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 makes 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.”
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?
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?