012 Are You Seeing Symptoms Clearly?

Did you know that there are eye disorders that share the same symptoms like ADHD and Anxiety? Can you believe that as many as 1 in 20 school-age kids are affected by a vision difference called Convergence Insufficiency (CI), yet routine eye exams and school-based vision screenings don’t routinely look for it? Kids who have ADHD are three times more likely to have CI which causes difficulty reading and concentrating.  Two core symptoms that are often quickly attributed to learning disabilities or ADHD rather than an eye disorder. If you want to learn more about these disorders including what to look for to determine if your child needs this specific, non-routine testing you definitely want to hear our interview with Michele Cohen OD.  Dr. Cohen is a Neuro-Optometric Optometrist and the owner and founder of InVision in Albuquerque, New Mexico. Many individuals with ADHD and Anxiety also have an eye disorder that can exasperate learning and behavior issues. Treatment that is similar to occupational therapy can correct the disorder.  

If you are in the Albuquerque area and would like to schedule an appointment with Dr. Cohen you can request an appointment online http://www.invisionvt.com/new-patient-center or call 505-341-2020 . 

Learn more about the vision problems and where to find an optometrist who tests for eye disorders like the ones in the episode here and here. You can find the Vision and Learning Checklist here and the Convergence Insufficiency Symptom Survey here.

Here at the Parenting Balance Podcast, you'll find simple, science-based tools and tricks for parenting kids with ADHD or anxiety. Although we are both family therapists, this podcast is for informational purposes only and should not replace the guidance of a qualified professional. Join us as we debate and discuss our own experiences as parents of kids diagnosed with ADHD and anxiety and breakdown the latest research into easily digestible portions. We created this podcast to educate, inspire hope, explore new ideas and discover together what we know to be true: you are not alone, and finding a community of support can make all the difference. Please join our Parenting Balance Podcast Community here and sign up here to be the first in line for our new Modern Guide to Understanding Kids With ADHD mini-course.

Transcript

Hi everyone, welcome to the parenting balance podcast. My name is Kelly Williams. I'm a licensed clinical social worker and an ADHD parenting expert by experience. I'm here with my partner. Hi, I'm Teresa Vanpelt. I'm a licensed mental health counselor and anxiety parenting expert by experience. And for the past 10 years, Kelly and I have had a family practice in Florida. This podcast is for parents who want to really understand what's going on with ADHD and anxiety. So you can ditch the chaos and feel confident and happy again. Think about this, up to 80% of our kids learning is through vision. Vision problems like vision coordination disorders, results in academic problems that are often confused for ADHD symptoms. It's estimated about 20% of children have a vision coordination disorder. But what's important to know is that most screenings don't check for them. So that's why I am super excited that our guest today is Dr. Michelle Cohen. She's a doctor of optometry with a practice in Albuquerque, New Mexico, that specializes in neuro optometric rehabilitation. What I think is especially cool about Dr Cohen's practice is that she's blending occupational therapy with vision therapy, in order to achieve better outcomes in less time. And of course I think faster is better with most things so I think that's very cool. Thank you so much for being here today Dr. Cohen. I know that I often ask parents when I'm assessing for ADHD in my practice, as part of my intake assessment involves asking the question of whether or not their child has been screened for binocular vision problems. And most of the time, parents do not know what that even means, and so I'm so excited and I hope that we could just get started with helping parents understand what is a vision coordination problem. So thank you again for having me here. I'm super excited to talk to you because a lot of my patients do have ADHD and anxiety, and they go hand in hand. A lot of times, so it's important for all of us to work together to best help everybody. So, in our office, we kind of break things down a little bit differently. We do a routine eye exam. So a person needs to be able to see clearly in order to be able to learn. And then we call it a functional exam but it is, how do their eyes work together. So, can they get both eyes to the same place at the same time, can they keep the image clear and single, can they get the information in, so that's like a physical issue.  So being able to see clearly is one thing, but a lot of times when you go to the doctor, they ask you to keep your head still and your body still and they're looking at a target, that's high contrast it's black and white. And it's staying still. Well, that's not how you see in the real world.  In the real world the things you're looking at are moving and our bodies are moving, especially in our populations. And can they still keep the image clear and single. And then the last piece is, what do they do with the information they've gathered? How do they process it? So, in our office we almost do three entirely separate exams to look for vision issues. Okay, whereas, kind of like the typical school screening, that involves only the one exam. So in a school screening actually, a lot of times they're only checking distance vision, they don't even look for near vision or close vision which is reading computer work artwork, all of that stuff is actually near a screening, a lot of times is just distance finishing schools are getting better and better and better about looking for near work issues, but you can be very very farsighted, which is where you see far away way easier than up close. And so you're working hard to read and to sustain that read but you can see 20/20 in the distance, and pass a screening with no issues.  