Vision Issues Masquerading as ADD/ADHD

Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD, AD/HD)
A Developmental Approach

by Patricia S. Lemer, M.Ed.

"Over the past several years, ADD has received a tremendous amount of attention from parents, professionals and policymakers across the country -- so much so, in fact, that nearly everyone has now heard about ADD or ADHD. While helpful to those challenged by this disability, such widespread recognition creates the possibility of improper diagnosis and inappropriate treatment. Now, more than ever, parents who suspect their child might have ADD or ADHD and parents of children who have already been diagnosed with the disorder need to evaluate information, products, and practitioners carefully."

National Information Center for
Children and Youth with Disabilities
(NICHCY)

Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (add-adhd, ADHD, AD/HD) is being diagnosed with increasing frequency in both children and adults. Many of these individuals were previously labeled hyperactive or minimally brain damaged. According to the American Psychiatric Association, it is estimated that there are approximately 1.6 to 2 million people who have this disorder.
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DMS-IV), published by the American Psychiatric Association, classifies three types of Attention Deficit/Hyperactivity Disorder or ADHD (officially called Attention-Deficit/Hyperactivity Disorder or AD/HD).

• AD/HD Predominantly Combined Type
• AD/HD Predominantly Inattentive Type
  Six of nine symptoms of inattention must be present for diagnosis
• AD/HD Predominantly Hyperactive-Impulsive Type
  Six of nine symptoms of inattention must be present for diagnosis

In each case, the symptoms must be present for at least six months to a degree that is maladaptive and inconsistent with developmental level. In addition, some symptoms must be present prior to age seven, and in two or more settings (e.g., at school, work and home). There must be clear evidence of clinically significant impairment in social, academic or occupational functioning, and the impairment cannot be caused by other disorders such as anxiety, psychosis or pervasive developmental disorder (PDD).
Even though it is generally assumed that people diagnosed as having ADD or ADHD evidence a common set of characteristics emanating from a common etiology, little agreement is found among researchers regarding these symptoms. Some symptoms seen in children diagnosed as having attention deficits such as Attention Deficit Disorder (ADD), ADD-ADHD, AD(H)D, Attention Deficit/Hyperactivity Disorder or ADHD (Attention-Deficit/Hyperactivity Disorder or AD/HD):

• Making careless mistakes in schoolwork
• Difficulty sustaining attention to tasks
• Not listening to what is being said
• Difficulty organizing tasks and activities
• Losing and misplacing belongings
• Fidgeting and squirming in seat
• Talking excessively
• Interrupting or intruding on others
• Difficulty playing quietly

These symptoms are also seen in both children and adults with learning-related visual problems and/or sensory integration dysfunction and/or undiagnosed allergies or sensitivities to something they eat, drink or breathe. See a chart that illustrates this graphically.

When Is Learning Difficulty Due to a Vision Problem?

While learning occurs through a number of complex and interrelated processes, vision plays a key role. Many signs, symptoms, and behaviors associated with learning disabilities are similar to those caused by vision problems. This is why it is so important that a comprehensive vision examination be part of the interdisciplinary evaluation of all children who are failing to succeed in school.

Here are some signs and symptoms to look for that may indicate a vision problem.

Symptoms of Possible Vision Problems
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-Complains of blurred vision
-Rubs eyes frequently
-Squints
Nearsightedness, Farsightedness, or Astigmatism
inability to see clearly in the distance or up close

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- Closes or covers one eye
- Occasionally sees double
- Rubs eyes frequently
- Able to read for only a short time
- Poor reading comprehension
Eye coordination problems
inability to coordinate the eyes together effectively

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- Holds things very close
- Complains of blurred vision
- Poor reading comprehension
- Says eyes are tired
- Able to read for only a short time
- Has headaches when reading
Eye focusing problems
inability to easily refocus eyes or maintain clear focus

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- Moves head excessively when reading
- Frequently loses place, skips lines when reading
- Uses finger to keep place
- Poor reading comprehension
- Short attention span
Eye tracking problems
inadequate ability to smoothly and accurately move the eyes from one point to another

