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September 12, 2007

BehindTheMedspeak: Is It A.D.H.D. — Or Convergence Insuffiency?


If you're like me you've never heard of convergence insuffiency (C.I.).

But if you keep reading you'll learn as much as I know about it.

In yesterday's New York Times Science section Laura Novak wrote that 5% of school-age children have C.I., which causes people to see double because their eyes cannot work together at close range.

That means there's one in every classroom, on average.

Even many pediatricians, quick to medicate for A.D.H.D. and A.D.D., haven't heard of it.

Here's the Times story.

    Not Autistic or Hyperactive. Just Seeing Double at Times

    As an infant, Raea Gragg [above] was withdrawn and could not make eye contact. By preschool she needed to smell and squeeze every object she saw.

    “She touched faces and would bring everything to mouth,” said her mother, Kara Gragg, of Lafayette, Calif. “She would go up to people, sniff them and touch their cheeks.”

    Specialists conducted a battery of tests. The possible diagnoses mounted: autism spectrum disorder, neurofibromatosis, attention-deficit hyperactivity disorder, anxiety disorder.

    A behavioral pediatrician prescribed three drugs for attention deficit and depression. The only constant was that Raea, now 9, did anything she could to avoid reading and writing.

    Though she had already had two eye exams, finding her vision was 20/20, this year a school reading specialist suggested another. And this time the ophthalmologist did what no one else had: he put his finger on Raea’s nose and moved it in and out. Her eyes jumped all over the place.

    Within minutes he had the diagnosis: convergence insufficiency, in which the patient sees double because the eyes cannot work together at close range.

    Experts estimate that 5 percent of school-age children have convergence insufficiency. They can suffer headaches, dizziness and nausea, which can lead to irritability, low self-esteem and inability to concentrate.

    Doctors and teachers often attribute the behavior to attention disorders or seek other medical explanations. Mrs. Gragg said her pediatrician had never heard of convergence insufficiency.

    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.”

    In 2005, Dr. Granet studied 266 patients with convergence insufficiency. Nearly 10 percent also had diagnoses of attention deficit or hyperactivity — three times that of the general population. The reverse also proved true: examining the hospital records of 1,700 children with A.D.H.D., Dr. Granet and colleagues found that 16 percent also had convergence insufficiency, three times the normal rate.

    “When five of the symptoms of A.D.H.D. overlap with C.I.,” he said, “how can you not step back and say, Wait a minute?”

    Dr. Eric Borsting, an optometrist and professor at the Southern California College of Optometry who has also studied the links between vision and attention problems, agreed. “We know that kids with C.I. are more likely to have problems like loss of concentration when reading and trouble remembering what they read,” he said. “Doctors should look at it when there’s a history of poor school performance.”

    Dr. Stuart Dankner, a pediatric ophthalmologist in Baltimore and an assistant clinical professor at Johns Hopkins, said that children should be tested for convergence difficulty, but cautioned that it was not the cause of most attention and reading problems.

    Dr. Dankner recommended an overall assessment by a psychologist or education specialist. “An eye exam should be done as an adjunct,” he said, “because even if the child has convergence difficulty, they will usually also have other problems that need to be addressed.”

    Doctors recommend a dilated eye exam and a check of eye teaming and focusing skills. Testing includes using a pen or finger to test for the “near point of convergence,” as well as a phoropter, which uses lenses and prisms to test the eyes’ ability to work together.

    There is no consensus on how to treat convergence insufficiency. Next spring, the National Eye Institute will announce the results of a $6 million randomized clinical trial measuring the benefits of vision therapy in a doctor’s office versus home-based therapy.

    For Raea Gragg, the treatment was relatively simple. For nine months she wore special glasses that use prisms to help the eyes converge inward. She then had three months of vision therapy. She has just entered fourth grade and is reading at grade level.

    “Raea didn’t know how to describe it because that’s all she’s ever known,” her mother said. “She felt like she had been telling us all along that she couldn’t see, but nobody listened.”

September 12, 2007 at 12:01 PM | Permalink


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Reptilian brain, 1; mammalian brain, 0...

Posted by: ScienceChic | Sep 12, 2007 4:52:12 PM

The BIG BIG BIG problem with these diagnoses are that no one is doing them...

I've had ADHD since I was a kid...I was just called hyperactive back then. It is worked well in my advantage for YEARS. Taking graduate courses, however, I wanted to see how well these drugs would work to focus my attention on a single item (for a reality check, I own two businesses, have a research position with a major university, and a consultant...I gave up a music career after realizing that I'll never be the star and will always be a behind the scenes guy...again, ADHD has worked well for me!)

I know a 'little' something about psychological testing...so I goes to the doctor to see about getting all medicated up, expecting a 3 hour introductory test. Attention tests, tap tests, blah blah blah...being that I force other people to take my tests, I thought it would be a good thing to see this stuff from the other side. I made no mention to being diagnosed as a child, nor my work in psychometrics.

Nope...nothing of the like. A 10 minute sit down with a nurse practitioner who asked a checklist of a little more than 10 items, provided as I would find out later by one of the pharms. I know from course work, ADHD is only supposed to be diagnosed *IF* it is a problem within multiple settings. For instance, if one is hyper in school but not at home -- most likely not ADHD. That is one of the MAIN diagnostics. I was never asked anything like this.

I'd venture to say 90% of all diagnoses are wrong. I know I gamed the system to my disadvantage to see what was considered abnormal (skewing the results towards what should be in the middle of the bell curve)...and I STILL was diagnosed...of course, I have been diagnosed correctly in the past with real testing, so I just needed someone to get me the stuff so I could try it out (and yeah, it does work to some extent...if you consider slug it out, non-creative, inefficient output to 'work'...oh wait, that is what the US educational system promotes anyways!).

I think saying it is CI is bulls**t, but also saying that most cases of ADHD are such is too. Everyone wants to prove they are broken so that they can either be sold something that will excuse their mistakes, or ummm...ok...they want to sell something to someone telling them they are broken and if they take this their flaws will be forgiven.

Rant rant rant...

Posted by: clifyt | Sep 12, 2007 12:50:10 PM

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