I know for myself as a parent, if the school doesn't alert me to a problem. I might not notice it because I would be relying on them like I would know that my kids are getting a screening at school, and I might not be looking for that. So it is a very different thing. They're screening mostly for nearsightedness so not being able to see the Blackboard. But, where a lot of the strain and struggle is is actually up close and reading and children don't know to tell you because it's always been that way. You know, I say that all the time. We don't know what we don't know right like it's, Yeah, you don't know. I love it. Can I ask you a question? This is particularly well actually both populations are gonna need to know this, the ADHD and anxiety population but what does the test look like?  I think sometimes kids need to know, and parents want to know what we are going to do and what it's going to look like so I can prepare my child. So, again, because we break it down a little bit differently and do a couple of different exams. The routine exam, you go in and look at a distance chart. I'm very big about explaining to children what all the equipment is so the Big Four Raptor are big ugly glasses, the slit lamp is a microscope to look at the health of the eyes, all of that kind of stuff. That’s easy. The functional exam or they're an ocular vision exam. We do depth perception testing so they get to wear red blue glasses and polarized glasses. We actually have a computerized tracking test, which the kids love because they get to blow up aliens with their eyeballs. And we're testing that’s a ton of fun. So, the parent sees exactly where the kids eyes are doing when they're trying to follow a dot around the screen. We have them crawl on the floor to check things like primitive reflexes. Those are things that we're born with that help us learn to creep and crawl. That should disappear by about two, but a lot of times they haven't just developmentally gone away. And that can lead to jerky more awkward movements. Trouble crossing midline. And then we look at vestibular in our ear ocular issues. So we put people on a swing, and we spin them in circles and look to see what happens so the kids have a lot of fun during those exams. So, even if they're nervous when they come in. I explained everything before I do it. And then they, they're you have a blast by the time they're done.  That sounds fun. Especially for kids that are active and want to do things, you know they have a hard time sitting still, through like a traditional exams. So those ones that I've been through my functional exams, they last actually quite a bit of time. They last about 45 minutes to an hour, but because they are so much fun. The kids generally don't have a problem with it. That's fine. Yeah. So I've read that there is among people diagnosed with ADHD, there's like a three times greater incidence of having this. I believe it's called convergence insufficiency, which is, I think that part where you were explaining about how do the eyes coordinate with each other, to be seeing the same thing. Did I get that right? Yeah.  And so I've read there's three times greater incidence of having a disorder like having a problem with that. If you are diagnosed with ADHD. So, now what should parents look for, for example, as we're talking here I know my daughter is diagnosed with ADHD, and she often complains of headaches. And would that be a sign that I need to try to seek out a functional vision exam for her? Yes it is. The symptoms overlap between convergence insufficiency and ADHD. So, it's not a coincidence that the term focus is both a mental issue and a visual issue, visual attention drives mental attention. So if you have a child that can't keep their eyes on a target and pay attention to it, they're not going to be able to focus on it mentally. So destructibility during reading or schoolwork. Mistakes small mistakes like not being able to quickly identify a plus versus a minus sign and a math problem. All of those things are symptoms of both ADHD and convergence insufficiency. So, we're not actually sure if the diagnosis of ADHD is even actually correct. A lot of times, it could very well, just be the eye coordination issues. So would you.. I tell parents, I can't tell you until we get rid of the eye coordination issues. They're able to pay attention. Visually, and be able to track with reading. Are they skipping those small words? Are they reversing letters because they have an eye coordination issue or because they have ADHD? Until we treat the eye coordination issues that their symptoms go away, they never had ADHD. Sometimes the medications for ADHD impact a child's accommodation or focusing system. It's one of the side effects. So, do they have eye coordination issues because of some of the medications they're on. So it's really complicated to tease out exactly what the issues are. So we don't know whether there's a causational relationship. So do they have eye coordination issues because they have ADHD or anxiety or are they just comorbid conditions where they're just more common in the same population. That's an interesting