The Need (part 2)

Dr. Eric Borsting and colleagues are still investigating the diagnosis, treatment and consequences of convergence insufficiency.  The most current research from the Convergence Insufficiency Treatment Trial (CITT) which was presented at COVD’s annual meeting considers the behavioral and emotional problems associated with convergence insufficiency (CI).

Fifty-three children with symptomatic CI were enrolled in the study.  For each child, the parents completed the Child Behavior Checklist (CBCL) and the teachers completed the Connors 3 ADHD Index.  The children were then enrolled in office-based vision therapy programs, and 44 of them completed 16 weeks of treatment.  The parents and teachers then completed the surveys again.

When scores at baseline (pre-therapy) were compared to normative data, the children with CI had more symptoms on both surveys.  On the Connors 3 ADHD Index, the symptoms most frequently reported by teachers were inattentiveness, distractability and giving up easily.  On the CBCL, the symptoms most frequently reported by parents were somatic, such as headaches and eye discomfort.  Children with CI exhibited more symptoms and behaviors associated with ADHD than children with no visual problems.  Following vision therapy, the children showed significant improvement on both scales.  Treatment of convergence insufficiency resulted in a reduction in the behavioral and emotional problems reported by both parents and teachers.

Here’s the take-home message:  if your child has been diagnosed with ADHD or exhibits many of the behaviors associated with ADHD, your child needs a comprehensive vision examination.  If vision deficits are revealed, then vision therapy might be the most appropriate treatment option.  This study is another contribution to evidence documenting the power of vision therapy in the treatment of learning-related vision problems.

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The Science: Performance-Related Symptoms

Convergence insufficiency (CI) is a common visual disorder that is characterized by great difficulty maintaining binocular eye alignment when looking at something close up (such as a book or a writing assignment).  This landmark study, funded by the National Eye Institute, provides strong evidence that office-based vision therapy is the most effective treatment for CI.  Treatment success can and should be measured 2 ways: objectively (looking at changes in measurements used in the diagnosis of CI) and subjectively (looking at changes in symptomology associated with CI).

The Convergence Insufficiency Symptom Survey (CISS) was developed to quantify the frequency and severity of symptoms reported by patients with CI.  The 15 symptoms on the CISS can be divided into 2 categories: performance- related and eye-related.  There are 6 performance-related symptoms evaluating visual efficiency when reading and/or performing near work:

• Loss of place
• Loss of concentration
• Having to re-read
• Reading slowly
• Trouble remembering what you read
• Getting sleepy when reading

The 9 eye-related symptoms include blur, headaches, double vision, tired, sore, uncomfortable eyes, words that move and jump, and pulling sensations around the eyes.

This study evaluated the symptomology of children with Convergence Insufficiency before and after optometric vision therapy.   Before vision therapy, the six most frequently reported symptoms were the six performance -related items. Fifty percent of all the children in the study responded “fairly often or always” when asked if they lose their place when reading.  Similarly, 45% of the children reported loss of concentration and having to re-read; 40% read slowly; 38% have trouble remembering what they read; and 37% get sleepy when they read.

Children with parent-reported ADHD (attention-deficit hyperactivity disorder) had significantly higher symptom scores on the CISS and the higher score was almost entirely attributed to an increase in the frequency and severity of these performance-related symptoms.

The good news is that ALL the children who responded to treatment reported a decrease in ALL their symptoms.  And while this study did not look at academic performance, the authors do note this relationship when they state: “the treatment of symptomatic CI may have a positive impact on reading performance and attention.”

What is the take home message?  If your child has a convergence insufficiency, it is important to consider both eye-related and performance-related symptoms.  Your child may not be complaining of blurred or double vision, but they still might have performance-related symptoms.  Loss of place, re-reading, poor reading comprehension, slow reading, sleepiness, poor concentration….. am I describing your child’s symptoms?  Have you considered a vision problem as a possible explanation?

Read more about convergence insufficiency here.

Reading more about vision and ADHD here.