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- Mistakes words with similar beginnings
- Difficulty recognizing letters, words, or simple shapes and forms
- Can't distinguish the main idea from insignificant details
- Trouble learning basic math concepts of size, magnitude, and position

Faulty visual form perception
inability to discriminate differences in size, shape, or form

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- Trouble visualizing what is read
- Poor reading comprehension
- Poor speller
- Trouble with mathematical concepts
- Poor recall of visually presented material
Faulty visual memory
inability to remember and understand what is seen

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- Sloppy handwriting and drawing
- Can't stay on lines
- Poor copying skills
- Can respond orally but not in writing
Faulty visual motor integration
inability to process and reproduce visual mages by writing or drawing

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- Trouble learning right and left
- Reverses letters and words
- Trouble writing and remembering letters and numbers
Difficulty with laterality and directionality
Poor development of left/right awareness

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Physical signs or symptoms

Frequent headaches or eye strain
Blurring of distance or near vision, particularly after reading or other close work
Avoidance of close work or other visually demanding tasks
Poor judgment of depth
Turning of an eye in or out, up or down
Tendency to cover or close one eye, or favor the vision in one eye
Double vision
Poor hand-eye coordination
Difficulty following a moving target
Dizziness or motion sickness
Performance problems

Poor reading comprehension
Difficulty copying from one place to another
Loss of place, repetition, and/or omission of words while reading
Difficulty changing focus from distance to near and back
Poor posture when reading or writing
Poor handwriting
Can respond orally but can't get the same information down on paper
Letter and word reversals
Difficulty judging sizes and shapes
How to Identify a Vision Problem
Children should be referred for a comprehensive eye exam whenever visual symptoms are noticed or if they are not achieving their potential. Many of these vision problems will not be detected during a school vision screening or limited vision assessment as part of a school physical or routine pediatric health evaluation.

Children With Special Needs: A Collaborative Approach to Vision Care

Children With Special Needs: A Collaborative Approach to Vision Care by Dr. Rochelle Mozlin

In a recently published article, Dr. Marie Bodack describes a program at the Herbert Birch Childhood Center in NYC in which 273 children with special needs received eye examinations.  These children, between the ages of 3 and 5 years, had been diagnosed with developmental delays and were enrolled in early intervention programs. Diagnoses included Down Syndrome, cerebral palsy and autism.  The occupational therapists at the school were instrumental in bringing optometric care to the Birch School because they felt that many of the students had undiagnosed vision problems.  Through an affiliation with SUNY State College of Optometry, optometric care was provided to the children during their school day.

The provision of eye care to these children was very collaborative and very flexible.  The children were accompanied to the eye examination by either their occupational, physical or speech therapist.  The therapists’ presence was very comforting to many of the children, and often they were able to assist during the examination process.  The therapists often made suggestions on how to modify procedures in order to obtain responses or helped prepare the children for the examination experience.  They were also instrumental in facilitating communications between doctor, parents and teachers.  If a child was having a “bad day,” or follow-up care was needed, a 2^nd appointment was scheduled.

Research has shown that children with special needs have a higher incidence of vision problems, and this population was no exception.  More than 10% of the children required glasses; 6% had strabismus, and 3.7% had amblyopia.  An additional 2.5% were referred for additional evaluation for potential ocular health problems.  ALL children with special needs should have comprehensive vision examinations ASAP!  Dr. Bodack's research has reaffirmed this.

Many children with special needs are unable to express their discomfort or explain their symptoms.  Their comorbidities often require large investments of time and money to manage.  The examination of pre-school children with special needs is often difficult.  Therefore, they do not receive the comprehensive vision care that they desperately need, and their vision problems remain undiagnosed.   This project is an example of what can be accomplished when the services are brought to these children instead of waiting for them to seek care.  The interdisciplinary environment facilitated the diagnosis and management of vision problems at an early age.  Most importantly, communication between optometrist, therapists and teachers created a better understanding of each child’s visual functioning and how to help that child reach his or her full potential.