question. You know I use family history as a barometer for my assessment. So usually, I'm doing the same sort of process of trying to rule it in or out when there are all these other factors going on, having trouble in school, you know all this other stuff. So, we know that ADHD neurology is about as heritable as height. And so when in doubt, I go back in the family history. Whereas, it's not always been identified. but you know through patterns of behavior, sometimes we can rule that in or out but in the research on the vision, how it impacts the symptoms and how similar the fidgeting and, you know, like the problem with the, with when you have a vision coordination problem is that you're over efforting all the time. Yeah. And so then you begin to see these outbursts and this anger and this, these behaviors that are quite vexing to parents, but it's because the kid is exhausted because right because they're having to exert triple the amount of effort to do something and we're missing kind of the root cause there. So that's, yeah. So let me ask you this, how because we have listeners around the world actually which is really exciting. And so while you have this very awesome, and, you know, yeah innovative practice in Albuquerque, New Mexico. What if parents want to find a practice like yours where they live. What do they look for? how do they, how do they find a functional vision exam for their child or themselves? So, the College of vision development of college of optometrist and vision development is C, ovd.org has a website where you can locate doctors through. I also belong to a group called Nora, and o RA, which has the neuro optometric vision Association, and they have a lot of resources about how to find doctors. There is also a group called pave which is parent organization of people who have gone through vision therapy. So those are all good resources. There are a bunch of different terms. So, I consider myself a neuro optometric optometrist, but also a behavioral or developmental optometrist or terms you can search for online. There are groups all over the world. They do similar things to COPD. So if you look up those terms, you'll find them kind of no matter where you are. It's always fun because our meetings have people from all over the world. Or, we're gonna definitely put links in the show notes for anyone who wants to look into that further, the things that parents can be looking for. Just in their child, like you were saying so headaches, especially on school days so if they don't have a headache. On the weekend if they're not reading or sitting on the computer. Although I don't know that there's a difference right now, but yeah. If the headaches are only school days, rubbing their eyes a lot when they're reading in weird reading postures. So, a lot of kids will be leaning over their hand or their arms so that they're basically covering one eye. Their eyes getting red looking or watery when they're reading, or just honestly the exhaustion at the end of the day that you were talking about right it's really common because they've just been working hard at the actual mechanics of reading, just the physical part of reading is harder for them than they should. And I'll talk to the kids about tripping over their eyes when they read and even the young kids are nodding because that's what it feels like to them, they're aware that something's not comfortable when they. And right so it comes down to having the right words, asking in the right way, which I find a lot when I'm assessing symptoms. Yeah, you found one that was vision and learning, which are for parents to fill out but the. It's called the CIS s, the convergence insufficiency symptom survey are good ones for kids or adults to fill out for themselves. You know in the research on the self assessment scales, and their sort of utility in coming up with an accurate diagnosis is very strong. So, you know, because I know sometimes in my office. Parents who are well meaning. Will coach their kid to be like no you don't do that. And I say, Don't do that. Don't do that because we want the child to be communicating from how, from their experience, right so it's kind of like how you said, Are you tripping over your own eyes like we don't have good words to explain what this weird, different feeling is. And so it's important when we give kids, one of those surveys that we allow them to, you know, to give their full opinion without a parent, putting their judgment on it. Yes. Well, and the other side of that coin is a lot of times kids don't even notice the tape sometimes split into two until you bring it to their attention, because it's always been that way. They just ignore all right, so they're not aware, they're not. They won't tell you that the words are floating on the page, because they don't know that it's not supposed to, or that the words are coming in and out of focus sometimes they're clear sometimes they're blurry. Because if they work hard, they can keep it clear, so it just must be an effort issue. Do you find that kids feel embarrassed or ashamed of this happening to them. So, they're not embarrassed about the words moving or floating, they're embarrassed. What they're embarrassed about is their reading ability. And so, actually I have a lot of times they get really excited to know that there's a reason that it's not that they're not, it's not that they're not smart, and I really drive that point home over and over again that this has nothing to do with how smart you are. It has nothing to do with how hard you're trying, because these are kids that have everyone knows they're super smart. But, how they do in