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The Splash – Persistent Parents

Our guest blogger this month, Carrie Hall,  is one of the very talented vision therapists at my practice. She brings a unique perspective to the blog since she works with patients every week often times for many months.  Because of this,  she often gets to know the patients and their families on a very personal level and truly gets to know the struggles, trials, and triumphs patients go through.  At the conclusion of COVD’s National Vision and Learning month, I think her perspective into one of our patients is a perfect addition to what has been a great highlight of many inspiring vision therapy success stories.

As a vision therapist, I often see a theme among the parents that I encounter. Though they are of various ages, personalities, beliefs and styles, they often share one certain characteristic that sets them apart as vision therapy parents. They are incredibly persistent. They have been told many times in their lives that their children may not be capable of certain things. Perhaps by a doctor intending to give them a realistic expectation of the future, or perhaps by a teacher who is frustrated by a lack of success in their child. Whatever the source, I encounter parent after parent who has been informed that their child will not be capable of a certain level of ability, be it athletic,  academic, or just general life skill development.

Lynn was one such parent. Her daughter Shelby was simply not blooming in school like her older sister had. Reading was inexplicably difficult for this 8 year-old. Always a fight, often involving tears, Shelby simply would not take to reading. Lynn was baffled. Shelby was obviously bright and determined, a spunky and enthusiastic girl. It just didn’t add up. The pieces did not fit. Her eye doctors confirmed that Shelby’s vision was fine. She had 20/20 acuity, so the only reason why she shouldn’t be learning to read was if she simply wasn’t as smart as Lynn thought.
Perhaps some parents are more inclined to take the words of professionals at face value than others. Perhaps some parents simply refuse to be satisfied with an underwhelming determination of their children’s potential. Whatever is the mitigating factor, Lynn could not and would not be satisfied with this evaluation of her daughter. She persisted in her search. When she eventually found Washington Vision Therapy Center whose symptom checklist of vision-related learning problems read like a specific description of Shelby’s struggles, Lynn knew she had found her answer. When confronted with the financial strain that therapy would mean for her family, her persistence did not waiver. She would make whatever sacrifices were necessary: she would ensure her daughter’s chances for success in school and life no matter what.
Maybe persistence is a genetic trait as well. I certainly saw the same attributes in little Shelby that her mother demonstrated. Months after beginning therapy, after countless lifesaver cards and hart charts, Shelby was burnt out with it all. Who can blame her though? When the goal of all the work is just to get better at doing homework, it hardly seems a fair thing to ask of a girl of 8 who would rather be playing outside than getting better at reading any day of the week.
But like I said, maybe persistence is a genetic trait. Or perhaps it’s more nurture than nature. Whatever the case, Shelby persevered. Not only did she make it through therapy, she did great at it. She learned to be able to coordinate the use her two eyes like the best of them by the time it was all said and done. She and her mother developed a balanced working relationship in regards to this specific area in order to attack vision therapy head-on and accomplish every last bit of what Dr. Winters wanted to see from her clinically. Neither one of them would quit. Lynn pushed Shelby, and Shelby pushed right back in order to finish well. That little girl was the definition of persistence.
It’s the characteristic that marks out the parents, and the patients as well, for success. They are all up against diagnoses and school evaluations that make the future look bleak. They have been told repeatedly that they can’t, that they won’t. But they refuse to listen. Little fighters, they are, coming in and out of our offices defying the odds stacked up against them.
The other day, Shelby came up to her mother after doing some reading and said, “You know Mom, I think I like this reading thing.”  She is now at grade level in reading.  That is the payoff for any persistent mother.  Lynn has continue to fight to get Shelby’s story of hard work and persistence out to the public and she is now being featured on COVD for National Children’s Vision and Learning month.
http://www.cisionwire.com/college-of-optometrists-in-vision-development/r/mom-of-struggling-reader-finds-help-and-speaks-out-for-college-of-optometrists-in-vision-development,c9283372
Imagine that. A homeshooling mom from Yakima, Washington who believed her child’s struggles with reading were more than a resistant attitude or just that her daughter wasn’t smart enough. Persistence is a powerful thing.

