The Egyptian Journal of Otolaryngology

ORIGINAL ARTICLE
Year
: 2015  |  Volume : 31  |  Issue : 4  |  Page : 250--253

The study of convergence insufficiency in children with attention deficit hyperactivity disorder


Dina A Elsayed1, Rania M Abdou2,  
1 Department of Ophthalmology, Department of Otorhinolaryngology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
2 Unit of Phoniatrics, Department of Otorhinolaryngology, Faculty of Medicine, Alexandria University, Alexandria, Egypt

Correspondence Address:
Rania M Abdou
Unit of Phoniatrics, Otorhinolaryngology Department, Faculty of Medicine, Alexandria University, Alexandria
Egypt

Abstract

Introduction Attention deficit-hyperactivity disorder (ADHD) is characterized by low levels of attention and concentration and high levels of activity, distractibility, and impulsivity. Convergence insufficiency (CI) is a common condition that is characterized by a patient«SQ»s inability to maintain proper binocular eye alignment on objects as they approach from distance to near. Several studies have been conducted to discover the relationship between ADHD and CI. Researchers reported that children with CI had a higher frequency of parent-reported ADHD and/or learning problems, but their studies were limited to patients with CI. Aim of the work The purpose of this study was to identify patients with CI in a cohort of patients diagnosed with ADHD. Materials and methods The study included 20 children diagnosed with ADHD. They were diagnosed on the basis of the clinical assessment and fulfilling the diagnostic criteria of the DSM-IV. Other assessments included mental age assessment using the Stanford-Binet scale and ADHD assessment using Conners«SQ» parents rating scale. Participants underwent complete ophthalmologic examination: visual acuity test using an illiterate E chart; stereopsis using Lang card; cover tests; convergence amplitude; near point of convergence; slit-lamp examination for the anterior segment; cycloplegic refraction; and fundus examination. Written informed consent was taken from the parents of all children included in the study. Results CI was present in 35% of cases, with a near point of convergence more than 6. Conclusion CI appeared to be a comorbid disorder in patients with ADHD, and may cause misdiagnosis, or exacerbation of the symptoms of ADHD. Patients diagnosed with ADHD should be evaluated for CI. It is worthy of mention that CI is a disease that can be effectively managed with orthoptic exercises, or surgically.



How to cite this article:
Elsayed DA, Abdou RM. The study of convergence insufficiency in children with attention deficit hyperactivity disorder.Egypt J Otolaryngol 2015;31:250-253


How to cite this URL:
Elsayed DA, Abdou RM. The study of convergence insufficiency in children with attention deficit hyperactivity disorder. Egypt J Otolaryngol [serial online] 2015 [cited 2020 Jan 27 ];31:250-253
Available from: http://www.ejo.eg.net/text.asp?2015/31/4/250/168361


Full Text

 Introduction



Convergence insufficiency (CI) is a common vision disorder characterized by exophoria greater at near than at distance, a receded near point of convergence, and reduced positive fusional vergence at near, and it has a prevalence of ~5%. The adverse impact of CI occurs during near viewing; typical symptoms include double vision, blurred vision, eyestrain, difficulty concentrating, and slow reading [1],[2],[3],[4] .

Recent studies have suggested a possible association between CI and a prevalent behavioral disorder, attention deficit-hyperactivity disorder (ADHD) [5],[6],[7] .

Attention deficit disorder (ADD) and ADHD are the most common neurobehavioral disorders during childhood, with a prevalence of up to 12% in the community settings. Children diagnosed with ADHD show developmentally inappropriate levels of inattention, hyperactivity, and impulsivity characterized by onset during childhood and may impair school performance, intellectual functioning, social skills, and occupational functioning [8],[9] .

It is well noted that symptoms frequently reported in CI, such as loss of concentration when reading or reading slowly, are similar to behaviors associated with ADHD (inattentive type), such as, failure to complete assignments and trouble concentrating in class. This study aimed to detect CI in children diagnosed with ADHD.

