Before you Medicate, Investigate- ADHD & Vision

Clinical research has established that there is a link between a diagnosis of ADHD and certain vision deficits or delays in children. Many children with ADHD also test positive for a saccadic eye movement deficit. This means that they have difficulty moving their eyes efficiently and accurately from one fixed visual target to another as in going from one word or line to the next on a page of text. Many children with ADHD also test positive for a convergence insufficiency (CI). This means that they are unable to cross their eyes or team them appropriately and may experience words moving, blurring, or doubling on a page. They may get headaches when reading or they may, without ever being aware of it, suppress the vision in one eye. Many children with ADHD also test positive for accommodative infacility (AI) which means that they have trouble adjusting their focus when looking from a near image to a different image in the distance.

The good news is that all three of these visual diagnoses can be addressed with a program of in-office vision therapy under the supervision of a developmental optometrist. So, if your child has been diagnosed or if you are being encouraged to obtain a diagnosis of ADHD, don't stop there. Arrange an appointment for your child to receive a comprehensive eye exam by a developmental optometrist who incorporates vision therapy into their practice. If the eye doctor finds that your child has any of these visual problems, follow through with the program of vision therapy. To find a developmental optometrist in your area, plug your zip code into the search box at www.covd.org.

You can read more about this in: Borsting, Eric; Michael Rouse, and Ray Chu. Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency: a preliminary study. "Optometry", Volume 76. Number 10. October 2005

Eye Movements & a Struggling Adult Reader Who Has an MBA

I recently did a very simple eye movement activity with a friend who reads very slowly. It has always been a problem for her from the time she was in elementary school. In fact, she chose her high school and college courses to avoid reading so she became good at math and ended up with an MBA in finance. It remains agonizingly difficult for her to find the energy to tackle reading even a few pages. When she reads aloud, she lacks fluency, obviously struggling to keep her place while decoding the words and trying to process their meaning. So, I suggested that she might have some basic eye movement deficits. Now, I am not an eye doctor. Nor do I play one on TV but I am a skilled observer of a person's eye movements because of the work I do as a vision therapist. I asked my friend to cover one eye and to follow my pen as it moved in a slow arc in front of her eyes, up, down, across, and circling in toward her face. Then she covered the other eye and we repeated the activity. She had no problem making smooth eye movements to track the moving pen so her ocular pursuits look fine. She could even maintain a conversation while doing this activity. Next, one eye at a time again, I asked my friend to look at one pen and then, on my signal, jump her eye to another. She could not keep her fixation on the first object, nor could she accurately locate the second. When she visits a developmental optometrist for a thorough eye exam, I predict that she will receive a diagnosis of saccadic deficits. This is the result of poor control of the six muscles in each eye and can be addressed through a program of vision therapy. (In fact, just as a side note, the Purple Book of the Eye Can Too! Read series of e-books that I wrote has a lot of activities that rely on and can improve these eye movement skills). Next I asked my friend to use two eyes and focus on the #2 written on the side of a pencil that I was holding about a yard away from her face so that the eraser was facing up. I asked her to keep the #2 single and clear and to tell me if it got blurry or doubled. Slowly I pushed the pencil towards her face watching her eyes to make sure that they were converging. They did get closer and closer to her nose which is appropriate. However, when the pencil was about a foot away, my friend said, "That hurts!" She did not look away right then but I could see the stress that she was under. I repeated the activity and she repeated her report of discomfort at about the same place. So, when she visits the developmental optometrist she will likely receive another diagnosis related to her eye teaming skills.She should have been able to track that pencil in to three inches or nearer to her nose without pain, blur, or double vision. No wonder reading has been so difficult in spite of her willingness to tolerate significant discomfort in order to succeed. No matter your age, if you have difficulty reading, see whether there is a visual issue that can be resolved with a few eye exercises. Locate a developmental optometrist by going to www.covd.org and plugging in your zip code. Make an appointment and see what the doctor discovers.

School-induced Headaches- What should you do?

Students with some learning-related visual problems tend to complain that school or reading gives them a headache. This makes them dislike school and reading even when they initially looked forward to it. What could really be going on? The student may have an undiagnosed, unaddressed learning-related visual problem. For instance, if the teacher projects material on a smartboard or writes on a blackboard expecting the class to copy information from the board into their notebooks at their desk, students have to adjust how their eyes are focusing from near to far and back again. This is the visual skill called accommodation. Children with inflexible accommodation skills often cannot handle that kind of classroom activity without getting a headache. It takes a skilled developmental optometrist to identify the problem. Sometimes the appropriate treatment includes glasses. It can also be addressed through in-office vision therapy using various near/far activities and special lenses. Headaches can also be caused by the eyes failing to team well together. A child diagnosed with a convergence excess may be unable to relax their eyes when they get tired from reading because when the look away they may not be able to return to the word without it seeming to blur, wiggle, or double. On the other hand, a convergence insufficiency diagnosis may indicate that the child cannot coordinate the eyes well enough to keep a word in focus when reading. These children may also complain of having headaches at school and when reading. Many of them suppress the vision from one eye without even being aware of it which, unfortunately, can cause additional visual problems to emerge. So, if your child has frequent headaches at school or when reading but is otherwise perfectly healthy, here's what you should do. First, believe that your child is telling the truth. Second, make an appointment with a developmental optometrist to have a comprehensive binocular vision examination. Third, follow your eye doctor's recommendations regarding glasses and vision therapy. Fourth, make sure that your child understands that the condition is not permanent and they should optimistically participate in the work it will take to overcome the problem. Don't ignore the complaints until you find a caring professional who doesn't quit until the correct diagnosis and treatment plan are made.

