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David A. Damari, O.D.
stereopsis, which was reported as “30 sec- Jeannette Liu, O.D.
onds of arc/normal.” For the examination Karen Bell Smith, O.D.
plaints, but her father was concerned be- cause of decreased working distance at the Abstract
Attention Deficit/Hyperactivity Disorder now characterized as a mental disorder are (ADHD) is one of the most studied, and most controversial, of the mental health even many adults. In addition, there is a concerned about his daughter’s difficulty disorders seen in children. Three cases are sustaining attention during reading.
presented which were, in hindsight, clearly misdiagnosed as ADHD when in fact the individuals had easily treatable five Caucasian males from ages 6 to 14 are visual dysfunctions. ADHD is often father maintained that she had been diag- misdiagnosed and misunderstood by par- tion1 and that even some preschoolers are ents, teachers, eye care professionals, her difficulty attending to nearpoint visual family practitioners, and pediatricians. In some other studies suggest that the condi- fact, some mental health professionals tion is still widely under-diagnosed.3 Be- still disagree about the diagnostic criteria for this disorder, especially in young adults. However, almost all agree it is a le- gitimate disorder that, when diagnosed dysfunctions, it is imperative that optome- symptoms or her academic performance.
and managed with a rigorous approach, trists understand this disorder and the vi- can be effectively treated. A complete vi- dence of external or internal ocular dis- sual evaluation by an eye care profes- eases or pathology, nor a visual field or sional trained in the thorough testing and CASE REPORTS
diagnosis of eye movements, accommoda- findings from BJ’s evaluation are listed in tion, and binocular fusion is one critical step toward avoiding misdiagnosis. presented to the resident (JL) at the South- Key Words
Attention Deficit/Hyperactivity Disorder (ADHD), vision disorders, diagnostic er- year before, she had been prescribed spec- rors, psychotropic drugs, interdisciplin- tacles for simple hyperopic astigmatism.
of the resident and the father. The resident degree of visual attention at that time. The tion for ADHD was no longer appropriate.
record did not report any binocular or ac- c o m m o d a t i v e t e s t i n g o t h e r t h a n Table 1. Visual Findings of the Three Cases
Case 1 pre-VT
Case 2 pre-VT
Distance VA
(OD, OS, OU)
Cover test
(distance, near)
Distance phoria
Near phoria
BI at near
may have been the cause of inat-tentive behaviors at school that had BO at near
(minus lens
method, OD/OS)
of having to re-read paragraphsfrequently, words running to- was receiving B’s and C’s at the time of gether, intermittent near and distance blur, tive infacility and binocular instability.
well in school until her junior year in high a selective serotonin reuptake inhibitor) be too costly, take too long, and has not her grades dropped to B’s and C’s.
e a c h d a y , a s w e l l a s P e r i a c t i n been scientifically proven to have any ef- appetite stimulation to counteract the ap- diseases or pathology nor a visual field or DISCUSSION
The nature of ADHD
thirteen office therapy visits, her symp- grades were poorer in fourth grade, while disorder of childhood.4 It has been found he was on medication.) His health history skills findings improved (see Table 1). She Psychiatric Association’s (APA) Diag- doctor. She then went to college and at a of ocular diseases or pathology nor a vi- nostic and Statistical Manual, 4th edition sual field or pupillary dysfunction. On his straight A’s in her first semester.
lows for “typing” of the disorder, with three different expressions of the condi- III,a the Wold Sentence Copy,a the Test of tion: attention deficit hyperactivity disor- was referred to the resident at SCO (KBS) Auditory Perceptual Skills,b and the Test for a visual perception evaluation because of Visual Perceptual Skills,b although he (ADHD-I), attention deficit hyperactivity of school and parental concerns about fall- ing grades over the previous two years. He vaccination, a nutritive disorder, or a reac- Table 2. Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Clinical Criteria for Diagnosis of Attention-Deficit/Hyperactivity
to be part of a spectrum of developmental The person must show at least six of the symptoms in one or the other of the disorders that includes pervasive develop- categories for at least six months. If the person shows at least six symptoms in each of the categories, then the combined type is considered the appropriate Symptoms of
Symptoms of inattention
characterized as signs of defects in execu- Often fails to give close attention to details or Often fidgets with hands or feet or squirms in tive functions. These executive functions Often has difficulty sustaining attention in tasks Often leaves seat in classroom or in otheror play activities situations in which remaining in seat is expected Often does not seem to listen when spoken to Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited tosubjective feelings of restlessness) i n t e r n a l i z a t i o n o f s e l f - d i r e c t e dspeech;14 Often does not follow through on instructions Often has difficulty playing or engaging in leisureand fails to finish schoolwork, chores, or duties activities quietly in the workplace (not due to oppositional behavior or failure to understand instructions) Often has difficulty organizing tasks and Is often “on the go” or often acts as if “driven by a others’ behaviors and learn how to pat- Often avoids, dislikes, or is reluctant to engage Often talks excessively in tasks that require sustained mental effort Often loses things necessary for tasks or Often blurts out answers before questions have activities (toys, school assignments, pencils, been completedbooks, tools, etc.) fest many different behaviors which result Is often easily distracted by extraneous stimuli Often interrupts or intrudes on others (butts into gressive and have an abnormal level ofemotion lability12 and intensity of actions tivity disorder, combined type (ADHD-C).
