Pediatricians
Editorials
Our guides
Click on the image to download the guide
The importance of sensorial assessment (eyesight, hearing) when concentration difficulties appear
After years of insufficient knowledge of attention deficit-hyperactivity disorder (ADHD), today there seems to be, in certain specific areas, an over diagnoses of this disorder which does not benefit the proper knowledge and handling of children with ADHD. First, a hasty diagnosis can lead to a child’s fundamental problems (emotional, sensorial or others) being ignored, when these problems surface with the same symptoms as ADHD without being that disorder. Second, because it means that those children are treated incorrectly; they are given medication that they do not need and they are deprived of (family, psychological, educational, sensorial stimulation/rehabilitation) interventions that could better help them. According to statistics, in Spain between 4 and 5% of children are hyperactive, and of these from 20 to 30% are medicated. Therefore, it is worthwhile to continue spreading the word about the need to identify ADHD, and equally as important, to identify it correctly without using the acronym as an umbrella for all children with concentration or learning problems.
In fact, in Spain, not too many years ago, we used to complain that many children with ADHD were not diagnosed, stressing the negative consequences this could have for their development. The situation remains that way in many parts of Spain, but little by little awareness of ADHD as a disorder affecting the development of the brain, with immaturity or slow maturing of certain regions, is spreading. ADHD is gaining recognition as a neurobiological problem with important social and environmental influences. However, every person is a world of their own. No matter how experienced we may be regarding ADHD, and no matter how clear the ADHD symptoms of a child may be, there are certain essential steps to the diagnosis process. ADHD cannot be diagnosed without information on the individual’s emotional and family situation, and ADHD cannot be diagnosed if we do not know whether the individual consumes toxic substances or has proper eyesight and hearing. The three symptoms defining ADHD (unrest, inattention and hyperactivity) are common in many other pathologies and circumstances.
In recent years alternative diagnoses and therapies in connection with ADHD have been spreading. All hypotheses and proposals must be tested in a consistent manner; only some of the proposals of recent years have managed to pass the required tests to show or prove their efficacy.
Hearing and eyesight problems are an example. Children who are hard of hearing or who have poor eyesight may show some of the same symptoms as hyperactive children, particularly difficulty concentrating. A few years ago, in September 2007, there was an article in The New York Times titled “Not Autistic or Hyperactive. Just Seeing Double at Times”. This provocative title was the result of a thorough review disclosing rigorous studies that showed that children with ‘convergence insufficiency’ have many problems concentrating. The good news is that ‘convergence insufficiency’ in many cases can be efficiently treated via visual therapy. In the same way that a convergence deficit will not be solved with treatments for concentration, a real case of ADHD will not be solved by doing visual exercises (as optometrists themselves admit). But what is this about? Convergence insufficiency is the difficulty to focus both eyes so that they converge as far as required for well-focused eyesight and a three-dimensional view of things. In the United States, it has been suggested that 10% of children with convergence insufficiency have an ADHD diagnosis and, conversely, 16% of children with ADHD also suffer convergence insufficiency.
In fact, apparently for every 20 children who have difficulty reading, there is one who suffers from exostosis (another name for convergence insufficiency); try to find out when your child says he doesn’t like to read whether he really doesn’t like to read or it is actually hard for him to read.
There are many other problems, besides the difficulties related to the proper convergence of the eyes, in the development of correct binocular vision, such as poor control of eye movements, poor integration of sight and movement, poor visual memory, and many others which are treated by optometrists, and for each particular difficulty it is necessary to assess the tested efficacy of the proposed interventions. Currently, visual therapy (eye exercises) for the treatment of convergence insufficiency seems to be supported by one of the major guarantors of interventions with tested evidence, the Cochrane Library.
