Vision problems and ADHD…why “rational management” should be as simple as glaucoma

review-of-optometryIn the October 15, 2016 edition of Review of Optometry  there is a feature article entitled, Controversies in Glaucoma Management written by Bruce Onofrey, OD, clinical professor at the University of Houston. Dr Onofrey begins with the following, “The rational management of ocular disease is simple. First, know the disease. Get acquainted with the pathophysiology…Second, know the patient. Consider the risk factors for, and the consequences of the disease as well as the the patient individual considerations for drug therapy. Finally, know the drug. Get familiar with the pharmacology of the many therapies available.”

Just one day prior to the above publication, on October 14, 2016 it was my pleasure to  present  along with our resident, Dr. Mark Takesuye, to the 3rd year graduate students at the Michigan College of Optometry at Ferris State University. Our lecture, entitled, Understanding ADHD and the role of Optometry was delivered as part of the Developmental Vision course taught by professor, Dr. Sarah Hinkley. I began with a question to the audience, “In your future career as optometrists, raise your hand if you see yourself diagnosing and treating glaucoma?” The response was unanimous, 100%, every hand was raised. Then I asked, “how many of you anticipate diagnosing and managing vision problems linked with ADHD, such as convergence insufficiency?” The response was much less about 20%. Now to be fair, this is what I expected given the early phase in these students training, but at the same time it mirrors a pattern that does exist in optometry overall about certain types of  developmental vision problems and their significance to the patient.


In the eye care arena, If you are an optometrist, glaucoma is a condition that gets a lot of attention from our earliest ocular disease courses as well as almost every general optometry conference where there are a multitude of continuing education courses dedicated to glaucoma. After all, glaucoma is an important healthcare issue and because if undetected and/or untreated, can lead to blindness. Fortunately, the good news is glaucoma in children and young adults is rare. Studies show that the prevalence of glaucoma in children (under age 20 yrs old) to be .0023% or about 2 in 100,000 individuals. In older adults (over 40) there is a greater prevalence but still uncommon at about 1.86%.

But, the topic of our lecture to the students at MCO was not glaucoma. Rather our lecture was about the vision problems that are common and known to exist frequently in children that can also lead to ADHD behaviors. Furthermore, there are too many children who have been diagnosed with ADHD and unnecessarily treated with stimulant medications when there is an undetected vision problem that, once identified and properly treated, will significantly reduce ADHD behaviors and improve the quality of that child’s life. Therefore, the purpose of this lecture was to provide a basic understanding for ADHD and  to show our future doctors how  specific types of developmental vision problems can and often lead to symptoms that can be mistaken for ADHD. Most important we wanted to demonstrate the  important role we in Optometry have for our patients through optometric  evaluation and management of these vision conditions including treatment considerations involving vision therapy.

Attention Deficit Hyperactivity Disorder (ADHD) is coined a  neurodevelopmental or neurobehavioral condition. It is the most commonly studied and diagnosed psychiatric disorder in children and adolescents. The American Psychiatric Association estimates ADHD occurs in about 5% of children when diagnosed via the DSM-V criteria. Map of ADHD by StateHowever, the CDC surveys estimate that approximately 11% of children 4-17 years of age (6.4 million) have been diagnosed with ADHD as of 2011. In some states the number diagnosed is nearly 20%!

How is ADHD diagnosed? Those with ADHD show a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with functioning or development.  Medicine’s primary diagnostic criteria relies on a symptom profile from family and non-family members, ex: Connor’s Rating Scale

In the pediatric medicine arena, ADHD is one diagnoses that captures the spotlight. However unlike glaucoma that is rare in children ADHD is much more common in children. Even using the DSM-V criteria of 5% the incidence would be reason to have concern. But, considering that the CDC estimates that diagnosis of ADHD is diagnosed and stimulant medication prescribed 1 in 10 children on average in the US and in some states as much as 1 in 5 children and predominantly on a symptom checklist, begs the question…what if the child diagnosed with ADHD has another cause for their behaviors? Are we overmedicating millions of children with potentially dangerous stimulant drugs when there is another explanation involving a vision problem?

In fact,  we have a large body of clinical research published in optometry, medicine, neuroscience in the United States and internationally (some of the most notable summarized here) to show that there is a direct connection between specific vision problems and ADHD behaviors. These vision disorders are known as: convergence insufficiency,  accommodative disorder,  oculomotor dysfunction and delays in visual processing (visual perception).  The prevalence of these conditions are significant. Convergence insufficiency and accommodative disorders tend to occur together and are 5-10% in children. Oculomotor dysfunction as high as 22%  Visual Information processing problems occur in about 15-20%

If we  in Optometry have the professional responsibility to diagnose and manage glaucoma a condition that is rare in children, shouldn’t the same be said for developmental vision problems that can mimic or exacerbate ADHD which have a significantly high prevalence in children?

