Category Archives: Mental Health

Do You Know What Convergence Insufficiency Is? You Should. Here’s Why.

In my post about the double-edged sword of pediatric and adolescent mental health, I promised to share my son’s personal story in detail. This is is a big part of it, but this post illustrates just how crucial it is for teachers to know about Convergence Insufficiency (CI). Herein may lie one of the primary reasons we’re seeing an increase in the number of children diagnosed with attention disorders like ADD and ADHD.

What the heck is Convergence Insufficiency? 

Before all of this, I didn’t have the slightest idea what Convergence Insufficiency is. In all my years of higher education, learning about psychology and education…never once did CI come up. Not once. This is shocking to me, and if you haven’t heard of CI before, it’s probably going to shock you, too.

Convergence Insufficiency is a vision disorder. As all teachers are aware, vision plays a key role in learning. “It is estimated that 80% of school learning involves the sense of vision,” according to the Vision & Learning Center of Northcentral PA, which only SymptomsCI2makes it all the more surprising that there’s not more emphasis placed on what is actually an extremely common disorder.

In fact, research estimates that between 2.5% and 13% of children and adults in the U.S. have Convergence Insufficiency. According to the Vision & Learning Center, it averages at about 10%, meaning that in a class of 30 children, three, on average will have CI.

CI: The specifics

What is it, exactly? It’s a binocular vision disorder — and it has nothing to do with visual acuity, which is what most school vision screenings evaluate. Therefore, a student can pass a visual acuity test with flying colors, yet still struggle to perform tasks requiring binocular vision, or the ability of the eyes to work together.

While we see what we perceive to be a single visual field, our vision is actually the combination of two distinct images — one captured by the right eye, one by the left. When the two eyes are unable to work together as a team and focus at the same precise point on a computer screen or piece of paper, the final, blended image becomes distorted.

Children with CI are often able to force the eyes to work together and focus on a single point simultaneously for short periods of time. After a short duration, it becomes more difficult and each eye ends up focusing at a slightly different point on the page. This leads to eye strain, fatigue, headaches, and a slew of other equally unpleasant and frustrating symptoms. And the words on the page? They become blurry, scrambled, “shaky,” or appear as doubles. Or, as my then 5-year-old described to the amazement of Dr. Marcus Myers, “They ‘swap places.'”

The A-ha moment

Now, if the picture isn’t falling into place for you quite yet, think about how these frustrations might manifest in a child. The child becomes hesitant to perform close work, such as reading, in anticipation of the pain and frustration that are sure to follow. Eventually, the child may flat-out refuse to do homework. When he does, it may take him hours to complete a simple assignment that should have taken 15 minutes.

“Children with eye teaming problems can be highly distractible, finding it difficult to concentrate and remain on task when the task involves near visual work such as reading, writing, and homework,” according to the Vision & Learning Center. “This vision problem frequently complicates or mimics A.D.D. and A.D.H.D. Recent studies have identified a significant overlap in symptoms between convergence insufficiency and attention problems that are usually treated with medications.”

A-ha.

As all of this begins to make sense, think about the challenges that exist in diagnosing CI. A young child has no point of comparison. They’ve been seeing this way their whole lives, so they have no idea that what they’re experiencing isn’t ‘normal.’

Suppression masks some CI symptoms

Adults can go through their whole lives without ever realizing something is off. I, for instance, only discovered at age 32 that I have had CI my whole life and never had the slightest clue. I only had a few of the typical symptoms off and on, primarily due to the fact that my brain developed its own coping mechanism and essentially ignores the visual input from my left eye, a phenomenon called “suppression.” I’ve always had a hard time focusing with my left eye by itself, but it was never a major issue because really, how often do you have to look at something with one eye closed? Funny men in stereo glasses with popcorn.

The result of suppression is multi-fold. One, I don’t experience the double-vision or blurred vision common with CI and can easily perform close work without struggling. Two, I only discovered at age 32 why it is that I never understood what the big deal was about 3D movies. I honestly spent my whole life thinking people are very easily amused, because I never ‘got’ it. Because I can’t see it. 3D requires binocular vision; my brain suppresses the vision in my left eye.

How did I discover this? In the process of looking into options when we suspected my son had CI, reading about suppression sounded suspiciously like my unexplained oddity of being unable to ‘focus’ with my left eye. That was my first clue.

