Thursday, September 25, 2014

Learning, ADHD and vision

Since this is the first week of school for most students in British Columbia, we'd like to share this article from the Victoria Times Colonist on the link between ADD and vision. For all the children who struggle in school, many (as many as 60% accordingg to some studies) have a treatable vision or eye movement disorder that may be an obstacle to learning. Many of these vision problems mimic the symptoms of ADD/ADHD causing some kids to be misdiagnosed with ADD when they actually have a treatable vision or eye movement problem.

The article interviews Dr. Quaid, an Ontario expert in the treatment of double vision. Dr. Quaid is also the author of a study that look at students who were on Independent Learning Plans (IEPs) at school because of learning difficulties, many of which were specific to reading.  In that study Dr. Quaid found that most of the students on the IEPs had vision problems which likely impacted their ability to learn and read.

The article quotes Dr. Quaid in this excerpt:

But Quaid says children with ADHD often get either a delayed diagnosis or no diagnosis of ocular disorder. Doctors treating a child with ADHD rarely consider arranging for an eye examination to detect ocular malfunction.
This highlights an important problem in the care of children because the symptoms of many vision disorders, especially convergence insufficiency, mimic those of ADHD.  It is probable that many children are misdiagnosed with ADHD when they actually have a treatable vision problem.

In the Times Colonist article, Dr. Quaid discussed the connection between ADHD and convergence insufficiency:

Convergence insufficiency is not rare. Quaid says that one in 10 people has some sort of eye-teaming problem. But what is shocking, and generally unknown, is that children showing signs of ADHD are three times more likely than other kids to have convergence insufficiency.
That’s why any parents who are investigating whether their child has ADHD should also arrange for the child to see an eye specialist with expertise in eye-teaming abnormalities.
Quaid adds that doctors often place ADHD children on Ritalin, or some other medication, without arranging for a detailed oculomotor examination.

There is a connection between attention deficit hyperactivity disorder (ADHD) and convergence insufficiency that has been recognized in scientific studies. Studies have shown that many of the academic and attention related behaviors associated with ADHD are also present in individuals with convergence insufficiency. As a result some individuals who have been diagnosed with ADHD may actually have treatable convergence insufficiency.

Very recent research has pointed out that children with visual impairments are more than twice as likely as the general population to have a diagnosis of ADHD.  For example, a study published in the Journal of AAPOS : The Official Publication of the American Association for Pediatric Ophthalmology and Strabismus/American Association for Pediatric Ophthalmology and Strabismus in February, 2014, found that children with vision disorders are more then twice as likely as the general population to be diagnosed with ADHD.

The authors of the study looked at a group of visually impaired children between the ages of 4 and 17. The authors found that 22.9% of the kids in this group had a parent-reported diagnosis of ADHD. That was 2.3 times greater than the national average, which is 9.5%.

The fact that a an ADHD diagnosis is twice as common in people with vision problems suggests that may people with vision problems are being misdiagnosed with ADHD. In fact ADHD diagnoses have increased “by 33% between 1997-1999 and 2006-2008.” These statistics are worrisome and suggest a possible over-diagnosis of this condition (see Feldman HM, Reiff MI. Attention Deficit-Hyperactivity Disorder in Children and Adolescents. N Engl J Med. 2014;370:838-846)

Many people are shocked that 11% of children have received a diagnosis of attention deficit hyperactivity disorder(ADHD). This sharp rise in ADHD diagnoses over the last decade is cause many to worry about inappropriate diagnosis and the unnecessary over medication of children.

Even more troubling, we can expect over-treatment to increase in the near future because, according to the New York Times:

the American Psychiatric Association plans to change the definition of A.D.H.D. to allow more people to receive the diagnosis and treatment. A.D.H.D. is described by most experts as resulting from abnormal chemical levels in the brain that impair a person’s impulse control and attention skills.

There are many reasons for the increase. Experts believe that some doctors are quick to jump to the conclusion that a child has ADHD when they present with any indication of inattention. Another factor may be advertising by the pharmaceutical industry that presents medication as something that can drastically improve a child's life. Some people blame the parents for pressuring doctors into doing something to improve a child's academic performance.  We believe that un-diagnosed vision problems contribute to the mistaken diagnosis of ADHD in children who actually have a treatable vision problem.

Here is  a short research summary on the connection between ADHD-like syptoms and vision problems:

  • Borsting E, Rouse M, Chu R. Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency: a preliminary study. Optometry. 2005;76:588–92. [Download]

    The results from this preliminary study suggest that school-aged children with symptomatic accommodative dysfunction or convergence insufficiency (eye movement disorders) have a higher frequency of behaviors related to school performance and attention as measured by the a survey called the Connors Parent Rating Scale–Revised Short Form. The survey uses 27 questions to test a broad range of school-related behaviors in the following categories: oppositional, cognitive problems/inattention, hyperactivity, and ADHD Index. 

  • Granet DB, Gomi CF, Ventura R, Miller-Scholte A. The relationship between convergence insufficiency and ADHD. Strabismus. 2005;13:163–8. [PubMed].

    In this study, the researchers found that people diagnosed with ADHD were three times more likely to have convergence insufficiency than the general population. 

  • Gronlund MA, Aring E, Landgren M, Hellstrom A. Visual function and ocular features in children and adolescents with attention deficit hyperactivity disorder, with and without treatment with stimulants. Eye. 2007;21:494–502. [PubMed].

    In this study, the researchers found that children diagnosed with ADHD have a higher frequency of eye problems than the general population and that the eye problems did not improve when children were on stimulants, which are the drugs that are commonly prescribed to treat ADHD. 

  • Rause, et al. Academic behaviors in children with and without parent-report of ADHD. Optom Vis Sci. 2009 October; 86(10):1169–1177.[PDF]
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