 Materials and methods



The studied group included 20 children with newly diagnosed ADHD. Their ages ranged from 5 to 11 years, with a mean of 7.3 ± 1.7 years. Fourteen patients were male and six were female.

Patients included in the study were diagnosed with ADD/ADHD on the basis of clinical evaluation using the criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) criteria for ADD/ADHD in addition to assessment using Conners' scale [9],[10] .

The following ophthalmologic tests were performed by a pediatric ophthalmologist:

(1) Determination of visual acuity: Visual acuity was tested monocularly at a distance of 3 m with an illiterate E chart. Values were noted in decimal format.

(2) Investigation of strabismus and ocular motility: Heterotropia was investigated using a cover test. Heterophoria was detected using an alternate cover test and was defined as a latent deviation of exophoria more than 4 pD or esophoria more than 2 pD at near (0.33 m) and/or at distance (3 m) [11] .

(3) Near point of convergence: For near point of convergence evaluation in cm, the Royal Air Force (RAF) ruler was used. A mean value of three measurements was recorded.

To meet the criteria for the diagnosis of CI, all three of the following signs were required: (a) greater exophoria at near-than distance by 4 pD; (b) failed Sheard's criteria or minimum normative positive fusional vergence at near (<15 pD for break); and (c) receded near point of convergence (>6 cm break point) [12] .

Diagnoses of CI was based on near point of convergence (>6 cm), fusional amplitudes (≤15 pD at near), and symptoms (headaches, asthenopia, and difficulty in reading) [13] .

(4) Refraction under cycloplegia: This was performed with an autorefractometer (Topcon RM-A7000B, Japan) after instillation of cyclopentolate (1%).

(5) Examination of the anterior segment, media, and ocular fundus: The anterior segment of the eye was examined using a slit lamp and the ocular fundus was examined by means of indirect ophthalmoscopy.

Statistical analysis

Statistical analysis was carried out using Statistical Package for Social Sciences (SPSS/version 15) software, and mean (X), SD, and percentages were calculated.

 Results



The studied group included 20 children with newly diagnosed ADHD. Their ages ranged from 5 to 11 years, with a mean of 7.3 ± 1.7 years. Fourteen patients were male and six were female [Table 1].{Table 1}

The spherical equivalent refractive error ranged from −0.25 to 3.75, with a mean of 1.0 ± 1.1 [Table 2].{Table 2}

CI was present in 35% of cases, with a near point of convergence more than 6 [Table 3].{Table 3}

Visual acuity was 1.0 in 75% of right eyes and in 85% of left eyes without glasses. Glasses were prescribed for 25% of cases, with attaining of a visual acuity of 1.0 in all eyes thereafter [Table 4].{Table 4}

 Discussion



Impact of ADHD on the global functioning of the patient is at many instances of great magnitude [14] . The diagnosis of ADHD remains essentially clinical and is based on certain behavioral criteria [9] . This diagnosis often depends largely on the inputs provided by means of questionnaires that both parents and teachers fill and also by the patients themselves. The clinician needs to correlate the results of these surveys with his own clinical findings. A comprehensive examination is needed to rule out any comorbid disorders with overlapping symptoms, including an eye exam.

The studied group included 20 children with newly diagnosed ADHD. None of the participants was on medications for the management of ADHD. Their ages ranged from 5 to 11 years, with a mean of 7.3 ± 1.7 years. Fourteen patients were male and six were female.

In the present study CI was found in 25% of patients (five out of 20 patients). This surprisingly high incidence in children with newly diagnosed ADD/ADHD compared with those reported in other studies reinforces the importance of screening this population for CI. Computer search review showed the prevalence of CI in elementary school students to be 2.25-4.2% during the year 1988 [15] .

A study by Granet et al. [6] reported an apparent three-fold greater incidence of ADHD among patients with CI compared with the incidence of ADHD in the general US population using strict criteria (1.8-3.3%), the incidence seen in subspecialty mental health settings (estimated at 3-5% of school-aged children), and in some cases the incidence in community settings (4-12% of children) [16] . The same study by Granet and colleagues suggested that there is a greater incidence of CI in ADHD patients. The review of computer records showed a 15.9% incidence of CI in ADHD patients.

