Assessment andInterventionofVisual

Perception and Cognition Following

Brain InjuryandtheImpactonEveryday
Functioning.
Kara Christy, MS, OTRL, CBIS
Natasha Huffine, MS, OTRL, CBIS
Vision and the Brain
•Occipital Lobe • Temporal Lobe
• Primary visual cortex • Combines sensory information
• Visual association cortex associated with the recognition
and identification of objects such
• Analyzing orientation, position, and
as people, places, and things.
movement.
• Initiation of Smooth Pursuit Movements • Parietal Lobe
• Visual Field Loss • Locating objects
• Eye movements
• Drawing/construction of objects
•Frontal Lobe
• Neglect
• Saccades and Attention
• Movement through space

2
 Definitions
Visual Perception is the ability to interpret, understand, and define incoming visual information.
Form Constancy is the ability to identify objects despite their variation of size, color, shape, position, or texture.
Figure ground Perception is the ability to distinguish foreground from background.
Visual Closure is the ability to accurately identify objects that are partially covered or missing.
Spatial Orientation is the ability to recognize personal position in relation to opposing positions, directions, movement of objects, and
environmental locations.
Unilateral Inattention is phenomenon that causes one to experience an inability to orient and respond to contralateral visual information.
Depth Perception is the ability to perceive relative distance in environmental objects.
Visual Memory is the ability to take in a visual stimulus, retain its details, and store for later retrieval.
Visual Motor Integration is accurate and quick communication between the eyes and hands.
Visuocognition is the ability to use visual information to solve problems, make decisions, and complete planning and organizational tasks
through mental manipulation.
Executive Functioning is the ability to reason, plan, problem solve, make inferences, and/or evaluate results of actions and decisions.
Memory is taking in new information, holding on to information, and recalling information when needed.
Information Processing is taking environmental stimulation in through the five senses, interpreting it, and responding to it.
Attention/Concentration is staying awake, alert and ready, focusing, and keeping a train of thought.
Focused
Alternating 3
Divided
Objectives
1. Improve understanding of evaluation
process for visual perception and
cognition for adolescents and adults
2. Improve understanding of treatment
techniques for visual perception and
cognition for adolescents and adults,
including bottom-up and top-down
approaches, use of technology, and shoe-
box treatment ideas
3. Identify impact of visual perceptual and
cognitive barriers on everyday function

