Visual Dysfunction vs. ADD/ADHD Misdiagnosed Child Behavior Disorders
Children presenting with inattention that can contribute to behavior disorders are often misdiagnosed and/or misrepresented. Teachers and parents commonly characterize these children as being difficult, with ADD (attention deficit disorder) and ADHD (attention deficit hyperactivity disorder) diagnoses commonly used to identify them. However, visual dysfunction can often be the cause of a child’s inattention, especially when associated with reading/learning disabilities and behavior disorders. Typically, it is the child’s pediatrician, pediatric psychiatrist and/or neurologist who routinely prescribe medications – Ritalin, Concerta, Adderall and/or Prozac to name a few – used to create order and quiet in a child’s behavior. Academically, it is well understood that ADD and ADHD are diagnoses of exclusion. Therefore, when children present with attention issues, treatment for all physical conditions that can simulate inattention behavior should be considered prior to use of medication, inclusive of visual, speech/auditory and motor dysfunctions.
Understandably, professionals are pressured to find answers for these children with inattention behavior and associated reading/learning problems. The school system and individual teachers are also pressured to create an environment where these children labeled as inattentive can become socially and academically able to function within the mainstream classroom. In spite of the fact that medication may promote a child’s behavior to be more predictable and even appear to cause a child to stay on task better, if the underlying problems children experience are not medical in nature, these children will not develop the appropriate skills to learn or to read any easier. In fact, they may become more frustrated because they don’t feel right not knowing what’s wrong. Side effects of medications may create additional overlays causing children to feel greater fatigue, restlessness, lose of appetite and even feelings of despair. Medicating without success can reinforce a child to feel unstable about his/her self, thus creating insecurity and, ultimately, resulting in reduced self-confidence and limited self-esteem.
Medications may also seem to cause children to be less disruptive in class, and children may appear to better stay on level with the rest of the class. However, if what was thought to be a chemical imbalance is truly a behavioral vision disorder, a child will still not be comfortable and effective processing visual information. Farrar et al. (2001), utilizing a small scale questionnaire study, found that ADD/ADHD children who had undergone medical treatment exhibited greater visual and quality of life symptoms than a similar group of non-ADD/ADHD children.
Vision processing is multifaceted and complex in its relationship to learning. A significant part of this process has been identified by Scheiman (2002) (p.47) as visual efficiency, referring to it as “effectiveness of the visual system to clearly, efficiently and comfortably allow an individual to gather visual information at school, work or play.”
Its components are comprised of ocular motility (tracking), accommodation (focus) and binocular vision (eye coordination).
Behavioral optometry has treated multiple conditions affecting inattention as a consequence of inefficient tracking, focusing and eye coordination skills. Conditions known to benefit from behavioral vision care include: “dyslexia, dyspraxia, any learning problem in the classroom (poor concentration, poor handwriting, low reading, poor comprehension, poor math, fidgety, etc.), eyestrain in the office including computer eyestrain, improving sports performance, traumatic brain injuries, strabismus and amblyopia, headaches, double vision, fatigue, attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), children with behavioral problems, poor coordination, clumsy and poor at sports, especially ball games and team games” BABO (2008).
A study by Borsting et al. (2005) presented data indicating that school-age children with symptoms, which arise from accommodative dysfunction (a focusing inefficiency) and convergence insufficiency (a common binocular dysfunction), have a higher frequency of ADHD behavior compared to a control group. Additionally, Granet et al. (2005) reported that the prevalence of convergence insufficiency in an ADHD population might be as much as three times higher than in a normal population.
Children suffering from a behavioral vision disorder commonly have difficulty converging their eyes inward (inefficiency turning eyes inward), have difficulty focusing (inefficiency in identification) and are unable to track (follow from one point to another). Misdiagnosis may not only support the status quo of visual inaccuracy, it can diminish self-esteem and even develop into what is called the “Failure Syndrome.” Children with this syndrome believe they not only are unable to perform a task but also they believe they are what’s wrong in not being able to perform the task. In other words, they believe they are incorrect.
Although misdiagnosed children may not always be considered “at risk” because medication has appeared to ease the situation, they will most likely be affected by a lack of self-worth instilled within them by the misdiagnosis. This may ultimately lower a child’s professional expectation and cause acceptance of a vocation or profession lower than his/her actual potential.
Parents and child study team members, who have consulted eye doctors, may often feel a false sense of security when told their child’s eyes are fine; they see “20/20.” Seeing with clarity is important, but a child’s visual concerns may have nothing to do with eyesight and everything to do with efficient, effective and effortless eye coordination, focus and tracking ability. Bright children who see with 20/20 vision may still be unable to comprehend what they see because they lack the visual coordination skills needed to perform the task.
A lack of visual coordination results in two sets of eye muscles not working together. One muscle system controls focus for clarity while the other system controls seeing single, not seeing double. These two systems are linked. Inaccuracy in one system will typically create a mismatch in the other creating inefficiency between the two. Classical symptoms of a motivated child trying to overcome inattention due to visual dysfunction are eyestrain associated with excessive eye rubbing/burning, headaches after sustained, visually demanding activities and blurred vision during near activities.
Symptoms of eye avoidance, typical of an unmotivated child, are double vision, omissions or substituting words while reading; difficulty finishing school work, and the most common symptom is loss of place while reading. Non-readers typically have no symptoms at all simply because they avoid any situation that calls for them to read for any considerable length of time.
Vision therapy (eye exercises) is the treatment of choice for children identified as inattentive due to visual dysfunction, associated reading/learning difficulties and behavior concerns. This therapy can be defined as the use of optometric techniques utilizing behavior modification and biofeedback designed to rearrange conditions allowing for new insights and an alternative approach fostering efficient, effective and, ultimately, effortless visual function. Therapy requires the participant to be active in the treatment, thus establishing a new learning experience that becomes transferable to other associated skills. Ultimately, these skills become the foundation for an automatic reliable visual system.
The success of vision therapy depends on the motivation of the team: inclusive of the child, parents and behavioral optometrist. If the condition is recent and academic lags have not yet occurred, the program is quite simple often resulting in complete remediation. When the condition is long standing, academic and/or emotional concerns can become secondary problems that must be addressed along with the primary visual. The more complex the situation, the more involved the treatment strategy. When secondary issues are evident the team must include appropriate professionals. With academic involvement, reading, learning and special education professionals need to be resourced, and social workers/psychologists consulted if emotional concerns have surfaced. Occupational and physical therapists are utilized for development of fine and gross motor skills, and speech and language therapists are responsible for treatment of receptive and/or expressive language delays.
Parents, teachers and school administrators have the power to advocate for children, especially when they realize symptoms of children labeled inattentive due to visual dysfunction can mimic and subsequently masquerade as ADD and/or ADHD.
Early and appropriate intervention is essential when changing a child’s course of development from one of inattention, frustration and lack of ability to one that encourages belief in oneself and a lifetime of success. The correct diagnosis and ultimate treatment for children with inattention behavior will do just that and more. Should parents medicate their child or redevelop his/her visual function to be efficient, effective and effortless?
The extent that we see is a reflection of the love that we feel.
To learn more, check out Warshowsky’s book, How Behavioral Optometry Can Unlock Your Child’s Potential: Identifying and Overcoming Blocks to Concentration, Self-Esteem and School Success with Vision Therapy, at Amazon.com.