Vision Problems May Cause ADHD Misdiagnosis

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Her name was Sheila
She was ten years old
She was making failing grades
She was diagnosed as ADHD-Inattentive type a year earlier
She was on three ADHD drugs
She was not getting better.

The more I learned from Sheila’s mom, the more I was convinced she was not ADHD. Her mom was sure that Sheila tried hard to do her best in class, yet she just couldn’t get her grades up. She was absolutely sure that Sheila tried to keep up with her homework, as that was the first thing she did every night after supper. She was not impulsive…not hyperactive… not disruptive…. Her mom thought she was just a normal little girl who just happened to make bad grades.

The biggest clue to Sheila’s ADHD Zebra (one of those more than 50 things that can look just like ADHD) was seen in her eyes. She was wearing very thick lens glasses and her mom assured me she had just seen her eye doctor six months earlier and he said everything was ok.

But…everything was not ok…. Sheila was suffering from a vision problem that was probably causing her failing grades. On direct examination, her left eye “looked” straight ahead and was normal, but on close examination her right eye was ever-so-slightly out of alignment… it “looked” outwards and the further she looked to that side, the worse it got. We call this a dysconjugate gaze… a failure of one or both eyes to properly align in all directions.  (I suspect Sheila’s problem wasn’t as obvious when she had last seen her eye doctor and was therefore easy to miss!)

To confirm my suspicion, I asked her to read a paragraph from a children’s book and to write a few short sentences for me. What do you think happened?

Sheila stumbled over the words as she read. She had to correct herself many times in the course of reading 250-plus words. Her handwriting was terrible. Some letters were small… some were large…. some were normal…. some were spaced tightly…. some were spaced widely. She made multiple mistakes, had to erase many words to correct her spelling and wrote several letters backwards.

Sheila’s visual impairment was causing a learning-expression-communication disability. Sheila had a condition called strabismus.

Strabismus can occur for many reasons:

  • Damage to the nerves that control the muscles that move and align the eyes (trauma, infections, drugs)
  • A brain disorder that affects the part of the brain that controls the nerves that control the muscles (stroke, tumor, infection, drugs)
  • Damage to the muscles that move the eye (accidents, trauma, lacerations, drugs, shingles)
  • Idiopathic reasons (unknown, present at birth or congenital)

What did we do to help Sheila?

I referred her to an ophthalmologist who specializes in neurodevelopmental vision problems. She underwent extensive testing, including an MRI of the brain, and testing of each of the cranial nerves responsible for normal eye movement.  It ended up that she simply had a “lazy” eye … no brain tumor, no muscle damage… just a slow nerve response.

What did we do next?

We sent Sheila for vision training and new corrective glasses that forced her to use that eye more than she was. The most frequently used therapy in the past was to patch the good eye, thus forcing the “lazy” eye to work harder and align itself. Vision specialists now incorporate progressive changes in the vision impaired child’s prescription lenses that accomplish the same thing. If this type of therapy doesn’t work, surgery may be required to repair muscles and tendons to help alignment and improve vision.

The good news is that Sheila responded to vision training rapidly. Some kids require 12 to 15 months to reach the point Sheila reached in only 6 months. By that time, her handwriting had improved to the point she was practicing calligraphy and she was spacing letters very precisely. She had a new level of confidence and pride as she could read without stuttering the words and her vocabulary expanded to match her new found skills. And of course…. her grades went up and everybody was happy.

Don’t you just love happy endings? Well, my goal in publishing this blog is the same as yours; to produce as many happy endings as possible by preventing children from being misdiagnosed and mislabeled as ADHD.

Your comments are always welcome!

Dr. Frank 

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