ADHD and “eye problems”

Abstract

Attention deficit disorders (ADHD—inattentive or hyperactive/impulsive or mixed) is considered one of the most common psychiatric disorders in children and adolescents.1Visser S.N. Danielson M.L. Bitsko R.H. et al.Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011.J Am Acad Child Adolesc Psychiatry. 2014; 53: 34-46.e2Abstract Full Text Full Text PDF PubMed Scopus (772) Google Scholar, 2Centers for Disease Control and PreventionIncreasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children—United States, 2003 and 2007.MMWR Morb Mortal Wkly Rep. 2010 Nov 12; 59: 1439-1443PubMed Google Scholar Yet separating cause from effect still challenges medical science, and educating families faced with an information gap challenges physicians. When a child is struggling, families desperate for help look everywhere and are confused by problems that defy simple solutions. The diagnosis of ADHD is complex and deeply impacts the child, family, school, and society. Once diagnosed, a child with ADHD requires treatment with pharmacologic or behavioral/psychosocial interventions. These treatments entail great effort on the part of the family and those involved in the child's care and supervision. School-based accommodations ensue—a costly and time-consuming but appropriate burden. Two recent contributions to this journal, “The possible association of attention deficit hyperactivity disorder with undiagnosed refractive errors”3Fabian I.D. Kinori M. Ancri O. Spierer A. Tsinman A. Simon G.J.B. The possible association of attention deficit hyperactivity disorder with undiagnosed refractive errors.J AAPOS. 2013; 17: 507-511Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar and “Prevalence of attention deficit hyperactivity disorder among children with vision impairment”4DeCarlo D.K. Bowman E. Monroe C. Kline R. McGwin Jr., G. Owsley C. Prevalence of attention deficit hyperactivity disorder among children with vision impairment.J AAPOS. 2014; 18 (000–000)Abstract Full Text Full Text PDF Scopus (13) Google Scholar contribute to our understanding of the problem. Parents think that when their child does not concentrate or “look” at what they should, the eyes may be involved. That seems to “make sense.” But the eyes are only at the beginning of a complicated series of word processing, cognition, and comprehension. Still, well-meaning educators and others may suggest visual evaluation and remediation to help the perceived problem. As summarized by the Centers for Disease Control, the new criteria for diagnosis of attention disorders requires 6 of the following to be present in a child under age 17 years of age5American Psychiatric AssociationDiagnostic and Statistical Manual of Mental Disorders.5th ed. American Psychiatric Publishing, Arlington, VA2013Google Scholar: (1) often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities; (2) often has trouble holding attention on tasks or play activities; (3) often does not seem to listen when spoken to directly; (4) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (eg, loses focus, side-tracked); (5) often has trouble organizing tasks and activities; (6) often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework); (7) often loses things necessary for tasks and activities (eg, school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile. One of the additional criteria notes that, “there is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.” Clearly, many of these symptoms could be found in children with ocular problems. Both of the current articles point out the difficulty in accurately diagnosing ADHD. As they note, parental (or teacher) reporting can be accurate but also confused by multiple issues.3Fabian I.D. Kinori M. Ancri O. Spierer A. Tsinman A. Simon G.J.B. The possible association of attention deficit hyperactivity disorder with undiagnosed refractive errors.J AAPOS. 2013; 17: 507-511Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 4DeCarlo D.K. Bowman E. Monroe C. Kline R. McGwin Jr., G. Owsley C. Prevalence of attention deficit hyperactivity disorder among children with vision impairment.J AAPOS. 2014; 18 (000–000)Abstract Full Text Full Text PDF Scopus (13) Google Scholar, 6De Nijs P.F. Ferdinand R.F. de Bruin E.I. Dekker M.C. van Duijn C.M. Verhulst D.C. Attention-deficit/hyperactivity disorder (ADHD): parents' judgment about school, teachers' judgment about home.Eur Child Adolesc Psychiatry. 2004; 13: 315-320Crossref PubMed Scopus (44) Google Scholar Even pediatrician accuracy is not always reliable.7Olson B.G. Rosenbaum P.F. Dosa N.P. Roizen N.J. Improving guideline adherence for the diagnosis of ADHD in an ambulatory pediatric setting.Ambul Pediatr. 