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Parents speak out about their children’s struggle with undetected vision problems

August is National Children’s Vision and Learning Month! This marks an important time of the year for public awareness of a critically important set of visual problems that can have serious impact on a child’s ability to apply him or herself in reading or other classroom activities in learning.  Parents are stepping up to tell their stories, like the one below by Kathleen Hayford who posted her child’s story on Pinterest.

“Our son struggled in school starting in second grade, once reading was required. He was frustrated, anxious, complained of frequent dizziness and headaches and was withdrawn socially. Over the years, he was diagnosed with various disorders, including ADD, Processing Disorders, Sensory Integration Dysfunction, anxiety, OCD. He had Occupational Therapy, Psycho Therapy, medication, and EEGs. Every year his vision was tested and he was 20/20. Clarity was fine.”

“Davis would scream out, ‘I’m stupid!’ more times than I’d like to remember,” Hayford continues. “He thought so little of himself.  Constantly frustrated, he developed anxiety that interfered with every aspect of his young life. It was heartbreaking for us as parents knowing he was a remarkable and intelligent boy, trying everything we could think of to help him, and not finding the appropriate help.

“Based on a tutor’s suspicion he had Dyslexia, Davis was referred to a Developmental Optometrist who tested and diagnosed him with Convergence Insufficiency, an eye tracking problem, and accommodation disorders to compensate. Basically, he had suffered with double vision because his eyes did not track together.”

After completing optometric vision therapy, Hayford shares, “He’s a new boy!!! He’s off the variety of medications he was on and is now an A/B student with increased confidence, less anxiety, and has better relationships. He is happier and has hope for his future. I wish we could have spared him the years of struggling and pain.”

A common theme within these parents stories of their children who have struggled, is a relatively common condition known as Convergence Insufficiency (CI). There are many reasons why obstacles block public awareness for this condition that affects over 20 million.  One reason could be its unusual name…Convergence Insufficiency. What is Convergence Insufficiency?  Take a look at this video produced by vision advocacy group, The VisionHelp and see if you have a better insight. Then please let us know your thoughts with a comment. We would especially like to hear from parents. Please speak out if you have a child who has struggled. Let’s all help make the 2012 August National Children’s Vision and Learning Month an event that will truly help more children struggle less due to an undetected vision problem…like Convergence Insufficiency!

 

Dan L. Fortenbacher, O.D., FCOVD

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Research on Convergence Insufficiency (CI): Insurance Companies Disregard for Patient Welfare

 It is important that we know and understand the research concerning CI for our patients’ benefit. This research clearly shows that in-office optometric vision therapy is the most efficacious treatment for convergence insufficiency. Major insurance companies are denying in-office vision therapy unless you conduct out of office/home therapy first. This rationale for the patient having 12 out of office/home based therapy sessions before in office therapy is inappropriate, unsubstantiated by research and potentially harmful to our patient’s well being and quality of life.They are recommending the least effective, most time consuming, and costly methodology of treatment. These insurance companies should reconsider this ill advised policy immediately.

If you are a patient reading this, go to your employer and ask them to support vision therapy by telling your insurance company to do no harm, to waste no money, and to support treatments shown to be effective.

Research on Convergence Insufficiency can be found by clicking here. DM

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The Science and Splash are Back

So today, let’s talk science.  I recently had a conversation with a well-known pediatric neuropsychologist in my area. She is a very caring and competent practitioner by all counts.  She expressed some concerns about referring patients to me.  She said while she felt the science would validate vision therapy in the future, she did not feel that there was enough scientific evidence currently demonstrating the relationship between the vision problems we treat, such as Convergence Insufficiency, and academic performance.  She felt that the science certainly shows that functional vision problems exist and that vision therapy would help alleviate discomfort associated with these vision problems, but that the science did not yet show that treating these vision problems would impact school performance.

I was happy to report to her that the future is here.  In fact, I would like to dedicate the next several “Science” posts to the great research being done showing the correlation between vision and academic performance.

The article I would like to focus on today was written by the same authors of the Convergence Insufficiency Treatment Trial.  In this original research article sponsored by the National Institute of Health these scientists validated what so many of us have known for a long time.  Convergence Insufficiency and many other functional vision problems not only exist but cause a host of problems such as double vision, headaches, eye fatigue, slow reading and poor reading comprehension.   The treatment trial found that in-office Optometric vision therapy is by far the best treatment to alleviate these symptoms.  After completing this research, I am sure they must have encountered some of the same skepticism elicited by my colleague.