4
Objective One

• Improve understanding of evaluation

process for visual perception and cognition
for adolescents and adults

Without knowledge of where a deficit is located in the

visual hierarchy, it is difficulty to design appropriate
evaluation and treatment strategies (Warren, 1993). 5
Visual Hierarchy
(Warren, 1992, 1993)
• Impact of vision at each skill level of this hierarchy influences the overall
integration of the visual environment.
• The foundation includes ocularmotor control, visual fields, and visual acuity.
These are the basic visual skills required to take in information accurately from
our visual world.
• Unilateral inattention is represented in this second level, and this deficit would
complicate our ability to properly scan and attend to incoming visual
information.
• Decreased visual scanning would present difficulties in pattern recognition,
which includes (1) from constancy, (2) figure ground perception, (3) visual
closure, (4) visual organization, and (5) spatial orientation. Moreover, the
optimal functioning of pattern recognition skills are necessary for our ability to
retain visual information, also known as visual memory.
• The highest skill level of this hierarchy is visuocognition, in which we are able to
integrate visual perceptual information with other sensory input in order to
complete executive functioning tasks, such as planning, problem solving, and
decision making.
• Determining the cause of a deficit requires an understanding of how brain
injury affects the integration of vision at each skill level and how the skill levels
interact to produce visual perception. 6
Vision Screen • Convergence – Coordinated movement of the two eyes
so that the image of a single point is formed on
corresponding retinal areas. Have the client follow an
object (finger, pen, etc.) in toward their nose. Note
• Visual acuity – How clear it is. Screened using Snellen distance from face when they cannot keep image single.
Charts for distance and near. Note if one eye breaks before the other. Approximately
• Accommodation – The automatic adjustment of the eye 4 inches is normal, however many can converge to the
for seeing at different distances. Screened using near nose (TTN).
acuity chart (or other reading material) and moving in • Visual scanning – Coordinating eye movement in an
until blurry. organized fashion (efficient search pattern) while
• Diplopia – Another name for double vision. Note if this is actively searching the environment for information (i.e.
scanning a store shelf for a specific product, reading).
in one area/quadrant only, or all the time.
• Depth perception – The ability to determine the relative
• Ocular pursuit – The ocular motor skill of following a distance between objects, figures, or landmarks and the
moving target with the eyes. Observe the client observer (i.e. the car in front of you or beside you when
following a moving object such as a pencil eraser with driving or parking a vehicle). Screened using the Stereo
their head still. Note lack of smooth movement, sluggish Fly Test or similar.
movement, overshooting or undershooting the target,
and complaints of double vision or pain. • Suppression – The neurological phenomenon of the
brain’s ability to disregard information from one eye;
• Saccadic eye movement –quick, simultaneous suppression frequently results following prolonged
movements of both eyes in the same direction. Ask double vision, and is thought a natural adaptation of the
client to alternate gaze between one object and another brain to try and make sense of the information received
rapidly. Observe for undershooting, overshooting, or from the eyes. Tested through red/green activities such
searching for the target. as the Worth 4 Dot Test.
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Visual Perceptual and Cognitive Screening
Deficit Area Clinical Observations Quick Clinical Screening

Form Constancy • Difficulty following directions with pictures • Occupational Therapy Adult Perceptual
such as a recipe, building furniture, or Screening Test (OT-APST)
learning a new board game. • Functional Exercise:
• Problems recognizing unfamiliar handwriting • Locating various brands and sizes of
or new fonts. items on a grocery store shelf
• Difficulty recognizing people wearing different • Locating utensils and correct size bowls
clothing. for baking tasks
• Difficulty in mastering the alphabet and • Reading directions to a game when
numbers words are in different fonts and colors
Figure Ground Perception • Unable to sort and match socks while folding • Bells Test
laundry • Occupational Therapy Adult Perceptual
• Difficulty locating clothing in drawers during Screening Test (OT-APST)
ADLs • Star Cancellation Test
• Missing road signs or vehicles when driving • Functional Exercise:
• Unable to locate toys in a toy box • Locating correct change during a
money management activity
• Locating puzzle pieces during a jigsaw
puzzle activity
• Locating classroom objects in a pencil
box (ie. Glue stick, eraser, blue crayon,
paper clip, etc)
8
Visual Perceptual and Cognitive Screening
Deficit Area Clinical Observations Quick Clinical Screening

Visual Closure • Cannot identify traffic signs that are partially • Functional Exercise:
hidden behind a tree or other vehicle • Completing partially
• Difficulty locating items in the refrigerator drawn pictures or
that are partially covered stencils
• Identifying 10
common objects in an
overlapping array of
30 items
Spatial • Letter and number reversals • Occupational Therapy Adult
Orientation • Difficulty with spacing and organization of Perceptual Screening Test
written school work (OT-APST)
• Baking Tray Test
Unilateral • Applying makeup or shaving only half of the • Occupational Therapy Adult
Inattention face Perceptual Screening Test
• Walking into furniture, doorways, and other (OT-APST)
objects • Clock Drawing Test
• Eating food from half of the tray • Line Bisection Test
• Bells Test
• Star Cancellation Test
• Albert’s Test
• Comb and Razor Test
• Baking Tray Task 9
 Visual Perceptual and Cognitive Screening
Deficit Area Clinical Observations Quick Clinical Screening