2005; 5: 138-142Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar DeCarlo and colleagues4DeCarlo D.K. Bowman E. Monroe C. Kline R. McGwin Jr., G. Owsley C. Prevalence of attention deficit hyperactivity disorder among children with vision impairment.J AAPOS. 2014; 18 (000–000)Abstract Full Text Full Text PDF Scopus (13) Google Scholar note that “since there is no definitive test for ADHD, it is plausible that other conditions with similar symptoms may be misdiagnosed as ADHD.” They conclude, “It seems reasonable then, if visual disorders that are not associated with decreased vision can mimic attention deficit, that vision impairment can also mimic attention deficit.”4DeCarlo D.K. Bowman E. Monroe C. Kline R. McGwin Jr., G. Owsley C. Prevalence of attention deficit hyperactivity disorder among children with vision impairment.J AAPOS. 2014; 18 (000–000)Abstract Full Text Full Text PDF Scopus (13) Google Scholar Faced with a child who has difficulty with near work, poor concentration, poor completion of work, and so on, why wouldn't the family think of the eyes? Mindful of these limitations, our group8Granet D.B. Gomi C.F. Ventura R. Miller-Scholte A. The relationship between convergence insufficiency and ADHD.Strabismus. 2005; 13: 163-168Crossref PubMed Scopus (82) Google Scholar reported a higher incidence of ADHD in convergence insufficiency and a higher incidence of convergence insufficiency in those with ADHD. Borsting and colleagues9Borsting E. Rouse M. Chu R. Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency: a preliminary study.Optometry. 2005; 76: 588-592Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar reported that those with symptomatic accommodative dysfunction or cognitive impairment have a higher frequency of behaviors related to poor school performance and attention. The CITT Study Group reported that 16% of their convergence insufficiency group and 6% of the “normal binocular” group were classified as ADHD by parental report— a similar difference as our group noted.10Barnhardt C. Cotter S.A. Mitchell G.L. Scheiman M. Kulp M.T. CITT Study Group. Symptoms in children with convergence insufficiency: before and after treatment.Optom Vis Sci. 2012; 89: 1512-1520Crossref PubMed Scopus (45) Google Scholar They recently reported that signs and symptoms of cognitive impairment were not strongly correlated as they worsen.11Bade A. Boas M. Gallaway M. et al.CITT Study GroupRelationship between clinical signs and symptoms of convergence insufficiency.Optom Vis Sci. 2013; 90: 988-995Crossref PubMed Scopus (33) Google Scholar Poltavski12Poltavski D.V. Biberdorf D. Petros T.V. Accommodative response and cortical activity during sustained attention.Vision Res. 2012; 63: 1-8Crossref PubMed Scopus (47) Google Scholar showed a connection between accommodation and sustained attention. So is this connection between ADHD and ocular problems an association, a cause and effect, or neither? If cause and effect, then in which direction? The recent studies may give us a clue. In children of mean age about 9 years, Fabian and colleauges3Fabian I.D. Kinori M. Ancri O. Spierer A. Tsinman A. Simon G.J.B. The possible association of attention deficit hyperactivity disorder with undiagnosed refractive errors.J AAPOS. 2013; 17: 507-511Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar found no significant correlation between ADHD and refractive error. But few children had hyperopia over 3.5 D, and the average age was about 9. The CDC survey showed that the average age of ADHD diagnosis is 7 years of age; children reported by their parents as having more severe ADHD were diagnosed earlier.2Centers for Disease Control and PreventionIncreasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children—United States, 2003 and 2007.MMWR Morb Mortal Wkly Rep. 2010 Nov 12; 59: 1439-1443PubMed Google Scholar What of the 4-year-old with high hyperopia and an aversion to reading? Have they already been corrected by age 9 years? Would their parents and teachers have worried about ADHD? Fabian and colleagues3Fabian I.D. Kinori M. Ancri O. Spierer A. Tsinman A. Simon G.J.B. The possible association of attention deficit hyperactivity disorder with undiagnosed refractive errors.J AAPOS. 2013; 17: 507-511Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar additionally reported that 12.5% of patients had a remote near point—part of the diagnostic criteria usually associated with convergence insufficiency. DeCarlo and colleagues4DeCarlo D.K. Bowman E. Monroe C. Kline R. McGwin Jr., G. Owsley C. Prevalence of attention deficit hyperactivity disorder among children with vision impairment.J AAPOS. 