Welcome to the world of children's vision!

Rouse et al., in 2009, also conducted a study to determine whether children with symptomatic convergence insufficiency, without the presence of parent-reported Attention Deficit Hyperactivity Disorder (ADHD) had higher scores using a questionnaire on school behavior, the ABS Academic Behavior Survey.

The group of optometrists developed a questionnaire called the Academic Behavior Index (ABS). The Academic Behavior Survey is a 6-item survey that evaluates parent concern about school performance and the parents’ perceptions of the frequency of problem behaviors that their child may exhibit when reading or performing schoolwork (such as: difficulty completing work, avoidance, and inattention). The survey was administered to the parents of 221 children 9-17 years old with symptomatic convergence insufficiency and to 49 children with normal vision.

The results of this study showed that 15% of the convergence insufficiency group and children with normal vision were classified as ADHD by parental report. The total ABS score for the symptomatic convergence insufficiency with parent-report of ADHD group was significantly higher than the symptomatic convergence insufficiency with no parent-report of ADHD group. The authors concluded that both children at risk for ADHD or related learning problems should have a comprehensive vision evaluation to assess the presence of convergence insufficiency as a contributing factor.

The ABS questionnaire:

  • How often does your child have difficulty completing assignments at school?
  • How often does your child have difficulty completing homework?
  • How often does your child avoid or say he/she does not want to do tasks that require reading or close work?
  • How often does your child fail to give attention to details or make careless mistakes in schoolwork or homework?
  • How often does your child appear inattentive or easily distracted during reading or close work?
  • How often do you worry about your child’s school performance?

The symptoms frequently reported in convergence insufficiency 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.

The same team of optometrists in 2012, sought to determine whether treatment of symptomatic convergence insufficiency had an effect on the scores of the questionnaire Academic Behavior Survey (ABS), used previously.

The ABS was administered at baseline and after 12 weeks of treatment to the parents of 218 children aged 9 to 17 years with symptomatic CI, who were enrolled in the Convergence Insufficiency Treatment Trial and randomized into (1) home-based pencil push-ups; (2) home-based computer vergence/accommodative therapy and pencil push-ups; (3) office-based vergence/accommodative therapy with home reinforcement; and (4) office-based placebo therapy with home reinforcement. Participants were classified as successful (n = 42), improved (n = 60), or non-responder (n = 116) at the completion of 12 weeks of treatment using a composite measure of the all visual tests.

A successful or improved outcome after the convergence insufficiency treatment was associated with a reduction in the frequency of adverse academic behaviors and parental concern associated with reading and school work as reported by parents.

ADHD and Vision

Children with undetected vision problems can exhibit symptoms similar to ADD.  Studies show that approximately 20% of school-aged children suffer from eye teaming or focusing deficits which make remaining on task for long periods of time difficult.  Like those with ADD, children with vision-based learning problems are highly distractible, have short attention spans, make careless errors, fail to complete assignments, and are often fidgety and off task.  However, their inability to remain on task is caused by the discomfort of using their eyes for long periods of time at close ranges, not true deficits in attention.  Unfortunately, parents and teachers are not trained to recognize the difference and these children are often misdiagnosed.

These children are often looking around the room, getting a drink, going to the bathroom, staring out the window, or talking to their neighbors.  They’re taking “vision breaks,” although they don’t realize that’s what they’re doing. Children with eye teaming problems have always seen this way, and most are not aware that their close-up vision is not normal.  Few report eye strain or blurred or double print; all they know is that they cannot continue with their seat work one more moment.  As the day progresses, they become increasingly fatigued and frustrated

Any child who is suspected of having ADD should have a complete eye exam by a pediatric specialist in children’s vision to determine if poor visual processing is a factor in the child’s behavior.  Unlike ADD  is diagnosed by a subjective checklist, objective clinical measures and tests can be run to determine for certain if the child has a learning-related vision problem which is making it difficult for him to remain on task.

25% of Children May Have a Learning-Related Vision Problem (source: www.covd.org)

Research supports what optometrists have known for some time — a significant percentage of children with learning disabilities have some type of vision problem.  One study found that 13% of children between nine and thirteen years of age suffer from moderate to marked convergence insufficiency, and as many as one in four, or 25%, of school age children may have a vision problem that can affect learning. If we now consider visual-perceptual problems, nearly 60 % of children with learning problems will sow these types of problems.

ADHD questionnaire

The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) contains the Diagnostic Criteria for diagnosing Attention Deficit (Hyperactivity) Disorder:


The child:

  1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities 
  2. Often has difficulty sustaining attention in tasks or play activities
  3.  Often does not seem to listen when spoken to directly
  4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure of comprehension)
  5. Often has difficulty organizing tasks and activities
  6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
  7.  Often loses things necessary for tasks or activities at school or at home (e.g. toys, pencils, books, assignments)
  8. Is often easily distracted by extraneous stimuli
  9. Is often forgetful in daily activities

It is interesting to note that five behaviors (outlined above) out of the 9 present in the DSM-IV may also be due to visual-perceptual problems!


What is important to consider in a visual and perceptual examination in presence of a child who suffers from an attention deficit disorder?

We must clearly identify the following visual and perceptual aspects that modulate visual attention and concentration:

  • Eye movements
  • Functional problems such as problems focusing, eye alignment and convergence problems (excess or insufficiency)
  • Visual attention skills
  • Visual discrimination skills
  • Visual memory skills


• Borsting E, Rouse M, Chu R. Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency: a preliminary study. Optometry 2005;76:588-92.

• Granet DB, Gomi CF, Ventura R, Miller-Scholte A. The relationship between convergence insufficiency and ADHD. Strabismus 2005;13:163-68.

• Gronlund 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 2007;21:494-502.

• Rouse M, Borsting E, Mitchell GL, Kulp MT, Scheiman M, Amster D, Coulter R, Fecho G, Gallaway M.Academic behaviors in children with convergence insufficiency with and without parent-reported ADHD. CITT Study Group. Optom Vis Sci. 2009 Oct;86(10):1169-77.

• Borsting E, Mitchell GL, Kulp MT, Scheiman M, Amster DM, Cotter S, Coulter RA, Fecho G, Gallaway MF, Granet D, Hertle R, Rodena J, Yamada T; CITT Study Group. Improvement in academic behaviors after successful treatment of convergence insufficiency. Optom Vis Sci. 2012 Jan;89(1):12-8.


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