The Relationship between Convergence Insufficiency (CI) and ADHD (Attention Deficit Hyperactivity Disorder)
In 2005, Dr. Granet studied 266 patients with a common near vision disorder called convergence insufficiency (CI). The study found that nearly 10 percent of subject with CI also had diagnoses of attention deficit hyperactivity disorder (ADD or ADHD). At the time of the study, Dr. Granet and his colleagues stated that this was three times the percentage of ADHD found in the general population. NOTE: estimates of ADHD in the population have continued to trend upward.
Dr. David Granet, a professor of ophthalmology and pediatrics at the University of California, San Diego, said: “Everyone is familiar with A.D.H.D. and A.D.D., but not with eye problems, especially not with convergence insufficiency. But we don't want to send kids for remedial reading and education efforts if they have an eye problem. This should be part of the protocol for eye doctors.”
“When five of the symptoms of A.D.H.D. overlap with C.I. (convergence insufficiency)," he said, “how can you not step back and say, Wait a minute?”
Dr. Granet also commented, “We don't know if convergence insufficiency makes ADHD worse or if convergence insufficiency is misdiagnosed as ADHD. What we do know is that more research must be done on this subject and that patients diagnosed with ADHD should also be evaluated for convergence insufficiency and treated accordingly.”
The Relationship between Convergence Insufficiency and ADHD
Strabismus 2005 Dec;13(4):163-8.
David B. Granet, MD FACS FAAO FAAP, Cintia F. Gomi MD, Ricardo Ventura, MD, Andrea Miller-Scholte, CO
Copyright: Strabismus Department of Ophthalmology, Ratner Children's Eye Center, University of California, San Diego, CA 92093, USA.
About Overlap of Symptoms
“The symptoms of convergence insufficiency (CI) can make it difficult for a
student to concentrate on extended reading and overlap with those of ADHD.”
“Some of the symptoms of ADHD overlap those of convergence insufficiency (CI).
Comparing the Convergence Insufficiency Symptom Survey... with the DSM-IV
criteria for ADHD, we noted that 5 of the 9 symptoms of inattention could also be
applied for CI (symptoms 1, 2, 4, 6 and 8 as follows).
DSM-IV Criteria for ADHD:
1. Often does not give close attention to details or
makes careless mistakes in schoolwork, work or other activities.
2. Often has trouble
keeping attention on tasks or play activities
... 4. Often does not follow instructions
and fails to finish schoolwork, chores, or duties in the workplace (not due to
oppositional behavior or failure to understand instructions).
... 6. Often avoids,
dislikes, or doesn't want to do things that take a lot of mental effort for a long period
of time (such as schoolwork or homework).
... 8. Is often easily distracted.”
“For the diagnosis [of ADHD], a complete medical evaluation should be performed and vision or
hearing deficits should be ruled out. Underlying visual or hearing problems may
cause the child's academic underperformance and/or lack of concentration.”
“Since the symptoms [of ADHD and convergence insufficiency] can be similar, it is not hard to imagine a diagnostic confusion.”
“We observed in our clinic that an unusual number of children with or suspected to
have ADHD also had convergence insufficiency.”
“...it is possible that the medications used to treat ADHD are aggravating CI. For
some of these drugs, difficulties with accommodation and blurring have been reported
(Bennett et al., 1999).”
“No matter what the true cause or cause and effect relationship, it is unavoidable
that the presence of CI may cause (1) misdiagnosis, (2) diagnostic confusion or
(3) exacerbation of the symptoms of ADHD.”
“In view of these findings, we believe it reasonable that CI be evaluated in
patients with or suspected to have ADHD.”
“CI is a condition that responds well to treatment...”
BACKROUND -- RESEARCH STUDY METHODS:
A retrospective review of 266 patients with CI presenting to an academic pediatric ophthalmology practice was performed. All patients included were diagnosed with CI by one author (DBG) and evaluated for the diagnosis of ADHD. A computerized review was also performed looking at the converse incidence of CI in patients carrying the diagnosis of ADHD.