Their latest research article found in the journal of Optometry and Vision Science demonstrated that children with symptomatic Convergence Insufficiency showed significant improvements in reading comprehension after being treated with vision therapy. To see  the article click here.  Sounds like an academic performance link to me.   However, their research is by no means the only research out there.  I am happy to report I was able to send many other research articles as well to the practitioner in my area and have to say that she responded very favorably.  I am excited to share more of these research articles with you in the coming weeks.  Stay tuned…

For more information on vision problems that affect school performance, learning, and reading please visit the COVD website at www.covd.org.  To find a developmental optometrist near follow this link.

I hope to be blogging here more often.  I want to give a shout out to all of the COVD blog authors who put in so much time to getting the word out about how vision can impact the lives of so many.  Especially a thank you to Dr. Rochelle Mozlin whose dedication to this blog has helped the lives of many seeking to learn more about these critical and often silent vision problems.

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The Science – Vision problem or ADHD?

I have just spent sometime venturing through the blogosphere of mothers with children with ADHD.  I was so impressed with these brave women that write about their experiences, triumphs, and challenges in raising their children with ADHD.  Many of their accounts truly broke my heart.  This is an excerpt from Penny Williams blog “A Mom’s View of ADHD” where she describes her experience of trying to find a good fit for educating her son with ADHD:

“I live in search mode these days, ever since my son Luke, age nine, was diagnosed with ADHD in 2008. I am searching for the medication, therapy, classroom accommodation, product that will make his life with learning disabilities a little easier. I guess you could say I’m searching for the magic bullet, but I don’t think that’s really accurate anymore. It was true the first year or two — I was looking for an “answer,” something to erase his ADHD symptoms. Then I realized that that “something” doesn’t exist. I didn’t think I was looking for a cure for ADHD because I knew that’s not possible, but that’s exactly what I was searching for nonetheless.

My focus in my search now is different, more refined. I am searching for tools to help him compensate for his differences, for environments where he can learn and prosper, parenting methods best suited to his needs, treatments that teach him the skills necessary to have a happy, successful life despite ADHD (and dysgraphia, SPD, Executive Functioning Deficits, and a gifted intelligence). This search is intense and stressful for me, his parent. There’s a lot of {self-inflicted} pressure to be diligent to find all opportunities and to make choices that will only have positive outcomes. In the area of making appropriate choices that lead to positive outcomes, I have failed miserably this year.Luke has struggled in school since the day he walked into kindergarten. Yes, the very first day. While it should improve each year with treatment, maturity, growing self-awareness and a diligent advocacy for accommodations and resources in school, it has not improved for Luke. I feel like we have been standing in the same place for three years, paralyzed, while the world continues to move on all around us. In our minds, we’re moving and working, but we’re getting nowhere.

That feeling of helplessness became overwhelming to me earlier this year. I fought hard with the school but mostly we just received lip service. I watched Luke struggle to fit in an environment that was clearly the opposite of what he needed. I knew he needed more help. I had to find that for him. ”

I think Penny encapsulates the very real struggle that many parents go through that have children with ADHD.  As a developmental optometrist I work everyday with children that have been diagnosed with ADHD.  I see in their parents’ eyes the same sentiments shared by Penny.  While I do not claim to have a magic bullet, I do have tools that have helped many of of my patients that have vision problems that can often mimic or complicate ADHD.

Dr. David Damari, Developmental Optometrist and Fellow of the College of Optometrists in Vision Development wrote a great research article, “Visual Disorders Misdiagnosed as ADHD,” that gives several great case studies of patients with ADHD  who had developmental vision problems. He speaks in the article of how similar the symptoms are for children with common developmental vision problems and those of children with ADHD.  He also describes in detail case studies of children that were misdiagnosed with ADHD and instead suffered from vision problems that affected their ability to perform well in school, learn, read, and maintain their attention.  He also references other research that shows the correlation between ADHD and Convergence Insufficiency, one of the leading developmental vision problems in children.

