Vision and AD(H)D

It is estimated that 3%-7% of school age children have ADHD, or about 4 million American children. Boys outnumber girls 3 to 1 and are more often diagnosed with ADHD.   Once thought that symptoms fade with the onset of adulthood, it is now estimated that 1/3 to 2/3 of all ADHD children become ADHD adults.

The only problem is 15 out of the 18 symptoms used to diagnose AD(H)D in the (Diagnostic and Statistic Manual, Version IV) are also symptoms of vision related learning problems.

Children with vision related learning problems often have 20/20 eyesight, but have difficulties with other key visual skills. Their visual systems cannot tolerate the demands within the classroom for very long, so avoidance behaviors are common. General habits that may be observed in children with vision problems, but can also be AD(H)D symptoms include:

  •  Careless mistakes in homework and class work
  • Poor ability to sustain attention and stay on task
  • Poor listening skills
  • Difficulty following directions
  • Loses and misplaces things often
  • Talks excessively and interrupts others
  • Fidgety
  • Difficult time organizing, prioritizing work and activities
  • Shifts from one activity to another
  • Difficulty playing quietly

 

The medical researchers at the Department of Ophthalmology, Ratner Children’s Eye Center, University of California, San Diego have shown that children with convergence insufficiency, a common treatable eye teaming problem, are three times more likely to be diagnosed as having ADHD as children without the visual disorder.  One of the reasons stated is because these children are being misdiagnosed.

Similarly, a study by Southern California College of Optometry reported that symptomatic school-age children with accommodative dysfunction or convergence insufficiency problems have a higher frequency of behaviors associated with ADHD.

The prevalence of Convergence Insufficiency is 17.6% of school-aged children.

Many children truly do suffer from ADD and ADHD, but certain visual and learning problems mirror the same symptoms and are often misdiagnosed.

Careful diagnosis of AD(H)D is important so as not to potentially inappropriately medicate a child.

Why?  65% of children diagnosed with AD(H)D are treated with psychostimulant medications.

Though medications have been found to improve manageability of children and increase time on task, it has NOT been proven that these medications actually affect academic achievement. A double blind study shows no cognitive, academic or behavior improvement over time between children diagnosed with ADHD that have taken medication compared to those who have not.

Paradoxically, these drugs can also cause visual side effects that can actually make it more difficult for a child with AD(H)D to concentrate on learning related tasks. Ritalin, Concerta, Metadate, Daytrana (methylphenidate), Focalin (dexmethylphenidate), Dextrostat, Dexedrine (dextroamphetamine), Adderal (amphetamine), and Vyvanse (Lisdexamfetamine) may include decreased focusing power, dilated pupils (also related to focusing) and blurry vision. Cylert (pemoline) can cause double vision, eye turns and nystagmus (”jumpy” eyes).

Nonstimulant medications can also cause visual side effects.  Strattera (atomoxetine) and Wellbutrin (bupropion) both can cause “visual changes” and blurry vision.

If a child has already been experiencing visual problems, these medications may paradoxically enhance their problem and make it more difficult to keep their attention and concentration.

To make a careful diagnosis of AD(H)D, it is important to rule out all other explanations for the symptoms manifesting, including health reasons, allergies, other behavioral problems such as depression, hearing problems and vision problems.  AD(H)D should be a diagnosis of exclusion.

 

It is recommended that all children suspected of having AD(H)D have a comprehensive vision analysis by a Behavioral Optometrist to avoid the possibility of misdiagnosis and unnecessarily medicating children.

 

Vision, however, can be only ONE piece of a complex puzzle.  It is even possible to have both a vision related learning problem and AD(H)D.

A multidisciplinary approach is important to fully assessing AD(H)D.

 

References:

Granet D.B., Gomi C.F., Ventura R, Miller-Scholte A. The relationship between convergence insufficiency and ADHD. Strabismus. 2005 Dec;13(4):163-8.

Borsting E, Rouse M, Chu R. Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency: a preliminary study. Optometry. 2005 Oct;76(10):588-92.

Rouse M, Borsting E et al. Frequency of convergence insufficiency in optometry clinic settings. Optom Vis Sci 1998 Feb,75(2):88-96.

Maples, WC, Hoenes, R. Near Point of Convergence Norms Measured in Elementary School Children. Optom Vision Sci 2007 Mar, 84(2): 224-228.

Brown RT, Wynne ME, Borden KA, et al. Methylphenidate and cognitive therapy in children with attention deficit disorder: A double blind trial. Dev Behav Pediatr 1986;7: 163-170.