school, isn't reflecting how smart they are. People have been telling them we'll just try, they're not trying they're not applying themselves, and actually are. But just in ways that you can't necessarily see. So, these are the kids that are falling out of their chairs because they don't know where in space, they are. And so people are telling them they're goofing off but they're not goofing off, they just really don't know. I say they don't know where their heads are in space, and I do mean that quite literally, because the main way we know where our body is is our vestibular ocular reflexes. And if you're getting a mismatch between what your ears, your vestibular system, and your eyes are telling you. You don't have a good sense of where you are in space and moving and fidgeting, and constant motion actually gives you more input about where you are in space. So they're moving their bodies constantly and always to get that necessary information about where they are in space. And if you treat that with the vestibular ocular reflex exercises with the primitive reflex exercises with peripheral vision which is where what localizes us, and the objects around us. you work on that. A lot of times that energy that motion can be lessened because they don't need that input, all of the time. Right, the brain gets what the brain wants. Right, exactly. so that brings up a great point is like let's get what does the course of treatment look like for this convergence and sufficiency how long, what is it a weekly appointment, are they daily appointments what what are parents you know what are kids need to do to, because my understanding is this, this treatment is very effective and curing the problem, is that correct? It is correct so vision therapy has been proven to be the best treatment for convergence and sufficiency in our office that we very rarely find convergence and sufficiency in isolation so we find other issues as well so gross motor coordination. Crossing midline issues, the stimulator ocular issues. So, our therapy ends up looking an awful lot like occupational therapy. We do a lot of exercises that are full body, because in order to know where your eyes are pointing you have to first know where your head is so we work from gross motor to find motor, the eye movements to find ocular vision or depth perception coordination, it usually is weekly in our office. There are some places that do more frequently or less frequently but in our office it's once a week. And then we give you exercises to practice at home. The activities should be challenging for the kids if it's too easy, you don't learn anything. And if it's too hard, then the kids give up and quit. So, every week you come back and we make those exercises are the activities harder and harder and harder. Usually a course of therapy is about 20 to 24 sessions. So it is quite a commitment. And we usually take a break, even if they need more at 20. To 24 sessions everyone's kind of done coming in every week for that long. And the exercises, they don't take long at home, about five to 10 minutes, which doesn't sound like a lot until you go to try and do them every day for five to 10 minutes. Yeah. Makes sense. So they're depending on the severity of the problem like if you have an eye turn, you can be doing therapy periodically throughout your life. So I have convergence insufficiency, you were talking about families. It's actually my dad, myself, my two kids straight down the line we all have convergence and sufficiency issues. And I have control over my eyes. Until I get the flu, or if I'm fighting off something I haven't slept in a week because my kids aren't sleeping. Or, if I have a glass of wine, and then I can't control my eye coordination anymore. And periodically, if I'm going through a super stressful time, I'll go in and do some of the vision exercises. Still to the stacking as a kind of like a reset to reset your eyes a little bit. It's partly to reset, but. So, when you are stressed or you have anxiety. The amount of visual information you pay attention to actually constricts so you get tunnel vision. And so you can do exercises to open up your peripheral vision. And yeah, would be like a reset but it's really just taking in more of your official space. Okay, that makes sense. I call it a tuna. Yeah, yeah right like you know you got to do it and then you got to keep you know like some just every now and then you need to tune up and you go back for a little bit more, because if you let it go, it gets worse but if you just do your practice, then the new doesn't get worse. Right, exactly. And this. This is viewed or listened to worldwide. So, this information is going to vary but approximately how much as this run and this might be more of a, like, the United States kind of estimate, but is just the treatment covered by insurance. Yeah. And so we do actually bill insurance in our office. Most places that I know I've actually don't. So, the cost really can vary greatly. I know in Canada, it's never covered through their health care system. In the US, even if so we do take insurance but there are some insurance plans that specifically exclude vision therapy. So, the cost can vary in our office, a session is about $100. If you're paying out of pocket. We do help patients fight to get it covered, because it should be. it's a physical coordination issue. There is no reason that what I do shouldn't be covered, right there. We're working on the same thing. We're just using. I use vision as a way into the brain to help the coordination centers in the brain. So it's actually incredibly effective for brain injury for concussion