Does Your Child Have a Head Tilt?

This could be a sign that your child favors one eye over the other. She may tilt her head because each eye may have a different visual acuity at near or in the distance. Perhaps she sees better and clearer with one of her eyes.

Another cause of your child's head tilt could be the result of a convergence insufficiency or a convergence excess. These conditions may indicate that she is having difficulty teaming both eyes together without experiencing blur or double vision. Her coping strategy could be to suppress the visual information received by one eye, shutting it off, in effect, by tilting her head.

If your child has always experienced these visual conditions, she may not even realize that it is abnormal.

So, if your child has a head tilt, don't scold her about her posture until after you take her to a developmental optometrist for a comprehensive eye exam. She may need glasses or a program of professionally supervised in-office vision therapy. You can find a developmental optometrist in your area at www.covd.org by plugging in your zip code.

"I like the book...my eyes are not in pain anymore"

Let me tell you about a fourth grade home-schooled boy. We'll call him Charlie (not his real name but he is a real boy). When Charlie's mother first called me she was really concerned about the fact that despite her background and advanced degrees in teaching, Charlie could not read with any fluency. He took forever to do his assignments, made very frequent reversals in reading and writing, and was not advancing at a pace that should have been possible given his obvious intelligence and ability to handle advanced concepts whenever they were presented orally. Charlie's mother agreed to help review the material which would soon become the Eye Can Too! Read series of books because she was ready to try anything. After having Charlie attempt to do some of the activities, she realized that his visual skills were very poor indeed. We helped her to locate a developmental optometrist in her area who concurred, gave appropriate diagnoses, and began to supervise a program of vision therapy to address the various layers of Charlie's difficulties. These included eye movement deficits, convergence insufficiency, and visual spatial as well as visual perceptual developmental delays. Did I mention that Charlie HATED to read? Well, he, like many children with learning related visual deficits, hated to read.

So, here's the good news. Six months later, this week, Charlie's mother told me that she couldn't find him when she wanted him to do something last week until she looked in the living room. Charlie was curled up in a chair reading a Hardy Boy mystery book all by himself. It was the first time that his mother had ever seen him choose to read and also continue to read for an extended period so she left him alone. 40 minutes later she asked him why he was reading.

"I like the book," he answered. "The words do not disappear at the end of the lines [like they used to]. My eyes are not in pain anymore. It doesn't hurt. It's easier."

Once again I conclude that children who resist reading or who seem to find it excessively difficult may have learning related visual issues which can be addressed through a program of optometric vision therapy under the supervision of a developmental optometrist.

Do words on the pages you read seem to wiggle, double, or blur?

If you can easily coordinate both of your eyes to point to the same place at the same time, you are unlikely to have this problem. However, if you can't, you may find reading very frustrating because the words may appear to wiggle or double up on the page so that it is very difficult to decode them. When this happens to beginning readers, the situation is more difficult because these very young children do not usually have the experience of normal single vision so they don't know that what they are seeing when they read is abnormal. They also don't have the language to explain what is happening. It is especially difficult for very bright, obviously articulate children who cannot counter the grown-ups' assertions that they are not trying hard enough.

Here is a simple test that anyone can do at home to check how well their eyes can team. It is called a pencil push-up. Hold a pencil in front of your face about arm's length away and slightly below your nose. Try to focus both eyes on the writing on the pencil keeping it clear. Slowly pull the pencil towards your nose, keeping the letters clear. Can you pull the pencil to within an inch of your nose without it becoming blurred or doubled? That is normal. If the pencil doubles or gets so blurry that you cannot see the writing, you should go to a developmental optometrist who specializes in binocular vision and who incorporates vision therapy into their practice.

If you sit opposite the person who is doing the pencil push-up, watch their eyes. You should see them move closer and closer towards the nose as if they are becoming "crossed." You may notice that one or both eyes suddenly stop crossing and bleep out towards the ears. When this happens, the person will probably report that they see two pencils. That is because the eyes stopped teaming to point to the same place in space at the same time so the brain received two separate visual images instead of one fused image with depth and detail.

This could be due to a condition called convergence insufficiency. Recent research demonstrates that it takes an average of 12 in-office sessions of vision therapy to address a convergence insufficiency. There are even some computer programs that can be purchased to address eye teaming problems at home which can be used in conjunction with in-office vision therapy with some patients who have adequate stereo vision.

So, don't accuse your child of being lazy if they report that the words wiggle or look double or blurry. Take them to a developmental optometrist who will be able to provide therapeutic interventions to address the problem in a few short months afterwhich reading should become much more efficient and enjoyable.