Depth Perception • Misjudging distances while pouring liquids • Titmus Fly Stereotest
• Fender bender auto accidents, running stop signs • Randot Stereotest
• Difficulty with grooming, putting in contacts, placement of make- • Cover/Uncover Test
up • Functional Exercise:
• Difficulty with catching a ball • Navigating a therapy gym, hallway,
or playground with obstacles
• Estimating common distances (ie:
from person to a fixed distance
point, such as a car)
• Pouring liquids into measuring
cups
Visual Memory • Cannot remember sight words • Clock Drawing Test
• Often transposes common words • Scenery Picture Memory Test (SPMT)
• Gets lost in familiar routes, or newly learned routes • Spot the Difference for Cognitive Decline
• Difficulty remembering faces or new people (SDCD)
• Functional Exercise:
• Study a photograph for 30
seconds, and describe the photo
and items included
• Display an array of items or words,
remove visual and report as many
items as they can remember 10
 Visual Perceptual and Cognitive Screening
Deficit Area Clinical Observations Quick Clinical Screening

Visual Motor Integration • Difficulty with letter formation • Occupational Therapy Adult
and handwriting Perceptual Screening Test
• Decreased participation in sports (OT-APST)
• Decreased ability to complete a • Clock Drawing Test
puzzle or construction of an • Trail Making A and B
object with pictorial instructions • Functional Exercise:
• Write name or copy a
sentence on paper
• Copy simple line
drawings
• Scissor along various
dotted lines
Visuocognition (Planning • Difficulty sorting and organizing • Trail Making A and B
and Organizing) personal belongings • Functional Exercise:
• Difficulty sequencing and • Sequence a recipe
planning for an activity or game based on pictorial
• Difficulty making sense of typed steps
or written words, and sequencing • Sequence a grooming
a story task with displayed
items (ie: toothpaste,
toothbrush, faucet,
towel, cup). 11
Visual Perceptual and Cognitive Screening
Deficit Area Clinical Observations Quick Clinical Screening

Executive Functioning • Hard to narrow down the key point or main idea of something. Hard to • Logic Puzzles
choose the best possible solution to a problem. • Packing a medication box
• Hard to come up with more than one way of thinking about • Problem solving picture cards
something. Hard to see another point of view. • The Occupational Therapist's Cognitive ADL
• Problems evaluating how your plan is going, fixing mistakes, and Workbook
changing the plan as needed. • Decision making scenarios
• Making Poor Decisions • Meal Planning
• Scavenger Hunt in community
Memory • Hard to hold on to even brief instructions or explanations. Difficulty • Remembering 3/3 items immediately and
remembering what was said at the beginning of a conversation. after 5 minutes
• Difficulty Storing New Information • Asking about current medications and
• Hard to recall the main point of a conversation, even if it just occurred. precautions
• May forget important things learned from experience, causing • Asking to recall previous meal
mistakes to be repeated.

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 Visual Perceptual and Cognitive Screening
Deficit Area Clinical Observations Quick Clinical Screening