the hallmarks is social difficulty. Because they can’t control their emotions and don’t make friends fairly easily, but they have there must be evidence of clinically sig- difficulty maintaining relationships. Al- been shown that their social problems are settings and often occur in most settings, group settings and least likely to appear in culty sitting still even during television viewing. When they do sit still for a movie that they do not attend as well as and cer- tainly do not recall the story lines as well this overall variability in the appearance also been shown to delay visual-motor in- tegration skills relative to their peers, in- soning, chronic otitis media, fetal alco- agnosed when there is the presence of at least Diagnostic dilemmas
six symptoms of the disorder at a level that is inappropriate for the person’s age.
academic and social life of a child, most physical markers that have been connected f o r e p r e s c r i p t i o n o f a s t i m u l a n t tions and in most of the literature on the bered that there are many other difficulties that play a large role in the misdiagnosis and the tricyclic antidepressants,27 have been reported to cause blurred vision, im- Differential diagnoses
frequently in children who appear to have tions is also in much of the literature on correctly diagnosed with the disorder. This could be a direct effect of the medication on (reading disorder), mathematics disorder, commodative dysfunction. It is certainly a have all been or have a strong potential to relationship that requires further study.
ratings scales make almost no distinction disorder is still poorly defined for pre- health professionals who strongly believe study), found that either medication ther- h a v e e v e n m o r e p o t e n t i a l t o b e in young adults and adults. These profes- sionals believe that almost any sign of in- over a 14-month period than either behav- attention in college students or adults is disorders and general health care profes- nity care.28 However, a critical analysis of sionals often assume that if audiological has devised a new rating scale that is so the study indicates that its design “predis- and visual screenings in their offices are posed the study in favor of a differentially positive outcome for pharmacological rel- ders. There is, for example, some concern pelled to criticize it for its tendency to ig- ative to behavioural treatment.” Never- in the literature about the potential for nore any other possible mental or physical central auditory processing disorders to be symptom patterns.19,22 This confusion has phase of behavioral therapy and indeed af- happened in part because the disorder has ter the therapy visits had ended but during the strong possibility that common visual not been as well studied in adults and the therapy.29 The debate still continues. Part of the rationale is that it is widely accepted viewing those criteria in order to make a study reporting that a sample of children symptoms of the disorder in the short term is fairly well established but that the effi- Management controversies
cacy of medication in the long term (lon- the incidence in the general population.33 ADHD. It is generally conceded in the lit- with convergence insufficiency score sig- nificantly higher on one of the most popu- Conners’ Rating Scale for Parents, than in the long term.12 In fact, some studies have indicated that even children without specialist care, such as with a neurologist pediatrician relies solely on this scale for tion when taking a central nervous system despite the fact that some studies indicate stimulant,23 even if the investigators had a strong tendency for primary care practi- does not even discuss the role sensory im- likely to pay for the long-term behavioral placebo trials that are commonly used be- Indications for further study
A c a d C h i l d A d o l e s c P s y c h i a t r y 1 9 9 9 23. Losier BJ, McGrath PJ, Klein RM. Effor pat- terns on the continuous performance test in 8. Bresnahan SM, Anderson JW, Barry RJ.
studied about the relationship of vision to Age-related changes in quantitative EEG in at- c h i l d r e n w i t h a n d w i t h o u t A D H D : a tention-deficit/hyperactivity disorder. Biol Psy- meta-analytic review. J Child Psychol Psychia- pact of central nervous system stimulants 9. Biederman J, Spencer T. Attention-deficit/hy- 24. Klein RG, Abikoff H, Klass E, Ganeles D, Seese peractivity disorder (ADHD) as a noradrenergic L M , P o l l a c k S . C l i n i c a l e ff i c a c y o f d i s o r d e r. B i o l P s y c h i a t r y 1 9 9 9 N o v methylphenidate in conduct disorder with and without attention deficit hyperactivity disorder.
10. Sunohara GA, Malone MA, Rovet J, Humphries behaviors listed in the more popular rat- T, R o b e r t s W, Ta y l o r M J . E ff e c t o f methylphenidate on attention in children with 25. Physicians’ Desk Reference54 ed. Montvale, fully, especially in the classroom setting.
Comprehensive visual evaluations of chil- 26. Physicians’ Desk Reference 54 ed. Montvale, 11. Jonkman LM, Kemner C, Verbaten MN, et al.
