It is estimated that 3%-7% of school age children have ADHD, or about 4 million American children. Boys outnumber girls 3 to 1 and are more often diagnosed with ADHD. Once thought that symptoms fade with the onset of adulthood, it is now estimated that 1/3 to 2/3 of all ADHD children become ADHD adults. The only problem is 15 out of the 18 symptoms used to diagnose AD(H)D in the (Diagnostic and Statistic Manual, Version IV) are also symptoms of vision related learning problems. Children with vision related learning problems often have 20/20 eyesight, but have difficulties with other key visual skills. Their visual systems cannot tolerate the demands within the classroom for very long, so avoidance behaviors are common.
General habits that may be observed in children with vision problems, but can also be AD(H)D symptoms include:
- Careless mistakes in homework and class work
- Poor ability to sustain attention and stay on task
- Poor listening skills Difficulty following directions
- Loses and misplaces things often
- Talks excessively and interrupts others
- Difficult time organizing, prioritizing work and activities
- Shifts from one activity to another
- Difficulty playing quietly
The medical researchers at the Department of Ophthalmology, Ratner Children’s Eye Center, University of California, San Diego have shown that children with convergence insufficiency, a common treatable eye teaming problem, are three times more likely to be diagnosed as having ADHD as children without the visual disorder. One of the reasons stated is that these children are being misdiagnosed.
Similarly, a study by Southern California College of Optometry reported that symptomatic school-age children with accommodative dysfunction or convergence insufficiency problems have a higher frequency of behaviors associated with ADHD.
The prevalence of Convergence Insufficiency is 17.6% of school-aged children.
Convergence Insufficiency can be detected with a simple 10 second vision screening test called Near Point of Convergence.
Many children truly do suffer from ADD and ADHD, but certain visual and learning problems mirror the same symptoms and are often misdiagnosed.
Careful diagnosis of AD(H)D is important so as not to potentially inappropriately medicate a child.
To make a careful diagnosis of AD(H)D, it is important to rule out all other explanations for the symptoms manifesting, including health reasons, allergies, other behavioral problems such as depression, hearing problems and vision problems.
Vision, however, can be only ONE piece of a complex puzzle. It is possible to have both a vision related learning problem and AD(H)D. A multidisciplinary approach is important to fully assessing AD(H)D.
Granet D.B., Gomi C.F., Ventura R, Miller-Scholte A. The relationship between convergence insufficiency and ADHD. Strabismus. 2005 Dec;13(4):163-8.
Borsting E, Rouse M, Chu R. Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency: a preliminary study. Optometry. 2005 Oct;76(10):588-92.
Rouse M, Borsting E et al. Frequency of convergence insufficiency in optometry clinic settings. Optom Vis Sci 1998 Feb,75(2):88-96.
Maples, WC, Hoenes, R. Near Point of Convergence Norms Measured in Elementary School Children. Optom Vision Sci 2007 Mar, 84(2): 224-228.
Brown RT, Wynne ME, Borden KA, et al. Methylphenidate and cognitive therapy in children with attention deficit disorder: A double blind trial. Dev Behav Pediatr 1986;7: 163-170.
Sensory abnormalities are found in over 90% of those with autism. Vision problems are more common (70-85%) in individuals with sensory impairments. Why? The visual system is made up of a sensory-motor set of systems developed over time and with experience.
The foundation of the brain pathways formed between the eyes, the brain and the body is laid down during the prenatal and first years of life. Motor development is the sequential development of the vision, vestibular and proprioceptive systems, or the eyes, brain and body, as a coordinated unit. A properly developed motor system allows the child to explore and inspect the world with his sense of touch, smell, taste, sight and hearing.
Ideally, the child gradually becomes aware of the body and begins working to control the body’s action. As the child plays, body movements become more relaxed and fluid, causing mind, body and vision to develop. A child’s intellectual development is often limited by an inefficient body and visual system.
Every child is unique. Just as all children with autism differ in many ways, so do the visual issues in those with autism. – Lemer
Though every individual is, indeed, unique, the development of visual behavior occurs in a predictable and orderly sequence. These developmental milestones, though they may be reached at different times for different children, are essential in creating a solid foundation for more sophisticated ways to see more, observe more, experience more, remember more, learn more and become more efficient in everyday life.