Information Processing • Thinking Speed and Response • Trailmaking A

Times are Slower. It takes longer • Complete a following
to understand sensory directions task
information and make sense of • Timed cancellation task
what is going on in a situation. • Game of speed
There may be a long pause
before the person responds with
words or behavior.
• Processes only Fragments of
Information. Parts of information
heard or seen may be missed.
Attention • Hard to Stay Alert • Trailmaking A and B
• Hard to Focus Attention. Easily • Basic meal prep activity
distracted by noises and things • Grocery shopping exercise
around you. Distracted by • Cancellation task
personal thoughts, feelings, and • Reading medication labels
worries.
• Lose "Train of Thought:“
• Difficulty alternating attention
between tasks and losing their
place
• Difficulty with attending to more
than one thing at a time 13
Common Standardized Assessments
• Baking Tray Test
• Clock Drawing Test
• Comb and Razor Test
• Line Bisection Test
• Trail Making A and B
• Bell’s Test
• Motor Free Visual Perception Test (MVPT-3)
• Subtests for Visual Discrimination, Visual Figure Ground, Visual Memory, Visual Closure, and Visual Spatial.
• Test of Visual Perceptual Skills (TVPS-4)
• Subtests for Visual Discrimination, Visual Memory, Visual-Spatial Relationships, Visual Form-Constancy, Visual Sequential-Memory, Visual Closure, and
Visual Figure-Ground
• Developmental Test of Visual Perception Adolescent and Adult (DTVP-A) (DTVP-2)
• Visual Motor Search, Visual Motor Speed, Copying, Figure Ground Perception, Visual Closure, and Form Constancy.
• The Occupational Therapy Adult Perceptual Screening Test (OT-APST)
• Screens for agnosia, unilateral neglect, body scheme, constructional skills, acalculia, and apraxia scales.
• Rivermead Perceptual Assessment Battery (RPAB)
• 16 Performance tests in areas of form constancy, color constancy, sequencing, object completion, figure-ground perception, body image, inattention,
spatial awareness
• Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)
14
• 26 subtests in six areas including orientation, visual perception, spatial perception, praxis, visuomotor organization, and thinking operations.
Common Standardized Assessments
• Test of Memory and Learning (TOMAL-2)
• Abstract Visual, Sequential, Linguistic, Numeric, Memory for Location, Object Recall, Facial Memory, etc
• Weekly Calendar Planning Activity (WCPA)
• Behavioral Assessment of Dysexecutive Syndrome (BADS)
• Rule Shift Card Test, Key Search, Temporal Judgement, Zoo map, Modified 6 Element, Action Program
• Test of Everyday Attention (TEA)
• Map Search, Elevator Counting, Visual Elevator, Telephone Search, Lottery
• Executive Function Performance Test (EFPT)
• Oatmeal preparation, Telephone, Taking Medication, Paying Bills
• Symbol Digit Modalities Test (SDMT)
• Verbal and Visual feedback

15
DTVP-A Copying Pre and Post Test

16
Objective Two
• Improve understanding of treatment techniques for visual
perception and cognition for adolescents and adults,
including bottom-up and top-down approaches, use of
technology, and shoe-box treatment ideas

17
Remediation Approach
• The remedial or developmental approach is typically initiated based on the
premise that the brain can acquire or reacquire function through
environmental stimulation.
• Reacquisition of skills should follow the original path of development.
• In Piaget’s model of cognitive development, the lower level performance
components are acquired prior to more advanced cognitive skills.
• Treatment activities should place initial emphasis on foundational skills, regardless
of the individual’s level of functioning, in order to ensure that the foundation is
solid prior to advancing to higher level cognitive skills.
• Choosing activities that have multiple levels of difficulty, the ability to alter
speed requirements, and offer the opportunity to adjust levels of attention
complexity are important to consider for grading activities up or down to
foster meeting the client’s goals while considering his or her just right
challenge.

18
Cognitive Loading Examples
 Active listening for recall of information
o Music
o Podcasts
o News stories
o How-to videos on Youtube
 Simplistic question and answer or categorical naming
o Trivia Cards or Applications
o Fitz It
o Joe Name It
o Respond Cards
 Alternating between multiple tasks
o Following a sequential key
o Self-timing transitions or following alarms
o Self-structure or Structure the therapy hour activity