for stroke, as well as for developmental delays, autism, ADHD, anything that affects brain is going to affect vision. And so much of our brain is dedicated to vision. The state of our insurance system that was a whole other conversation. Exactly. Well, you know, and I like to, I tell parents this all the time that you know that the cost of treatment may initially seem expensive, but you know really an accurate diagnosis, and an effective treatment will save you money in the end. And so, you know, I'm sure I've said that before on this podcast. But it's really worthwhile to, you know, to get an accurate diagnosis and use a treatment that we know is effective, and the emotional cost I always point out the emotional costs so I was just going to address that, if you think they're stupid because they can't read. fixing that is worth every penny. and the sooner the better. Absolutely. So, 60% of kids who struggle with reading struggle because they have an eye coordination issue. So, we have a lot of patients whose DeRay scores their reading scores, just skyrocket. Again I said my two children have these issues. My daughter does fine in school and always has. But when we put her through vision therapy, her dear, DER scores jumped to grade levels in three and a half months so well in the thing that's to like her baseline was so high. Some parents may not have noticed, and they thought you know my child's on level or a little above level but in her case. Her baseline is much higher. She still wasn't reading where she should have been. My son also jumped levels. He started younger so the numbers are a little bit different, but went from below grade level to above grade level within a couple of months, and his handwriting improved just drastically. Yeah, that's another thing that we see with kids with ADHD, sometimes anxiety when definitely with ADHD when they're not the medication isn't optimized the handwriting is horrible. Yes, so if you again it's mostly with the concussion patients but there's a great test I call it the George Washington test. And if you just take a piece of paper, and you write the words George Washington down. You can look at your handwriting. If you want to give yourself an eye coordination or an over focusing problem. If you take that pen. And you stare just at the tip of the pen. And you keep your eyes and your attention and you keep that staring posture, at the pen, and you write down the words George Washington again. It's amazing how different the handwriting is sometimes there's misspellings, in the words that you could just spell three seconds before. It's really amazing what the impact of vision is on spelling on handwriting on coordination. It's a. I see how these kids might be misdiagnosed as having ADHD or like we said like a morbid disorder, you know like, they have both kits. Yeah. So, um. Alright, so at this point in the podcast I usually do something I call the takeaway for today for parents so that's like, kind of, if there's one key point here that we want our listeners to get from this, would it be to check out the cisterns yeah the downloads and just go through that with your kid even if even if you don't have any red flags would that be a useful thing for parents to do it would. So, but I am also an eye doctor so I'm going to tell you if your child hasn't had just a routine eye exam, they should. The first eye exam should be at six months, because that's when all the connections in the brain for using both eyes together starts. So, all children should have a just a routine eye exam just to make sure that everything is healthy, and that there's no need for glasses, but especially in the population that you both work with it is incredibly important to have routine eye exams. And when you say eye exam as you're not referring to the screenings that the pediatrician does at the well checks Correct, correct. Okay. And how, how often? How frequent? So, six months, and then usually about two and then bright before kindergarten. And then every other year just routinely after that. There is a huge issue with our population becoming more and more nearsighted, and there are things now that we can do to prevent that or stop that. But especially if there are any developmental delays, ADHD, again, any concussion brain injury clumsiness. You need to make sure that eye coordination isn't a huge contributing factor to those things. And this is so exciting. And I'm so like there's, you've opened my eyes to a lot of things that I wasn't aware of. Thank you so much for doing this interview with us today Dr. Cohen. You're welcome. It was a pleasure being here. Yeah. And so we're going to, like I said, we're going to put all this information, and we can put Dr Cohen's information for her practice if you're local to her, and you want to check her out. We will put that information in the show notes as well. And we hope that you continue to join us for our future episodes in the series where we do interviews. we’re really excited about it. We have a lot of great people lined up. Thank you so much for having me. And for doing this for us. Thank you for listening to the parenting balanced podcast to join our mailing list, go to parenting balanced. COMM slash podcast. When you join you will be notified of upcoming live Q and A's. You can help us plan future episodes, we'd love to hear comments and questions. You can reach us by email. Hello at parenting balanced calm. And if you found this information helpful, please share it with anyone else who can benefit and subscribe and give us a rating on your podcast platform. 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