My second clue was in a meeting with Dr. Myers, in which he did a little demonstration of what it takes for the two eyes to focus on a single point together — by asking me to focus on a pencil point as he moved it closer and closer to my face. When one eye literally drifts off to the outside when the pencil gets too close, that’s a pretty key indicator that you have a convergence problem.

Now, while it is possible for someone with CI to make it through life relatively unscathed (but at least now I have a good reason for my lack of ability to parallel park — poor depth perception!), suppression isn’t exactly something that you want to happen, and most kids with CI aren’t suppressing the vision in one eye to the extent that it alleviates the symptoms of the disorder.

Convergence Insufficiency and ADD/ADHD

For those kids, school is a challenging and intimidating place. But because school vision screenings only evaluate eye health and visual acuity, CI is easily overlooked. These children are usually placed in Title I reading programs because they’re behind their peers, and many are evaluated for ADD and ADHD, sometimes even treated with medications, because the symptoms overlap so heavily with CI.

It’s important to point out that a diagnosis of CI does not automatically mean that a child does not also have ADD or ADHD. It’s entirely possible for the two to be co-morbid, so adequate screening should be conducted to rule out the possibility of other underlying conditions. But it’s also entirely possible that a child has CI that is manifesting with symptoms that closely match ADD/ADHD, and treatment with vision therapy could resolve most or all of these symptoms, as was the case with my son.

What’s so disheartening about this?

  • There are many, many children struggling with reading and tasks requiring close work who could be helped by vision therapy. But many of these children will never be screened for CI.
  • Many children with CI who show symptoms of ADD/ADHD are misdiagnosed and treated with medications that may mask some of the symptoms, but fail to address the true, underlying condition. ADD/ADHD medications will not help a child with CI learn to read better or improve binocular vision.
  • Most schools do not screen for binocular vision, only for eye health and visual acuity.
  • Many teachers do not know what Convergence Insufficiency is, yet they are in the perfect context for easily picking up on potential signs of a convergence problem.

Teachers may hold the key 

How did we find out that my son has CI? His teacher. Early in his kindergarten year, we were discussing how he was doing with certain things and she mentioned that she had noticed a few things that made her think he may possibly have a convergence problem. Having never heard of this before, I looked it up. I was pretty convinced that’s what we were dealing with, and screenings proved it to be so.

Words cannot express how grateful we were to my son’s teacher for literally changing his course. His life could have taken a decidedly different turn had we never learned he had CI. He would have struggled with reading, and therefore, with everything else learning-related throughout his education. It would have impacted his grades, his self-esteem, his college prospects, and his potential for securing gainful employment post-college. Not to mention, it could have led us down the ADHD path. She changed his life. And ours.

Barriers to successful screening and treatment

Now, vision therapy is not cheap — it can cost between $5,000 – $6,000 or more. Naturally, this is a pretty substantial amount of money for a family to fork over, meaning cost alone could be a barrier to getting some children the services they need. And, I can tell you from experience, health insurance and/or vision insurance is highly unlikely to cover more than a portion of the initial $300 screening.

Is it worth it? Absolutely, without a doubt. But that doesn’t mean all parents will be willing to pay for it, even considering many vision therapy providers offer zero-interest loans or similar programs to help make the costs more bearable.

What about schools? “According to law in many states, if a child is classified as having a specific learning disability, the school is required to either provide the necessary therapy, or to pay for the parents to obtain the necessary help not provided by the school,” according to VisionTherapy.org. Of course, $5-6k in therapy costs for 10% of students isn’t exactly in the budget, so schools generally react in one of two ways:

  • Have a district staff member perform the necessary therapy.
  • “Deny that the therapy has anything to do with the child’s learning problems.”

To be honest, it never occurred to us that the school might be responsible for paying for part or all of these services. Do I think that schools should be responsible for covering these costs? Not necessarily, but I do think that schools should be screening for CI just as they do visual acuity. Think about the many children who could be helped, particularly if CI is treated before significant delays in learning occur.

I do think there should be some form of assistance for families dealing with CI. Given its prevalence, coverage under vision insurance or health insurance would certainly make sense. Most families can’t realistically spend $5,000 to $6,000 without warning, which may lead some to forego treatment. I could go on about my thoughts on health insurance, but that’s another rant entirely.