Perceptual and response interference in children with attention-deficit hyperactivity disorder, 27. Physicians’ Desk Reference 54 ed. Montvale, multi-center setting. It should also be de- a n d t h e e ff e c t s o f m e t h y l p h e n i d a t e .
Psychophysiology 1999 Jul;36(4):419-29.
12. Dworkin, PH. Hyperactivity: Overactivity to 28. The MTA Cooperative Group, Multimodal attention-deficit disorder. in Rudolph AM, Hoffman JIE, Rudolph CD. Rudolph’s Pediat- 14-month randomized clinical trial of treatment the role of patient advocacy. It is therefore rics, 20th ed. Stamford, CT:Appleton & Lange, strategies for attention-deficit/hyperactivity absolutely essential that optometry under- d i s o r d e r. A r c h G e n P s y c h i a t r y 1 9 9 9 stand this clinical condition and the many 13. H e r s k o v i t s E H , M e g a l o o i k o n o m o u V, Davatzikos C, Chen A, Bryan RN, Gerring JP. Is 29. Pelham WE Jr. The NIMH multimodal treat- possible differential diagnoses, including the spatial distribution of brain lesions associ- ment study for attention-deficit hyperactivity the visual disorders, such as latent hyper- ated with closed-head injury predictive of sub- disorder: just say yes to drugs alone? Can J Psy- o p i a , o c u l a r - m o t o r d y s f u n c t i o n s , deficit/hyperactivity disorder? Analysis with 30. Miller A. Appropriateness of psychostimulant prescription to children: theoretical and empiri- lays, that can negatively impact attention.
14. Lemer PS. From Attention deficit disorder to A careful history and thorough evaluation autism: a continuum. J Behavioral Optom 1996 31. Buttross S. Attention deficit-hyperactivity dis- of all aspects of the patient’s visual system order and its deceivers. Curr Probl Pediatr 2000 15. Schweitzer JB, Faber TL, Grafton ST, Tune LE, is key to providing the patient and his or Hoffman JM, Kilts CD. Alterations in the func- 32. Chermak GD, Hall JW 3rd, Musiek FE. Differ- her family with advice about the appropri- tional anatomy of working memory in adult at- ential diagnosis and management of central au- ateness of the diagnosis and the best way tention deficit hyperactivity disorder. Am J ditory processing disorder and attention deficit to manage the visual side effects that often hyperactivity disorder. J Am Acad Audiol 1999 16. Maedgen JW, Carlson CL. Social functioning and emotional regulation in the attention deficit 33. Ventura RH, Granet DB, Miller-Scholte A. Re- hyperactivity disorder subtypes. J Clin Child lationship of convergence insufficiency and at- tention deficit hyperactivity disorder. (paper References
17. Biederman J, Faraone SV, Mick E, et al. Clinical p r e s e n t e d a t 2 0 0 0 A A P O S m e e t i n g . ) 1. LeFever GB, Dawson KV, Morrow AL. The ex- correlates of ADHD in females: findings from a
large group of girls ascertained from pediatric cit-hyperactivity disorder among children in and psychiatric referral sources. J Am Acad 34. Borsting E, Rouse MW, De Land PN, CIRS Group. Prospective comparison of convergence insufficiency and normal binocular children on 2. Zito JM, Safer DJ, dosReis S, Gardner JF, Boles 18. Sanchez RP, Lorch EP, Milich R, Welsh R.
Comprehension of televised stories by pre- psychotropic medications to preschoolers. J Am 3. Jensen PS, Kettle L, Roper MT, et al. Are stimu- 19. Raggio DJ. Visuomotor perception in children a. Optometric Extension Program Foundation, lants overprescribed? Treatment of ADHD in with attention deficit hyperactivity disor- Inc., 1921 E. Carnegie Ave., Ste. 3-L, Santa der—combined type. Percept Mot Skills 1999 Adolesc Psychiatry 1999 Jul;38(7):797-804.
b. Psychological and Educational Publishers, Inc., 4. National Institutes of Health Consensus Devel- 20. Gordon M, Barkley RA. Is all inattention O.O.Box 520, Hydesville, CA 95547-0520.
opment Conference Statement: diagnosis and treatment of attention-deficit/hyperactivity dis- order. J Am Acad Child Adolesc Psychiatry 21. Blackman JA. Attention-deficit/hyperactivity disorder in preschoolers. Does it exist and 5. Barkley RA. Attention-deficit hyperactivity should we treat it? Pediatr Clin North Am 1999 disorder. Scientific American 1998 Sep:66-71.
6. American Psychiatric Association. Atten- 22. Heiligenstein E, Guenther G, Levy A, Savino F, tion-deficit/hyperactivity disorder. in Diagnos- Fulwiler J. Psychological and academic func- tic and Statistical Manual of Mental Disorders, 4 tioning in college students with attention deficit hyperactivity disorder. J Am College Health 7. Baving L, Laucht M, Schmidt MH. Atypical frontal brain activation in ADHD: preschool and elementary school boys and girls. J Am


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