2014; 18 (000–000)Abstract Full Text Full Text PDF Scopus (13) Google Scholar show a rate of ADHD diagnosis in their visually impaired group significantly higher than expected in normal subjects. They also questioned cause and effect. Does the visual problem cause ADHD or is the diagnostic criteria for ADHD no longer valid when considering the visually impaired child? The diagnosis of ADHD involves the evaluation of specific behaviors.5American Psychiatric AssociationDiagnostic and Statistical Manual of Mental Disorders.5th ed. American Psychiatric Publishing, Arlington, VA2013Google Scholar, 13Leslie L.K. Implementing the American Academy of Pediatrics Attention-Deficit/Hyperactivity Disorder Diagnostic Guidelines in Primary Care Settings.Pediatrics. 2004; 114: 129-140Crossref PubMed Scopus (145) Google Scholar While very useful, this leaves the door open to confounding errors. How we test refractive errors from study to study varies. With or without cycloplegia? Autorefraction? How is remote near point defined? How do we define convergence insufficiency—signs, symptoms, or both? How are accommodative amplitudes measured, and what is normal? What is needed are stricter definitions of terms. The CEMAS group gave us clear and useful terminology.14CEMAS Working Group. A National Eye Institute Sponsored Workshop and Publication on The Classification of Eye Movement Abnormalities and Strabismus (CEMAS). Natl Eye Inst Publ Bethesda, MD Natl. Institutes Heal Natl Eye Institute. 2001. Available at http//www.nei.nih.gov/news/statements/cemas.pdf.Google Scholar The CITT reports use one definition of convergence insufficiency, which includes both signs and symptoms.15The Convergence Insufficiency Treatment Trial Study GroupThe convergence insufficiency treatment trial: design, methods, and baseline data.Ophthalmic Epidemiol. 2008; 15: 24-36Crossref PubMed Scopus (97) Google Scholar As for the behavioral component, in published reports the age of the child being evaluated and who is doing the evaluation—teacher, parent, pediatrician or psychiatrist/psychologist—and what precise criteria are being met should be documented. The behavioral expert may be unfamiliar with some of the confounding diagnoses—ocular or otherwise—and may be misled. Bias—in the form of which parents seek treatment—matters. One could imagine the family of a child with a known vision-related dysfunction not seeking other input while another family does. Until a carefully planned, thoughtfully randomized (for confounders) and age-controlled trial is completed, all involved in the care of children diagnosed with ADHD must use the available science and common sense to make the best plan of action possible. A willingness by experts to change gears in the face of a child's failure to improve is then needed. For now, the question of whether visual problems cause ADHD or cause symptoms similar to ADHD remains unanswered. This crucial issue is what recommendations to make regarding treatment. Whether ocular problems can even cause true ADHD is even harder to determine. Further, could ADHD result in a poor near point or poor convergence-related effort? Do these problems share some common root cause? Are they comorbidities? Would treatment of ADHD help eye problems? This isn't just “Which came first—the chicken or the egg?” This is, “Does the chicken come from the egg?” Parents worry about their child's current and future success and are particularly anxious about school performance. In view of these articles and the current state of knowledge, it seems prudent to recommend that children with ADHD be evaluated for a complete ocular examination, particularly for accommodation, ocular motility, and binocular function (especially convergence) and high refractive errors. Generally these problems can cause physical impediments in reading, can be directly remediated, and do not require significant parental financial or family time resources.16Handler S.M. Fierson W.M. the Section on Ophthalmology and Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists. Learning disabilities, dyslexia, and vision.Pediatrics. 2011; 127: e818-e856Crossref PubMed Scopus (94) Google Scholar It seems reasonable to consider ADHD in patients who are referred for poor concentration and are diagnosed and treated for ocular issues without resolution of their symptoms. This does not include the larger category of school-based reading problems or vague “eye tracking” issues.16Handler S.M. Fierson W.M. the Section on Ophthalmology and Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists. Learning disabilities, dyslexia, and vision.Pediatrics. 2011; 127: e818-e856Crossref PubMed Scopus (94) Google Scholar Finally, referral to a reading and educational specialist for concurrent evaluation with all the information going to the pediatrician and/or true behavioral specialist will be essential in a coordinated care approach.