cue Child is asked to ‘‘look again’’ which indicates the child was incorrect. Observe if child can self-
correct

Analysis cue Therapist asks the child to describe further the form or object; assists the child to
pay closer attention

Perceptual cue Therapist emphasizes the critical feature of the form or object

Semantic cue Therapist provides a choice of three categories

Additionally, there are many excellent educational computer programs that are highly motivating for
children of all ages and can be used as part of an intervention approach. Computer programs have been
designed to assess processing as well as increase reaction time, visual scanning, attention, speed of
information, memory, and problem solving.

Processing: Visual Reception Strategies

Suggestions for visual reception strategy use include the following:
• Left to right searching
• Finger to follow lines in reading
• Ruler to keep place on a worksheet
• Close eyes frequently to rest to prevent visual fatigue
• Organized movement for scanning the environment to gather information

Processing: Visual Cognition: Strategies

Strategies are cognitive processes that support successful performance of visual cognition skills (Pressley
et al., 1990). It has been shown that good strategy users are more successful with visual cognitive tasks.
Children can be taught problem-solving strategies and then they are enabled to discover additional
strategies that will support their skill acquisition. There are three types of strategies: domain-specific or
goal-specific strategies that achieve a specific part of the task, monitoring strategies that evaluate the
success of the strategy, and higher order or global strategies that are used to control and coordinate other
strategies (Pressley et al., 1990).
Domain-specific or goal-specific strategies are often used for a short time and are often task or situation
specific (Polatajko & Mandich, 2004). These are taught to the child by the therapist. They are used to solve
specific performance issues as they arise. Situational strategies (Toglia, 1989) can be domain or goal
specific. These could include the following:
• Scanning: Learning organized movement for scanning the environment to gather information.
• Visual imagery: Visualizing what one is looking for before initiating a visual search allows the child to have a visual
image of what he or she is looking for.
• Organization: Organizing visual information in the environment whenever possible.
• Visual analysis: Silently verbalizing specific characteristics to help ascertain the meaning or function of the object
(Toglia, 1989). This might include the shape, size, and thickness of an object. This process is similar to verbal
mediation.
Todd (1999) suggested giving specific attention to the distinctive features of a visual stimulus (letters and numbers)
through highlighting and verbal enabling to enhance visual discrimination learning. Verbal enabling involves
emphasizing these characteristics of a visual stimulus through verbal, visual, kinesthetic, and tactical cues and referring
to other familiar objects that have the same distinctive features. The child then uses the strategy of emphasizing
distinctive features of letters and numbers and then memorizing them. Verbal labeling involves using speech to provide
a name to a visual stimulus. This helps to also provide another type of input to be paired with the visual stimulus.
Strategies that can be used to increase visual attention include the following:
• Taking time-outs from a task
 Chapter11• AFrameofReferenceforVisualPerception 34

• Attending to the whole situation before attending to the parts

• Searching the whole scene before responding
• Monitoring the tendency to become distracted
• Devising time–pressure management strategies
The importance of getting the correct visual information for learning cannot be overemphasized. First the child needs
to have good attention to the task, which allows the visual information to be stored in memory. Memory strategies are
described in Table 11.14.
Monitoring strategies that can be taught to the child which can be used for selfmonitoring a visual perceptual task
are described by Toglia (1989). These strategies include the following:
• Anticipation: This is learning to predict potential difficulty in certain situations. The correct anticipation of problems
leads to the ability to plan and initiate the use of strategies by the child.

Chunking Organizing information into smaller units, for example, cutting up worksheets and presenting one task at a time
Information can be categorized or held together by some meaningful association to be stored
in memory

Maintenance rehearsal Repetition and practice

Elaborative rehearsal New information is consciously related to knowledge already stored in long-
term memory

Mnemonic devices Helps organize information to enhance the retrievability through use of
language cues such as songs, rhythms, and acronyms
• Checking outcomes: Interpretations are double-checked, which then allows the child to correct errors.
• Pacing: Learning when to slow down or speed up while doing tasks that require visual cognitive analysis.
• Stimulus reduction: Reducing the amount of visual information to be perceived at one time (Toglia, 1989).