It was suggested that the medications used to treat ADHD aggravate CI. For some of these drugs, difficulties with accommodation and blurring have been reported [17] . Another point to add is that, of those diagnosed with CI in ADHD patients discovered by Granet and colleagues, 76.9% were on medication. Our series included all newly diagnosed children with no history of medication administration for the management of ADHD. This indicates that medication administration by itself is not the only cause for the high incidence of CI in ADHD patients.

CI appears to be a comorbid disorder in patients with ADHD, and may cause misdiagnosis, or exacerbation of the symptoms of ADHD. Patients diagnosed with ADHD should be evaluated for CI. It is worthy of mention that CI is a disease that can be effectively managed by means of orthoptic exercises, or surgically [18] .

Acknowledgements

The authors thank all study participants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Borsting E, Rouse MW, Deland PN, Hovett S, Kimura D, Park M, et al. Association of symptoms and convergence and accommodative insufficiency in school-age children. Optometry 2003; 74:25-34.
2Rouse MW, Borsting E, Hyman L, Hussein M, Cotter SA, Flynn M, et al. Frequency of convergence insufficiency among fifth and sixth graders. The Convergence Insufficiency and Reading Study (CIRS) group. Optom Vis Sci 1999; 76:643-649.
3Letourneau JE, Ducic S. Prevalence of convergence insufficiency among elementary school children. Can J Optom 1988; 50:194-197.
4Letourneau JE, Lapierre N, Lamont A. The relationship between convergence insufficiency and school achievement. Am J Optom Physiol Opt 1979; 56:18-22.
5Borsting E, Rouse M, Chu R. Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency: a preliminary study. Optometry 2005; 76:588-592.
6Granet DB, Gomi CF, Ventura R, Miller-Scholte A. The relationship between convergence insufficiency and ADHD. Strabismus 2005; 13:163-168.
7Gronlund MA, Aring E, Landgren M, Hellstrom A. Visual function and ocular features in children and adolescents with attention deficit hyperactivity disorder, with and without treatment with stimulants. Eye (Lond) 2007; 21:494-502.
8Faraone SV, Sergeant J, Gillberg C, Biederman J. The worldwide prevalence of ADHD: is it an American condition? World Psychiatry 2003; 2:104-113.
9American Psychiatric Association TFoD-I. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed. Washington, DC: American Psychiatric Association; 1994.
10Conncrs CK. Clinical use of rating scales in diagnosis and treatment of attention-deficit/hyperactivity disorder. Pediatr Clin North Am 1999; 46:857-870.
11Moses RA. Adler's Physiology of the eye. 5th ed. St Louis, Missouri: Mosby; 1970.
12Rouse MW, Borsting E, Hyman L, Hussein M, Cotter SA, Flynn M, et al. Frequency of convergence insufficiency among fifth and sixth graders. The Convergence Insufficiency and Reading Study (CIRS) group. Optom Vis Sci 1999; 76:643-649.
13Scheiman M, Mitchell GL, Cotter S, Cooper J, Kulp M, Rouse M, et al. Convergence Insufficiency Treatment Trial Study Group A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmol 2005; 123:14-24.
14Mercugliano M. What is attention-deficit/hyperactivity disorder? Pediatr Clin North Am 1999; 46:831-843.
15Letourneau J, Ducic S. Prevalence of convergence insufficiency among elementary school children. Can J Optom 1988; 50:194-197.
16Leslie LK, et al. Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings. Pediatrics 2004; 114:129-140.
17Bennett FC, et al. Stimulant medication for the child with attention-deficit/hyperactivity disorder. Pediatr Clin North Am 1999; 46:929-944.
18Wallace DK. Treatment options for symptomatic convergence insufficiency. Arch Ophthalmol 2008; 126:1455-1456.