What if your 3-D glasses didn't work?

Did you put on a pair of 3-D glasses to watch the special Super Bowl commercials yesterday? At least 4% of you probably did not notice any difference in the picture after you put on the glasses. This is the percentage of the American population that has a strabismus or an eye-turn. Even more people have difficulty teaming their eyes together whose conditions may involve a convergence insufficiency, convergency excess, or other problem that involves binocular function and would also have found the commercials less impressive than they had been led to believe. Other people probably were able to appreciate the added depth and detail in the commercials with the 3-D glasses at first, but then their eyes began to hurt or the special effects seemed to fade away. Still others, who have amblyopia, commonly called a lazy eye, tend to suppress the information gathered by the weaker eye, so they would also have had difficulty using the 3-D glasses.

3-D glasses work by providing the right eye with different visual information than the left eye so that a more complex image will be perceived when the two pictures are combined in the retina. ( See http://www.3dglassesonline.com/how-do-3d-glasses-work/ for a discussion of how 3-D glasses work.) For them to work requires that the individual has good binocular vision. Strabismus, eye teaming disorders, and amblyopia all correlate with reduced or absent binocularity. People who have these conditions usually have difficulty with depth perception. Some of these conditions also impair the individual's ability to read efficiently because, with a convergence insufficiency, for instance, the words may seem to be unstable on the page. They may also get headaches or report seeing double when they read.

Fortunately, with appropriate diagosis and vision therapy, these conditions can be helped. New research demonstrates that convergence insufficiencies can be addressed with a program of in-office vision therapy. Children who have been diagnosed with other binocular disfunctions have the best prognoses but even adults can be assisted to gain ground as has been demonstrated by the experience of Sue Barry, dubbed "Stereo Sue". (See ttp://www.newyorker.com/archive/2006/06/19/060619fa_fact_sacks for her story.)

What is my point? If you or someone at your Super Bowl party was unimpressed by the 3-D glasses because they didn't seem to change anything about the picture, or if anyone found wearing the glasses uncomfortable or intolerable, it probably means that they need to schedule a comprehensive eye exam with a developmental optometrist who specializes in binocular vision and who also is a vision therapy provider. Then, if there is a diagnosis that can be helped by vision therapy, know that the benefit of seeing in stereo is worth the investment of time, money, frustration, and effort.

What Do Children Say When They Have Learning-Related Visual Challenges?

"I shut one eye when I read because it is easier," one second grade boy admitted to me at a recent in-office vision therapy session. His diagnosis includes saccadic deficits and convergence insufficiency. He hates to read. No wonder! The words don't stay put on the page when he attempts to read and he can't keep them single unless he closes one eye. However, that strategy deprives him of some detail and appreciation for depth. Within the next 6-12 weeks, though, he should notice a significant difference. The vision therapy activities that we do together and that he does between the weekly sessions at home are research-based and proven to strengthen the eye muscles as well as to help him realize how to coordinate and team both eyes to point to the same location at the same time, thus keeping the image single as well as 3-dimensional.

The next patient, a first grade girl who is in her eighth week of in-office vision therapy, surprised both her mother and me. Her diagnosis is saccadic deficits. This means that she has difficulty moving her eyes quickly and efficiently from one stationary visual target to another- like what the eyes do when moving from a word or a line of text to the next without loss of place, or skipping. I asked her if she has noticed any changes when she reads since she started coming to vision therapy. She said, "Yes, there aren't two words anymore." While this correlates with some of the anecdotal findings I have recorded about her progress, since she did not have a diagnosis related to eye teaming such as convergence insufficiency or convergence excess, we did not realize that she was suffering from dyplopia, double vision. Children have no other visual experience than their own so frequently they do not identify their visual challenges in language that tips off the adults that they need some interventions. This child has more vision therapy work to do to resolve the saccadic deficits but imagine how much more comfortably and successfully her school days must be now that the letters and words on a page look clear, stable, and single.

Vision therapy is an intervention that works to address quite a few learning-related visual issues. If your child is struggling at school, let me encourage you to schedule a comprehensive binocular vision exam with a developmental optometrist who is experienced with pediatric patients and who also incorporates vision therapy into their optometry practice.

Can a vision problem make reading seem too hard?

Children who are unable to team their eyes efficiently on a near-point visual target may have a condition called Convergence Insufficiency (CI). These children may complain that reading is too hard or that it is boring or that it gives them a headache. They may also complain that words double on the page or wiggle. Recently the results of a randomized clinical trial of treatments for symptomatic convergence insufficiency in children was published in the Archives of Ophthalmology (vol. 126 No. 10, October 2008). The study found that this condition can be successfully treated through in-office vision therapy. You can read the full study online at http://archopht.ama-assn.org/cgi/content/full/126/10/1336. CI is not the only learning-related visual issue that can interfere with a child's reading performance. If your child is having difficulty with school, arrange for a binocular vision examination by developmental optometrist who will be able help if there are any contributory visual issues. To find a developmental optometrist in your area go to www.covd.org and search for members of the College of Optometrists in Vision Development near you. The American Optometric Association recommends that every child receive an annual eye exam. It's important.