Processing: Environmental Adaptations for Visual Reception

Modifications to the environment can be made to promote improved functioning and mitigate the child’s
limitations. Reducing glare can be useful for children with visual perceptual disorders. Some ways to limit
glare are as follows:
• Change the lighting in the room, but ensure that the lighting is still good
• Modify the desk height or tilt the surface so that the child is properly positioned with limited glare
• Using pastel colored paper
• Recommend that the chalkboard be regularly cleaned
Other environmental adaptations to increase visual reception include the following:
• Providing visual stimuli that will assist the child to direct his or her attention
• Using a carrel to limit peripheral vision for a child who is distractible
• Limit the visual information that is presented at one time
• Using color-coded worksheets
• Placing a black mat under the worksheet to increase visual attention
• Using a ‘‘mask’’ that covers everything but the item on which the child needs to focus
• Moving closer to the board
• Columns for aligning numbers for math problems

Visual Cognition: Environmental Adaptations

Classroom materials or instructional materials and methods can be modified to accommodate the child’s
limitations and promote improved functioning. One of the primary modifications would be to promote
 Chapter11• AFrameofReferenceforVisualPerception 35

increased visual attention through the reduction of potential visual distractions. Some examples of this
would be as follows:
• Drawing lines on worksheets to group information to increase focusing
• Reorganizing worksheets using larger print or more space between areas requiringattention
• Cuing the child to important information by pointing, underlining with a marker, orverbalization
• Using the computer for specific activities
There are various adaptations that can be made to classroom and instructional materials to promote
increased memory skills. Some examples are providing consistent experiences for the child; using
consistent visualization activities as cues for encoding materials; and using various memory aids, such a
notebooks, assignment pads, hand-help computers or calculators, tape recorders, etc.
Adaptations used in the classroom or with instructional materials that can be helpful in developing an
understanding of spatial relations are as follows:
• Using graph paper for math examples, which help with spatially aligning numbers
• Placing visual cues on paper to indicate where a child should start and stop whenwriting
• Using a slant board at a desk to promote upright orientation may decrease directionalconfusion
• Pairing directional cues with verbal cues can decrease letter reversals
• Teaching the child to use his or her finger as a spacer between words
The following are some examples of classroom or instruction adaptations that can be used to promote
shape, letter, and number recognition:
• Using a multisensory approach, where the child can employ a combination of sensoryexperiences
including, but not limited to, feeling, tasting, and saying letters and numbers
• Forming letters with various tactile materials such as clay in sand with beads or withpudding
• Devising activities that move from simple to complex
• Using activities that include drawing, painting, and crafts to encourage explorationand manipulation of
visual forms

Output: Remediations of Performance Skills

Vision is essential for integrating gross, fine, and oculomotor control. Gross motor components of balance,
postural control are needed to support fine motor dexterity. Erhardt & Duckman (2005) suggest the
following to improve visual motor skills:
• Selection of meaningful functional tasks
• Preparation of the therapeutic environment to encourage the child to initiate andexplore materials and
then structural tasks to ensure success
• Use of appropriate handling techniques
• Verbal and manual assistance
• Teach using the child’s preferred sensory modes of learning
• Provide opportunities for practice and generalization
Motor skills such as posture, mobility, and eye–hand coordination or VMI should be addressed by the OT
during intervention. Other frames of reference that appear in this text may be appropriate here. When
working on remediation of performance skills, it is important to consider temporal organization and the
energy for pacing and attending to visual tasks. Therapists must also consider the tools that are used during
performance. A child must know the tool, its properties, and how it is used. Finally, the therapist must
create an environment that supports performance by address and adapting the organization of the workspace
and the objects within that environment.
Output: Strategies for Performance
The therapist works with the child to develop performance strategies that will help the child to be
successful. One strategy is to give the child verbal step-by-step directions that describes how to complete
the task. Included in these directions are motor and visual expectations of the task. It also includes
organizing the workspace and the objects within to support performance. For example, when working on
handwriting, the therapist designs the workspace, selects the writing implement, and gives the child verbal
 Chapter11• AFrameofReferenceforVisualPerception 36