If the rational management of a serious vision problem is to “know the disease, understand the patient’s needs and know the treatments, both drug treatments and other therapies”, how long will it take before optometry and all of healthcare considers the same for the vision problems found with ADHD?

However, in spite of the best efforts by many of our optometric organizations, The American Optometric Association which has published Clinical Practice Guidelines for Optometrists (Care of the patient with Learning Related Vision Problems and Care of the patient with Accommodative and Vergence Dysfunction), The American Academy of Optometry (position paper on vision and learning), The College of Optometrists in Vision Development which offers Board Certification, continuing education for doctors and has a plethora of materials on these diagnosis and much more, and the Optometric Extension Program which also provides continuing education and many resources, too many children with vision problems linked to their ADHD are unfortunately being overlooked. Could this be one of the primary reasons why the CDC estimates for diagnosed ADHD are so over the top out of sync with what the American Psychiatric Association?

Consider the facts: ADHD is a neurodevelopmental/behavioral disorder  and medicine’s “best practice” for diagnosing ADHD is based on a symptom profile with a high frequency of certain behaviors.

Since there are many other medical diagnoses that can mimic and/or increase  ADHD behaviors and since  vision problems have been proven to be significant, optometrists and all healthcare providers should rule out vision problems such as convergence insufficiency, accommodative dysfunction, oculomotor dysfunction and delays in visual information processing as possible causes first before beginning medication.

While there can be a role for medication for some with ADHD, the important message for doctors is to know how to first diagnose and treat when vision problems co-exist with ADHD.

The time has come to end the senseless struggle for those children who have vision-based ADHD behaviors and apply a rational management of these vision problems just as simply as identifying and treating glaucoma. 

Dan L. Fortenbacher, O.D., FCOVD

9 thoughts on “Vision problems and ADHD…why “rational management” should be as simple as glaucoma

  1. This is a wonderful post, and certainly how the brain uses the eyes should always be considered in children with difficulty attending. That 80 percent of optometric students do not see themselves as participating in this process is not encouraging. The confusion about causes of inattention could easily be part of the problem. Attention deficit disorder is not unlike acuity deficit disorder. There are probably many reasons that children have difficulty attending, just as there are many reasons for failure to read the correct letters on an eye chart. Optometry does very well when considering eye problems, so long as they do not have to be correlated with consciousness. Then the science of optometry becomes an art. We have ways to assess dry eyes. The assessments do not always agree with symptoms. The same is true of convergence insufficiency, not to mention refraction. One patient with a half-diopter of myopia will be severely frustrated, another oblivious to blur or other symptoms. Visual fields in Glaucoma—also dependent on consciousness—are similarly frequently inconsistent. Physical science has allowed us to travel to the moon, has doubled our life spans, and has given us the digital age. Sciences of the mind, of behavior, of society, of anything concerned with consciousness, have hardly kept pace. We are little nicer than we were a hundred years ago. As optometrists we are responsible for both the art and science of patient care. Eye care falls closer to the scientific end of the spectrum. Vision care (how the brain uses the eyes) is still heavily dependent on our art. Evidently, four out of five optometrists were not selected for their artistic skills or more would be interested not just in protecting patients from blindness but allow them to reach their visual potentials in life.

  2. Love the post, Dan. I really wish optometry students had this as part of their curriculum. When people call my office and ask if I do “dyslexia” testing, my staff replies with “Dr. Bazin used to teach children with learning disabilities before she became an optometrist. She will test your child to see if s/he has a learning related vision problem. That is what we treat.”

  3. This is such a good article. I have a grandson who suffered through school until sixth grade when he actually became suicidal because he just couldn’t do it anymore. He had trouble reading and retaining and when he would write all his words would run together. He would get so frustrated that he would write and erase so many times….it would take him 30 mins or so just to write one sentence. He finally went to a local Dr that suggested he see someone to have his vision tested. He passed the actual vision test no problem but when they did the additional testing for other problems he failed miserably. He had no depth or spacial perception. After 6 months of vision therapy he began to excel. He was on the Honor roll his eighth grade year! Thank God for that Dr. Schools should check for other vision problems when they do their testing or at least the optometrist at a regular visit. I can’t imagine how different his life would be if his problem wouldn’t have been discovered.

  4. In the Olympics or professional sports, those who use performance enhancing drugs are disqualified, but when it comes to school and our children, performance enhancing drugs are promoted as a positive?
    Perhaps as Fagin sings in Oliver (Charles Dickens) ” I think I better think it out again”.

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