19
Activity Examples Deficit Area
Card Games Mattel BLINK Form Constancy
Set/ Set Jr Figure Ground Perception
Nertz/Peanuts/Dutch Blitz
Visual Closure
Spot It!
Carl’s Cards Visual Organization
Fast Flip! Spatial Orientation
Uno Unilateral Inattention/ Neglect
Mattel Skip-Bo Depth Perception
SwishTM Executive Functioning
On the Line/ On the DotTM
Information Processing Speed
Fluxx
Memory
Attention
Board Games QwirkleTM Form Constancy
Q-BitzTM Figure Ground Perception
IQ TwistTM
Visual Closure
I TraxTM
Acuity Visual Organization
AztackTM Spatial Orientation
Gravity MazeTM Unilateral Inattention/ Neglect
NMBR9 Depth Perception
Avalanche Fruit Stand Executive Functioning
WonkyTM
Information Processing Speed
Connect 4®
Guess Who® Memory
KerplunkTM Attention
Sequence/ Sequence Jr®
Eye Found It®
Cribbage
PandemicTM
Ticket to Ride 20
Activity Examples Deficit Areas
Yard Games Ladder Ball Form Constancy
Bean Bag Toss Figure Ground Perception
Washers Visual Closure
Can Jam® Visual Organization
Horse Shoes Spatial Orientation
Yard Darts Unilateral Inattention/ Neglect
Putt Putt Golf Depth Perception
Archery Executive Functioning
Catch Information Processing Speed
Table Tennis Memory
Hopscotch Attention
Tabletop/Shoebox Activities Pixy CubesTM Form Constancy
Labarynth Figure Ground Perception
Find It® Visual Closure
Beading Visual Organization
Color/Paint By Number, Mandala Spatial Orientation
Sand Art Unilateral Inattention/ Neglect
Tanagrams Depth Perception
Knitting/ Crocheting Executive Functioning
Cross Stitch Information Processing Speed
Where’s Waldo®/ Eye Spy Books Memory
Bingo Attention
Tactile Kinesthetic Pegboard
Sewing
Wordsearch, crossword puzzles
Sudoku, Colorku
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Activity Examples Deficit Areas
Tablet Exercises Subway Surfers© Form Constancy
Cooking Fever© Figure Ground Perception
Candy Crush© Visual Closure
Bejewled© Visual Organization
Temple Run©/ Minion Rush© Spatial Orientation
Look Again!© Unilateral Inattention/ Neglect
Fruit Ninja® Depth Perception
Glowburst© Executive Functioning
Minecraft© Information Processing Speed
Find It - Match It© Memory
Vision Tap© Attention
Tap the Frog©
iSays©
Monster Hunt©
Cut the RopeTM
Flow Free©
Unblock Me©
Gaming Systems Nintendo WiiTM Form Constancy
 Big Brain Academy – Wii Degree Figure Ground Perception
 Wii SportsTM Visual Closure
 Guitar Hero® Visual Organization
 Wii PlayTM Spatial Orientation
 Wii FitTM Unilateral Inattention/ Neglect
 Band Hero® Depth Perception
X Box Kinect/ 360® Executive Functioning
 Fruit NinjaTM Information Processing Speed
 Dance Dance RevolutionTM Memory
 Deca Sports FreedomTM Attention
 Kinect Sports® 22
Activity Examples Deficit Areas

Functional Therapy Structure the Therapy Hour Form Constancy

Activities Geocaching Figure Ground
Scavenger Hunts Perception
Meal Planning and Preparation Visual Closure
Medication packing/pictographs Visual Organization
Active Passenger Spatial Orientation
Shopping Unilateral Inattention/
Work simulation Neglect
Using public transportation Depth Perception
systems Executive Functioning
Applying make-up, putting in Information Processing
contacts Speed
Shaving Memory
Laundry sorting/folding Attention
Home management activities

23
Handwriting before and after

24
Compensatory Approach

• Compensation is a treatment approach that aims to

maximize existing visual function by providing strategies
to enhance the patient's ability to assimilate visual
information efficiently.
• A compensatory approach should also place emphasis
on understanding underlying difficulties in visual
perception in order to learn when to initiate the use of
strategies to overcome limitations.
• Rather than focusing on one task specific skill, the client
should gain the ability to use the learned strategies in
various situations.
• Warren supports the use of practicing strategies for
visual perceptual deficits within context to ensure
carryover of application to ADLs.