Probably, though most compelling are the stories from parents whose children were misdiagnosed with ADHD.  Here is a story from the parent of a child from the website, “Vision Therapy Success Stories”:

“Recently, “Sarah” came into the office just to talk to Dr. X. She was so excited .she was no longer struggling with reading and schoolwork and couldn’t wait to thank him. She is no longer taking Ritalin and is doing well in school.

Prior to seeing Dr. X, Sarah struggled to do the work required of her in high school. She found reading burdensome, was unable to finish her homework in a reasonable amount of time, and was unable to keep up with all her assignments. She was feeling frustrated and discouraged. Sarah had been put on Ritalin in order to help her focus on her work, but she continued to struggle.”

Bottom line, if your child is stuggling with attention in school, check to be sure there is not a vision problem.  To find a Developmental Optometrist near you that can diagnose and treat these types of vision problems, please follow this link.

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The Science – A Glimpse into our Children’s Vision

As I go out and speak with parents, teachers, and doctors, I am almost invariably asked one question.  How can we do a better job of detecting vision problems in our children?  It really is a great question when you consider the following grim statistics:

• One in four children have a vision problem that can affect learning¹
• 60% of students identified as problem learners have undetected vision problems²
• 64% of children ages five and younger have never had their vision screened by a healthcare professional³
• 32-63% of vision problems identified by comprehensive eye examinations were missed in school screenings⁴

Looking at the scope of the problem, anyone can see that this issue is not going to be solved overnight.  Enhanced vision screenings in our schools, more children receiving comprehensive vision exams before entering school, and educating the public on how vision can affect school performance; these are large-scale efforts currently underway by many of COVD’s members throughout the country.  However, there are things each of us can do to help those children we work with everyday.

One great tool we have is the Convergence Insufficiency Treatment Trial (CITT) Symptom Survey.  Other than being a mouthful, this checklist represents one of the great accomplishments of evidence-based medicine.  In 2008, the Archives of Ophthalmology published the results of research sponsored by the National Institute of Health on the treatment of  Convergence Insufficiency, one of the leading vision problems in children.  This condition is often associated with headaches, double vision, and eyestrain.  The study concluded that for an overwhelming majority of these children, the condition is very treatable.

From that study, we have gleaned the CITT Symptom Survey.  In a matter of a few minutes we can now screen children with a tool that is highly predictive for both convergence insufficiency and other functional vision problems⁵.  This one-page symptom survey can easily be filled out as part of the intake process in any office or can be sent home with parents.  It is quick, easy to score, and communicates to parents the types of vision struggles their child is having.   Here is a copy of the CITT Symptom Survey.

Unfortunately, we can’t see through a child’s eyes.  The CITT symptom survey at least gives us a glimpse.

1. Comprehensive Eye Exams Particularly Important for Classroom Success. (2008, August 4). American Optometric Association.

2. ADD/ADHD and Vision. (2011).  College of Optometrists in Vision Development

3. Cotch, M. (2002). Visual Impairment and Use of Eyecare Services and Protective Eyewear Among Children. USA Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report, 425-429.

4. Danahuse, S. P., Johnson, T. M., & Leonard-Martin, T. C. (2000). Screening for Amblyogenic Factors Using a Volunteer Lay Network and the MTI Photoscreener: Initial results from 15,000 Preschool Children in a Statwide Effort. Ophthalmology, 1637-1644.

5. Rouse, M., Borsting, E., Mitchell, G., Cotter, S., Kulp, M., Scheiman, M., et al. (2009). Validity of the Convergence Insufficiency Symptom Survey: A Confirmatory Study. Optometry and Vision Science, 357-363.