A child with autism has a visual system that develops erratically. This erratic development is often caused by a compromised motor system.
Patricia Lemer, author of Envisioning a Bright Future and Executive Director of Developmental Delay Resources, talks about how motor and vision develop in conjunction with each other. The following stages of vision and development are paraphrased from her explanation of how this takes place and expanded below:
The Motor (and Sensory) Development of Vision
The motor system develops incrementally from large to small, and from the midline out. Vision develops from the bottom up and from the whole body to lower body…then upper body….trunk, neck head and eyes. Each body part, including the eyes, eventually functions independently of the core, head and upper body.
Children learn to use their vision in the context of movement. This happens in a 4 stage developmental process.
The Motor Stage – At first, the baby is simply a motor being. Many motor movements are driven by reflexive actions until the baby learns to take control.
The Motor-Visual Stage – In its early years, the motor system drives vision. The eyes go along for the ride, rather than directing the motor movement.
The Visual-Motor Stage – Now is the time when vision guides movement, an enormous developmental jump. To reach this step successfully, the body must know where it is in space and move automatically. Many with autism never get this far. Kids with autism who have organizational difficulties are usually “lost in space” as a result of underlying visual dysfunction.
The Vision Stage – This stage requires moving concepts and ideas around in the mind’s eye without actually moving the body in space. Well-functioning individuals store all types of sensory images and can visualize and retrieve them upon demand. They no longer need to touch and move to experience their world. Vision directs their thinking, organization, listening and actions and becomes the dominant sense.
Unfortunately, motor development, one of the most essential areas in dealing with autism, is often neglected in pursuit of developing the child’s intellect. Understanding the visual components that accompany each stage of healthy motor development is key to teaching vision skills that have not automatically developed in a child with autism.
We have all experienced a situation in which we had to sit through a lecture, speech or church sermon when we needed to go to the bathroom, particularly after drinking caffeine because we did not get enough sleep the night before. For a short period of time, our motor system is compromised. We need all our energy to control our body. We are unable to focus on that portion of the sermon, lecture or speech.
Individuals with autism have a compromised motor system on a more full time basis due to lack of development. This can lead to poor vision skills, trouble paying attention, poor language skills, and learning difficulties because all the energy is used up in an effort to control the body instead of being used to concentrate or perform on the task at hand.
Studies have shown that there is a significant correlation between levels of independence and ocular pursuits, visual attentiveness, position in space, body scheme, figure-ground and form perception.
Vision Lays the Foundation for Language and Relationships
Vision plays a major role in language and social-emotional development. Pragmatic language and social skill development are the most complex outcomes of tactile-motor-visual integration. For instance, if you cannot accurately interpret what is seen, it is difficult to describe what you see. If a toddler is not speaking or relating to others, a vision evaluation is essential to ensure that vision is not impeding progress.
Visual Patterns Associated With Autism
When the visual system is working properly, the individual can see, understand what is seen, and remember what is seen to be able to use vision to guide a thought or action in a meaningful way with speed, accuracy, at any time and with little energy. An inefficient system makes this process more difficult and requires more energy to go into the set of visual skills required for a task rather than the task itself.
Because vision development is erratic in an individual with autism, the visual system interferes with learning life skills and academics. An inefficient visual system can cause the following:
- Poor eye contact (looking through rather than at objects; visually sweeping a room rather than fixating on specific targets)
- Inability to pay attention (child doesn’t work at near for long because of blur or double vision)
- Vision is reflexive rather than directive (touch directs the visual system)
- Using Peripheral Vision OR Central Vision but not integrating both with ease (distracted by things in a room, or, conversely, unable to break away from a task)
- Form constancy (cannot recognize an object from another angle, resulting in rigid behavior)
- Language delays (lack of visualization)
- Lack of integration (knowing ice cream is cold without touching it)
- Inability to move out in space very well (can’t see beyond what is grasped)
- Vision Can Be Trained
In general, inefficient visual skills can interfere with the ability to react and interact with surroundings, particularly in individuals on the spectrum and AD(H)D. The best way to know if vision has developed properly and efficiently is to get a thorough visual analysis. Any development delay in vision can be trained so that the the system can run efficiently. Our goal is to improve the overall quality of life of our patients. We can do this by helping individuals reach their full potential.