25
Compensatory Approach

• Pattern Recognition • Unilateral • Depth Perception • Cognition

• Reducing Inattention • Monocular Cues • Reduce stimulation
overlapping objects • Prisms • Shadowing • Rest breaks
• Changing spatial • Attention training • Lines of parallax • Slowing down
arrangements into • Scrolling text • Superimposition
categorized or • Repetition!
• Audiovisual • Prisms • Multi-sensory
linear arrays
stimulation techniques
• Slowing down
processing times • Video feedback • Verbalization
training • Chunking/grouping
• Forming proper
scanning patterns • Learn new scanning • Association
patterns
• Multi-sensory • “W” Questions
techniques • Lighthouse
scanning • Pro and con lists
• STOP strategy
• Double checking
• Pre-planning

26
Objective Three

• Identify impact of visual perceptual and cognitive barriers

on everyday function

27
Basic Activities of Daily Living

• Putting makeup on or shaving only one half of the face

• Difficulty locating shampoo amongst several toiletries
• Trouble locating clothing in a drawer
• Difficulty sequencing shower and dressing routine
• Unsafe transfers (depth perception or executive functions)
• Difficulty remembering a change to morning routine
• For example, donning an AFO
• Difficulty resuming routine if interrupted

28
Functional Ambulation and Transfers

• Navigating curbs and uneven surfaces in the community

• Vehicle transfers
• Navigating stairs
• Colliding with walls and furniture
• Tripping over rugs and items on the floor
• Determining safe distance for transfers or sitting

29
Financial Management

• Difficulty locating account number on a bill

• Trouble remembering to pay bills
• Unable to follow columns while balancing a checkbook or while online banking
• Cannot recognize different coins
• Counting cash incorrectly for making payment or change
• Not able to follow a budget

30
Health Management
• Trouble remembering medical appointments and arriving on time
• Remembering to take medications or if they have been taken
• Difficulty accurately packing a medication box
• Cannot accurately read medication labels
• Trouble remembering information from medical appointments
• Missing prescription refills
• Difficulty remembering health information
• Diagnoses
• Precautions
• Allergies
• Specialists
• Insurance information
• Cannot organize appointments and billing information
• Trouble identifying medications and the various forms and changes
• Trouble making decisions in health related emergencies

31
Shopping
• Trouble locating items in the store
• Bumping into displays while shopping
• Gets overstimulated in public
• Cannot remember where vehicle is parked
• Backtracking in the store due to poor organization and planning
• Unable to locate stores in the mall
• Overspending in the store
• Impulsively buying unneeded items
• Only attending to one side of aisle

32
Meal Planning and Preparation

• Difficulty pouring liquid ingredients

• Unable to identify appropriate utensils for use
• Cannot identify an appropriate weekly meal plan and grocery list
• Unsafe with heat surfaces and sharps especially when in the field of visual inattention
• Inability to sequence a recipe
• Forgetting to turn the stove or oven off
• Overcooking and burning food
• Not utilizing full baking sheet when making cookies

33
Home Management

• Cannot sort laundry

• Hitting walls and furniture while vacuuming
• Poor lines in the lawn while mowing
• Poor home organization
• Forgetting to take out the trash
• Difficulty staying on task
• Unsanitary sequencing while cleaning

34
Community Integration

• Unable to identify road signs and pavement markings

• Stopping too soon or too late at intersections
• Unable to plan complex intersections
• Difficulty managing a bus route
• Requires assistance to schedule rides with transportation service
• Difficulty attending to navigation system while driving
• Only scanning one side of the environment and missing signs on the left side
• Poor lane management and speed control

35
Communication Management/Accessing Resources

• Difficulty scanning for information on phone book pages or websites

• Unable to identify appropriate search terms to locate information
• Cannot remember contact information for personal needs
• Unable to attend to a phone conversation and take notes
• Difficulty sequencing apps on your phone
• Decreased ability to identify the most appropriate professional to contact for person needs

36
Vocation and School
• Difficulty with alternating between projects, phone calls, e-mails,
etc.
• Difficulty learning a new job task or role
• Unable to scan for and identify jobsite hazards
• Increased headaches from visual stimulation and lighting
• Difficulty reading small print text
• Cannot maintain organization of work space or school
supplies/homework
• Decreased developmental progression of visual perceptual and
cognitive processes impacting school performance
• Increased visual strain with screen time requirements
• Decreased ability to sequence and prioritize tasks
• Unable to multitask and retain information from meetings or
conference calls

37
Questions?
Thank You
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