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Congratulations, Dr. Shin

Congratulations to Dr. Hoy Sun Shin, on becoming an FCOVD-A; Academic Fellow of the College of Optometrists in Vision Development.  Dr. Shin is a full-time member of the faculty at Yangsan College in Yangsan City, South Korea.  She has been conducting research investigating the efficacy of vision therapy for children with binocular and accommodative dysfunctions.  Most of her research began with a screening process to identify children with  visual dysfunctions by using a “quality of life” questionnaire.  Parents were asked to describe the degree to which their children exhibited certain symptoms associated with vision problems, such as difficulty copying, headaches when reading, and/or poor reading comprehension.  Children with more symptoms, either in frequency or intensity, were then given comprehensive vision examinations to determine if there is a vision problem contributing to these symptoms.  Dr. Shin has conducted numerous investigations with these results:

• A large percentage of the children with symptoms of vision problems did indeed have binocular and accommodative dysfunctions.
• The children with visual dysfunctions did not perform as well on academic achievement tests when compared to visual “normal” children.
• Vision therapy was effective at improving visual function and reducing symptoms in these children.
• A year after completing vision therapy, the children retained these improvements in their visual skills as well as the reduction in symptoms.

Thank you, Dr. Shin for this valuable research.  Here is more evidence that children with poor visual skills are at a disadvantage in the classroom (and in life!) and that vision therapy is an effective treatment modality.

Dr. Shin is looking forward to further research to expand the evidence-base.  She is already evaluating the visual skills of a popuation of children diagnosed with ADHD.  We know that she is going to be a highly valued and contributing member of COVD with influence in Asia and around the world.

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The Growing Epidemic of Adult Convergence Insufficiency

Today’s guest blogger is Dr. Mary VanHoy.  Dr. VanHoy practices in Indianapolis, Indiana. Her practice is limited to behavioral/developmental and neuro-rehabilitative optometric care.  She has been practicing for over 30 years and hopes to practice for another 30 years!

This summer I became acutely aware of a growing number of adult patients, predominately female, either self-referred or referred by other health care offices, with complaints of blurred vision, dizziness, disorientation, double vision, and difficulties adjusting to their bifocals or reading lenses.  A careful health history did not reveal any remarkable clues such as a change in medication or recent health challenges.  Some noticed an increase in myopia (nearsightedness) along with the need for a bifocal yet they could not adjust to the bifocal portion.  Another interesting observation was that their ages ranged from the early 40s to early 50s.

Clinical testing usually revealed unaided or correctable 20/20 visual acuities and good ocular health but in carefully evaluating their ability to maintain convergence, it became clear that this particular population had been relying primarily upon their accommodative convergence rather than utilizing fusional convergence to maintain clear, single, binocular (two-eyed) function.

When accommodative convergence is used, the extraocular muscles are being stimulated to point inward by a neurological link to the muscles that control the crystalline lens of the eye in order to change of focus from far to near.  When fusional convergence is used, the extraocular muscles are being stimulated to point inward in order to avoid double vision. Perhaps these patients have relied upon their accommodative systems all their lives and this may account in part for their myopia.  However, their difficulties and symptoms arose when they began to lose the flexibility of their crystalline lens due to aging (presbyopia) and their ability to call upon their focusing system to maintain clear, single, binocular vision began to fail them.

Clinical evaluation of these patients will show that while their eye muscles are certainly strong enough to converge, they do not fully utilize their fusional convergence system but instead rely upon their accommodative convergence system.  Paradoxical findings such as the ability to pass the convergence range tests but difficulties with divergence (relaxing eyes outward) range and the inability to look through plus lenses and still maintain single, binocular vision are definite indicators of this syndrome.  These findings clearly indicate their reliance upon their focusing system rather than their eye teaming system or fusional convergence system.   Using this ineffective response to try to maintain single vision would explain blurred vision, double vision, and dizziness.  They are straining their poor eyes but the over-exertion no longer works for them due to normal aging processes of the eyes.

The good news is that even as adults in their 40s and 50s, the ability to learn how to utilize their fusional convergence system is still viable.  Specific guided visual activities and procedures through optometric vision therapy will allow this population to learn to become aware of where their eyes are pointing and how to aim them closer for near viewing without over-focusing to accomplish this.  So, it is not a matter of building stronger eye muscles but of improved eye muscle coordination and the use of the proper visual system to maintain clear, single, binocular vision for all their visual needs.

Read more about convergence insufficiency:

NEI Video about convergence insufficiency

Important research on the treatment of convergence insufficiency

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