At this point, I think the most we can realistically hope for is increased awareness. If every teacher is aware of Convergence Insufficiency, educated on the basic symptoms, and armed with checklists like this one, educators could at least initiate screenings for some children.

Not that teachers need yet another obligation on their plates. In these trying times, it’s ultimately still teachers who are changing lives. And if you could make a huge impact that would change the direction of even one child’s life, wouldn’t you?

The Double-Edged Sword of Pediatric/Adolescent Mental Health

The October 2014 issue of Psychology Today magazine features two fascinating articles representing different perspectives related to pediatric and adolescent mental health. I’m always drawn to this sort of thing, so I immediately read both articles upon getting the mail that day before I even looked at the rest of the bills that were now gracing my counter top.

The first article is a memoir, written by the mother of an adolescent boy who has struggled with mental health issues for years, titled “A ‘Normal’ Day.” The second is an opinion piece, written by Allen Frances, M.D., professor emeritus and previous chair of the Diagnostic and Statistical Manual of Mental Disorders-IV task force and the department of psychiatry at Duke University School of Medicine. 1 out of 5 (4)

This article, titled, “No Child Left Undiagnosed,” delves into the diagnostic statistics for childhood disorders such as ADHD; namely, the fact that there has been a dramatic increase in the number of children diagnosed with these disorders, as well as the number of children and adolescents who are being treated with pharmaceuticals that are making drug companies billions of dollars.

Alarming statistics on the incidence of ADHD in children and adolescents

Are we in too much of a rush to diagnose children at an early age? The evidence is clear that early intervention is beneficial for children with mental health disorders, and failing to diagnose a true mental health condition in a timely manner can have disastrous consequences for an adolescent’s life.

Yet, in our efforts to ensure that diagnoses are being made early, are we introducing inaccuracy? Are we being too lax with diagnoses? Or have we educated the public too much about the possibility that their children may have these disorders, leading parents to seek easy solutions for difficult children: a simple pill can take care of the extra energy your son seems to have?

A few eye-opening statistics from “No Child Left Undiagnosed”:

  • 81% of American kids could be labeled with a mental disorder by age 21.
  • 11% of children in the U.S. have a diagnosis of ADHD.
  • 6% of children in the U.S. are on daily medication for ADHD.
  • The rate of ADHD diagnoses in the U.S. has doubled in the past 20 years.
  • Among teenage boys, 1 in 5 is diagnosed with ADHD; 1 in 10 medicated.
  • Diagnoses of developmental and childhood bipolar disorders have increased 40-fold in the past two decades.

Have we conditioned parents to seek the “easy fix”? 

I’ve known people who have pushed and pushed for a diagnosis for children as young as age two or three. Children who, at that time, I was rather certain were exhibiting perfectly normal, energetic, and full-of-life behaviors typical for that stage of development.

But push some of these parents did until they finally received the validation they had been seeking from a psychologist. There are so many diagnoses now with symptoms that overlap with normal childhood behavior, but can truly represent an underlying diagnosis when those behaviors are extreme. Parents without a background in mental health can easily read an article or two and walk away convinced that their child has ADD or ADHD. And when the solution to those tantrums and that short attention span is only as far away as the local pharmacy, we’ve created a pretty slippery slope. 

Fast-forward about a decade, and those children, who have, for the past 10 years, been shuffled in and out of numerous doctors’ offices, psychiatrists’ offices, and mental health clinics, along with dozens of meetings with school officials and counselors, have some significant difficulties in their daily lives. These kids have taken more pharmaceuticals in their short lives than many adults have by middle age. Constantly adjusting dosages, switching brands due to health insurance or side effects, and adding and removing medications from the “cocktail” has become the norm in their lives.

Wake up: these pills alter children’s brain chemistry! 

Was this failed early intervention? Or was it actually that this “early intervention” created some of the problems these children are experiencing today? Those drugs, such as Adderall and Ritalin, Xanax, and a slew of other anti-psychotics, anti-depressants, and anti-anxiety medications can wreak havoc on a patient’s brain chemistry. Neuropsychiatric roborating pills

That’s the intended effect — but how is your brain ever supposed to function ‘normally’ when it has been artificially manipulated throughout the key stages of its development? It’s as if being prescribed medication before the age of five automatically signs you up for a lifetime of stocking your own pharmacy at home.