instructions on how to complete the task. The therapist should monitor the amount of energy needed to
complete the task and should adjust the task demands accordingly. As the child progresses, therapist input
decreases and the child should begin to self-evaluate his or her performance.

Output: Strategies for Occupation

Occupational therapy is concerned with performance in daily life and how performance affects engagement
in occupations to support participation. Treatment is designed around what is important and meaningful to
the child. Therefore, goals are created in collaboration with the child to address the targeted outcomes
(Figure 11.14).
Practice of children’s occupations with monitoring is important. Practice of an occupation progresses
from the cognitive to the associative to autonomous stage following motor learning principles. The
cognitive stage is the initial encoding of the instructions and cognitive attention is given to all aspects of
the task. The associative stage shows improved performance with gradual detection and elimination of
errors.

FIGURE 11.14 Participating in a baseball game, meaningful social participation for a child, involving visual perception.
During the autonomous stage, gradual improvement is seen. Practice in ADL, such as dressing and
functional mobility, and instrumental activities of daily living (IADL), such as communication devices
(computer and text messaging on the cell phone), community mobility, financial management, and meal
preparation, will be needed at various stages of development. Work is begun in prevocational and
vocational activities in school and at home. Often creative strategies to accomplish tasks are needed such
as color coding of clothing, use of labels so that shirts are not put on backwards or inside out, various
methods for tying shoes, sorting utensils, and grooming. Strategies can be used to help accomplish these
tasks such as always putting keys in the same place so that one can find them.
Strategies may be used for education occupations such as mathematics (solving geometry problems),
reading, and handwriting. For students who experience visual motor difficulties and therefore have poor
handwriting ability, Chwirka, Gurney, & Burtner (2002) suggested that keyboarding may be a tool to assist
individuals. Lee (2006) has developed a frame of reference for reversal errors in handwriting (Lee, 2006).
In addition, specific handwriting programs can be utilized which offer strategies for children experiencing
visual perceptual problems. For specific information about handwriting, see Chapter 13. For children with
visual perception and reading problems, the therapist can help the teacher determine the best method for
teaching the child to read and write. For reading, phonics approaches work well for children with visual
perceptual problems because auditory and analytic strengths are used. The Orton-Gillingham method
(Gillingham & Stillman, 1997) is another useful reading approach that utilizes multisensory input and
reinforces learning through multiple senses. In the Fernald approach (Bingman, 1989), students trace over
new words with their index finger utilizing the kinesthetic approach. The therapist can help match the
reading program to each child’s strengths.
 Chapter11• AFrameofReferenceforVisualPerception 37

Case
Study Application
The following are two case studies to demonstrate examples of how to apply the visual perception frame
of reference.