RESEARCH STUDY RESULTS:
We reviewed 266 charts of patients with CI. Twenty-six patients (9.8%) were diagnosed with ADHD at some time in their clinical course. Of the patients with ADHD and CI, 20 (76.9%) were on medication for ADHD at the time of diagnosis for CI while 6 (23.1%) were either not on medication or the medication was discontinued several months before the diagnosis of CI. The review of computer records showed a 15.9% incidence of CI in the ADHD population.
We report an apparent three-fold greater incidence of ADHD among patients with CI when compared with the incidence of ADHD in the general US population (1.8-3.3%). We also note a seeming three-fold greater incidence of CI in the ADHD population. This may simply represent an association and not be a causative relationship. Until further studies are performed, however, patients diagnosed with ADHD should be evaluated to identify the small subset that may have CI -- a condition that responds well to treatment at home.
Locate the entire article on PubMed at The Relationship
between Convergence Insufficiency and ADHD.
The Eyes Have It in Attention Disorder
Visual focus may be affecting mental focus
By Thomas D. Schram
Copyright © 2000
Doctors have found an intriguing relationship between a common eye disorder and attention deficit hyperactivity disorder (ADHD), but the doctor who released the findings says the discovery opens more questions than it answers.
Dr. David B. Granet, director of the Ratner Children's Eye Center in San Diego, says workers at the center began noticing that many patients being treated for convergence insufficiency -- an inability to focus the eyes at close range -- were also being treated for ADHD.
ADHD is marked by inattentiveness, impulsive behavior and hyperactivity. This means that kids who have it have trouble sitting, focusing and controlling their impulses.
By reviewing the charts of 266 patients, doctors at the center found that nearly 16 percent of the people with ADHD had convergence insufficiency problems. That's more than three times as many as would be statistically expected.
"It just seemed over and over this was coming up. That's how a lot of research begins. Your clinical impression comes first and that leads you down a pathway," Granet says.
But this pathway may be more of a rocky road, adds Granet, who cautions against jumping to any conclusions.
"I think we've got something in convergence insufficiency that makes the symptoms of ADHD worse, and by treating it, we may be able to help those kids with ADHD cope and function," he said.
But he warns that there are many possible explanations for the relationship:
- Convergence insufficiency may be being misdiagnosed as ADHD, skewing the numbers.
- ADHD may be causing the convergence insufficiency.
- The same problem in the brain that causes ADHD may also cause convergence insufficiency.
- The drugs that children take for ADHD may be causing convergence insufficiency.
The size of the group and the fact that they all were all eye patients may present a statistical aberration.
"We just don't know yet how this association works," Granet says.
Dr. Maria Lymberis, treasurer of the American Psychiatric Association, echoes those sentiments.
"Hyperactivity is a very complex subject. All the ingredients have to be there if the brain is going to work properly. So you can think about what the people at the eye center are doing as one piece of the puzzle," she says.
Lymberis would not be surprised if a relationship between the two disorders is eventually proven to exist.
"It's not exactly a new idea. The brain is not one uniform thing. It is many centers with many different highly specialized functions. So if you're having a problem even in a relatively minor part of the circuitry, it can affect your overall attention performance," she says.
"The next step is to roll up our sleeves and do more work," says Granet. The Ratner Center next will look at children before and after they take ADHD drugs to see if the drugs were part of the equation, he says.
"I'd bet that most psychiatrists and pediatricians are not that familiar with convergence insufficiency and maybe the best thing that comes out of this is that those experts dealing with ADHD will be more aware of this."
What To Do
Conversion insufficiency affects 3 percent to 5 percent of the population. It can usually be treated with special eye exercises. If your child seems to have difficulty focusing when reading, see an eye-care specialist.
SOURCES: Interviews with David B. Granet, M.D., director, Ratner Children's Eye Center, University of California at San Diego; and Maria Lymberis, M.D., clinical professor of psychiatry, University of California at Los Angeles