The bottom line is that placing any child on medication should never be a decision made lightly. It’s not a matter of finding an easy solution for parenting frustrations. The first time a child is handed a pill to swallow, it can never be taken back. And it’s a pivotal moment that will shape the rest of that child’s life.

My own son had signs of ADHD around age four to five. We discussed the possibility with his pediatrician and ruled out some other possibilities like Type I Diabetes. Instead of trying medication, we switched to a gluten-free diet and still follow it today — not 100%, but most of the time when it’s feasible. It turns out he actually has a vision disorder called Convergence Insufficiency (CI), which has many overlapping symptoms with ADHD.

That’s an interesting story that I’ll share in detail in an upcoming post, but the point is we investigated all options and were willing to try other solutions before trying medications. Had I pushed for it, I could have gotten him on meds back then. Easily. Had we done so, we would have masked symptoms that were actually pointing to a different underlying disorder and ended up overlooking the CI, which would have had negative consequences for him for the rest of his life. In the end, he never had ADHD and certainly never needed medication.

I’m not anti-medication. I’m anti- medicating children as an easy fix-all when it’s truly not warranted.

Parents feel hopeless; teachers have their hands tied

On the other hand, there are children and adolescents with truly accurate diagnoses, or as in the case of the child in “A ‘Normal’ Day,” a catch-all diagnosis after years of trying to pinpoint the specific underlying cause. Many of these parents feel isolated and helpless, unsure where to turn for help or resigned to the fact that there is no “fix” to this situation.

This is an issue that resonates with many teachers who regularly encounter children in their classrooms who could benefit from mental health and social support interventions, yet their hands are tied to do anything about it. In many cases, teachers can refer students to school counselors or administration, but their involvement may end there. Originality

Some may get to participate in meetings with parents and administrators or counselors, but they have no control over whether any particular child actually receives social services. Parents can outright refuse it, and there’s little anyone can do to change that until the child ends up in the criminal justice system, which is too often the ultimate outcome. For the children who clearly need help but don’t go on to receive it, teachers are left to continue observing and coping with behavior that might be easily managed with appropriate intervention.

Then there are children like the young man in “A ‘Normal’ Day,” whose mother is desperate to get him the help that he needs, yet she’s simply exhausted all of her available options. Perhaps most disheartening is the fact that in some cases, his only chance of continued support is if he is arrested, which places him in the justice system in which some services are available for free — services most parents simply can’t afford to pay for otherwise. 

Research proves challenging

Part of the problem stems from the fact that the science behind all of this is so complex. It’s challenging to adequately control for the many variables that come into play when seeking to prove causal relationships. For instance, those children who were started on medications at age three: how do we know what the outcomes would have been had that not been the case?

Those children were subjected to many situations that wouldn’t have otherwise taken place. They’ve possibly been surrounded by other troubled children in emotional or learning support classrooms. And most importantly, they’ve been raised by a set of parents who could be influencing these behaviors in a multitude of ways, such as choosing different disciplinary actions based on their perceptions that their children have “problems.”

Some existing research points to clues that our diagnostic methodology is resulting in diagnoses that are too broad. For instance, Frances mentions a study of one million Canadian children, in which the biggest predictor of whether a child would eventually be diagnosed with ADHD was the child’s birthday.

“The youngest boy in the class was almost twice as likely as the oldest to be diagnosed. There can only be one way to interpret this result: Perfectly appropriate developmental immaturity is being mislabeled as a mental disorder and treated with unnecessary, expensive, and potentially harmful pills,” says Frances.

No clear and obvious solution 

If we are over-diagnosing our children, that’s a big problem. The other problem is that there are not enough services to support the number of children being diagnosed, not to mention the fact that both teachers and parents who try to advocate for children in need of help often hit roadblocks that leave them helpless. 

We need change, but there’s no easy answer. We can develop more pharmaceuticals. We can — and should — give parents and teachers more power to get children help and support. But we’re too worried about politics and administering more tests to equip teachers with tools they can use to actually help their students in meaningful ways that will have positive impacts throughout their lives.

Read a related article from Allen Frances, M.D. at Psychology Today online.

What’s your take on the current state of mental health diagnostics in children and adolescents? Are we over-diagnosing, or is there a true rise in the incidence of ADHD due to extraneous forces? What can be done to provide adequate support systems in our communities for children and adolescents with mental health disorders? Share your thoughts with us in the comments.