Case Study: Kyle, Aged 5 Years

Kyle, aged 5 years, is in kindergarten. He was born prematurely at 31 weeks’ gestation. He remained
in the neonatal intensive care unit (NICU) for 3 weeks with apnea of prematurity, hyaline membrane
disease, and hyperbilirubinemia. At approximately 1 year, he was evaluated and seen by an early
intervention program. His diagnosis included developmental delay and visual disorder including
hyperopia, astigmatism, and right estotropia. He had surgery at 13 months for a resection of the right
medial rectus muscle to correct the right estotropia. Glasses were prescribed for the hyperopia.
He was referred to occupational therapy in kindergarten because of poor fine motor skills and
visual perceptual problems. Kyle was unable to complete the
TVPS (Gardner, 1982) because of poor visual attention skills. He demonstrated
head posturing, squinting, and blinking throughout the evaluation. Results of the evaluation indicated motor
planning, visual perceptual, and visual motor problems. Occupational therapy screening of vision indicated vision
problems and he was referred to a developmental optometrist. The findings of the optometrist included inadequate
ocular mobility, reduced binocular skills, and amblyopia. Kyle received optometric therapy to increase
oculomotor mobility, binocular skills, and eye patching. He was seen by the OT for fine motor, visual perceptual,
and visual motor activities. Reevaluations at the end of the school year indicated significant improvement. He
was able to complete and score age appropriately on the TVPS.

Case Study: Gene, Aged 8 years

Gene is an 8-year, 9-month-old student just entering third grade. He has been classified as being perceptually
impaired. Most of Gene’s day is spent in the regular third grade curriculum with his peers. Educational reports
indicate that he is functioning at grade level in all areas of academics with the exception of reading and language
arts. Gene receives supplemental instruction in these areas, daily, in the resource room.
An occupational therapy referral was generated because of the parental concern about the performance of
fine motor skills and the team’s outline of poor performance components, poor handwriting, and deficient
auditory and visual perception.
Evaluation tools indicate that Gene’s deficiencies lie primarily in the area of VMI and selective areas of
visual perceptual weakness. An age-equivalent score on the Test of Visual Motor Integration is 6 years, 11
months. Although achieving a median perceptual age of 8 years, 2 months on the TVPS, areas of weakness were
noted for visual spatial relations, visual figure ground, and visual sequential memory.
Evaluation of other foundational areas revealed deficiencies in processing movement sensation, mildly low
tone, and reduced fine motor speed and dexterity. Classroom observations indicate that Gene transitions between
four classrooms throughout the day as his program uses ‘‘team teaching.’’ It is noted that Gene takes more time
than the others ‘‘settling’’ into his desk and getting ready for the assignment. Each desk was observed to be of
adequate size, and desk grouping varied from front, to back, to ‘‘desk grouping’’ in one class which required
Gene to complete board copying from a side-view perspective. At the desk, Gene demonstrated poor placement
and alignment of his work when writing.
A review of the curriculum and teaching styles revealed little or no opportunities for manipulative activities
to reinforce concept development. There was a heavy focus on copying, worksheet completion, and drill repetition
techniques.
Gene disliked change and became noticeably uncomfortable with the OT in the classroom. Given the
findings, it was felt the OT could best provide for Gene’s visual perceptual needs through integrated classroom
programming and consultation with the family to focus on home strategies. Because of Gene’s general discomfort
with the OT coming into the mainstreamed classes, she worked directly with Gene and his resource room teacher
to set up strategies and materials that were then carried over into all classrooms.
 Chapter11• AFrameofReferenceforVisualPerception 38

The visual perception frame of reference is used for children who have difficulty interpreting and using
visual sensory information. Such problems affect a child’s performance in critical areas of occupation,
including education, ADL, play, and social participation. The goals of the frame of reference are to aid the
child in attending to and processing visual information so that it can be used for task performance.
The theoretical base of this frame of reference uses theories from cognition, developmental
psychology, education, and optometry. It also uses Warren’s (1993a) developmental hierarchy of visual
perceptual skills, which presents a bottom-up approach to evaluation and intervention. The visual system
is viewed as interacting with other systems for obtaining and processing information. Processing is seen as
an ongoing and interactive approach involving input, processing, and output, followed by feedback which
will bring about a change in behavior.
Application to practice follows this pattern involving input, processing, and output. Within input, the
therapist can initiate various environmental adaptations, whereas in processing and output, the therapist
employs techniques of remediation, strategies, and environmental adaptation. The ultimate goal of this
frame of reference is to allow the child to engage in meaningful age-appropriate occupations.

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