In the case of hearing, a mild hypoacusia or an auditory processing disorder (APD) can also be accompanied by many learning difficulties (including concentration problems and secondary learning difficulties). To assess hearing difficulties other than substantial hypoacusia (deafness), it is not sufficient for a paediatrician or parents or teachers to make a superficial evaluation of the child’s hearing. It is easy for a child with mild hypoacusia to hear us without seeing us, for example snapping our fingers or talking behind his back. One of the causes of this is the fact that different sound frequencies require different intensities in order to be heard. For instance, ‘s’ sounds require a greater intensity to be heard; thus a child may hear ‘strong’ consonants without needing to see the speaker and yet miss out on the ‘s’ sounds. Thus, children with mild hypoacusia, although they may understand general auditory messages, could miss a substantial part of the information and that would make their learning process less efficient. Auditory communication is very redundant, meaning that we can all roughly make out what somebody is telling us when speaking to us with is a lot of background noise or even if they speak to us in a language we don’t know, but it will always be at the expense of a greater cognitive effort. This is why good learning requires good hearing capacity—not just sufficient hearing capacity. Similarly, in the case of eyesight, related difficulties, the treatment of auditory problems is not the same as that of ADHD.
Auditory Processing Disorder is a general term used to refer to all ‘core’ auditory difficulties, in other words, those caused by alterations in the neurological processing of auditory stimuli. This includes difficulties in which peripheral hearing (hearing itself) is correct but the storing of auditory information, the processing required to extract information or the recovery (remembrance) thereof is defective. These difficulties usually surface as difficulty hearing in noisy environments, difficulty discriminating between similar letters or words, difficulty following a sequence of orders given orally, difficulty identifying where a sound is coming from, etc. Additionally, children with this problem may experience language difficulties, attention or concentration difficulties and, in general, learning difficulties. Handling these problems requires environmental manipulation (modification of environmental stimuli, for instance a reduction of background noise and a reinforcement of relevant stimuli), compensatory strategies to make hearing easier, and phonoaudiological training. As with many other interventions for problems where there is a diagnosis capacity, treatments for APD are not always sufficiently backed by studies allowing their efficacy to be controlled compared to other treatments or to doing nothing at all. An example of this is the modulation of sound frequencies, a treatment that is prescribed in many guides on auditory processing disorder, but for which there is very little valid information from studies evaluating their efficacy. The assessment of the possible interventions for sensorial difficulties in children is a priority given the repercussion that these difficulties have on learning and the extended use of these treatments.
In summary, it can be said that hearing and eyesight related difficulties do not seem to be the cause of most concentration problems but they do account for a substantial minority of these problems. It is worthwhile to identify and properly treat these difficulties. It is particularly important to look for sensorial problems or other problems other than ADHD in cases of attention and/or concentration deficit without hyperactivity or impulsiveness. A diagnosis of sensorial problems (basically eyesight and hearing) cannot be arrived at in isolation (just like a diagnosis of ADHD cannot be given in isolation). It is necessary to bear in mind the general functioning of a child in respect of his higher cognitive functions such as attention or memory. A proper assessment first requires a reasonable suspicion and, following the application of specific eyesight and hearing tests (to check how sharp the child’s eyesight is and audiometric tests), the assessment of the processing of visual/auditory information and the application of other specific tests is necessary (such as the potential tests mentioned).
The exact relationships between different development and/or learning difficulties such as dyslexia, attention disorders, language disorders or auditory processing disorder are controversial, and there are many cases where it is hard to categorically establish whether one of these difficulties is present on its own or whether there is a more general development disorder requiring a direct intervention in several of these areas. In fact, there is a great deal of overlap between these disorders in terms of the difficulties that may be observed in a child. Thus there is a heated debate on whether auditory processing difficulties should be considered a disorder in their own right or part of many learning difficulties. In any event, it is worthwhile to assess the different processing of information by a child when that information is received in visual or auditory form and, generally, the child’s strengths and weaknesses in terms of how he learns, because some children learn better with visual support than with auditory support and others are the other way around.
As a conclusion, a full assessment of eyesight and hearing, integrated with the rest of the evaluation of a child’s learning problems, may be necessary in many cases where children have difficulties concentrating and ADHD is suspected.