If you're like most parents with a child with ADHD, the first thing you do when you notice your child is struggling with reading & attending is look for a reading tutor, phonics instruction, or some support for attention.

It's totally natural–and I've done it, too!

But there's a problem...

When those techniques don't work, your child might feel even worse. They might feel trapped in a cycle of failure.

There is a solution for these kids - it just may not be in the obvious places.

Like, when your tomato plants aren't producing well, you have to look at ALL the different reasons... Once you've taken care of all those obvious big things and it still isn't working, you can dig a little deeper - maybe there's a fungus or bug infecting the plant, or maybe the nitrogen levels in the soil are off, or maybe there's a cracked branch – you get it!

The ability to attend and read can be a little like the ability to produce tomatoes. When it isn't working, we have to look at all the reasons why. For kids, the reasons can be related to nutrition, sensory systems, processing abilities, and so much more.

When we take the time to look deeper, we can figure out the root causes and – once we work on those – open up the possibility for kids to improve their reading abilities, self-regulation, performance, overall confidence, and self-esteem.

This week, we're looking at the visual system and how it affects children with ADHD with Dr. Laura Knapp. Did you know many of the ADHD symptoms have visual connections? The kids really might not 'see' that well. These can cause children to be easily distracted, frustrated when reading, unable to focus on the task at hand, lose their place while reading, or have difficulty in sports. 

Join Dr. Laura Knapp and me as we discuss vision therapy, including:  

• what it is and how it can be helpful to children
• why your pediatrician might be saying don't bother
• the benefits that can come from improving the visual system 

Kids tend to get frustrated with visual difficulties because they need to put more effort into focusing on and remembering the little details, and at the same time processing the bigger input. Determining visual problems can get rid of one more roadblock that kids with ADHD have to deal with.

This interview could ‘change your vision’. ;) 

Links

Dr. Knapp's Practice

Find a practitioner near you

Facebook group Vision Therapy Parents Unite

Get the book: The Hidden Link Between Vision and Learning by Wendy Rosen

SHAREABLE GRAPHICS

FULL TRANSCRIPT

Veronica: So how can vision be related to ADHD? That's what we're going to talk about here today. My name is Veronica Hunter, the host of ADHD - What Now?, where we look at what the options are for your family when your kiddo has ADHD. And today we have with us Dr. Laura Knapp, who has a behavioral optometry practice. And we're going to be talking about all things related to vision and ADHD.

So I'm just going to be honest and start with when I went to the pediatrician's office and I mentioned vision therapy for my child, the pediatrician was like, "I don't think you should spend your time or money in that way." So Dr. Knapp, what do you have to say about that?

Dr. Knapp: Yeah, that's a story I've heard before. As I was, you know, kind of just sharing, you know, even for my own professional relations, I was seeking a pediatrician and happened to mention what I do. And they really were happy to just say to me, "Hey, you know, I don't really believe in what you do. I don't align with your professional, you know, job, but you know, we're happy to take care of your kid".

So it's a story I've heard many, many times. Definitely more in the MD community versus from other, I'll say healthcare professionals like OTs, but honestly it comes up even within optometry. So it's not something that's unheard of by any means.

Veronica: At the same time, from my own personal experience, I have seen how much benefit it has had for my children. I think one of my children went from reading below grade level to at, or above grade level in a fairly short period of time. So definitely can you share some, what are the benefits or what have you seen or what can be accomplished with vision therapy?

Dr. Knapp: So a lot of what happens with vision therapy is weeding out the visual difficulties to improve your visual processing skills, which oftentimes as parents, one of the things that we look at most is our reading ability or academic performance, but another nice side effect of that is also increasing things like sports performance and self-regulation, and being able to attend better to what we're doing.

So a lot of times children's frustration is increasing because doing a simple task like jumping from word to word in a book is challenging, or you put so much work into reading that you can't remember what you've read. And all of those things are facets that we can really work through and improve from a vision therapy perspective. So our visual system guides all our motor.

So if our visual system is connecting with our ears and helping us navigate space and walk and interact with sports, sports activities, it works in the same way when it comes to reading; our eyes guide all of our neurological input so it makes better sense for us to remember our spelling word or reading for content instead of having to keep rereading and have to be read to understand what we're doing. So the whole idea is to use different techniques to improve those aspects.

Veronica: And you have a practice that covers, can you just explain, like for the layman's terms, what do people go to you for? And then sometimes vision therapy is a part of that, is that right?

Dr. Knapp: Yep. So the practice these days is almost almost 50/50. The majority of cases are what we would classify more of a learning related vision problem. So maybe someone has an eye drift, or maybe someone has decreased eyesight, and for those reasons, the eyes don't work well together. So we're using vision therapy to improve those aspects. And then kind of in a secondary way, also improving what's happening from a visual processing perspective.

The other side of the practice is a lot of neuro rehabilitation. So those patients are coming to us post-concussive and most frequently post-stroke because they're dealing with other things that are interfering with their eyesight as well. So maybe they can see clearly, but they have debilitating headaches every time they do near close work, they have double vision, they have visual field loss. They're wanting to get back to driving, but their spatial or depth perception's reduced.

So for those types of patients, it's skills that they have had previously that we're working to achieve again. And for learning related, it's trying to help those students get to their academic potential, instead of being stuck in a rut as their peers are able to keep up with the work and trying to understand why they're not able to, especially if it's a visual related cost.

Veronica: So how can vision therapy - is it related or kind of potentially help kids with ADHD?

Dr. Knapp: Most definitely. So there is a lot of crossover between vision related learning problems and ADHD. If you look at a lot of the leading symptoms from an ADHD perspective, of those 18 symptoms, upwards of 13, 15 of them can have visual connections. So easily frustrated when we're trying to read, easily distracted, loses attention very easily when asked to do a near task.

Imagine trying to keep your focus and your attention on a task that's incredibly hard to do. So maybe you see double and it's a lot easier to look out the window or get up and wiggle in your chair because you can't keep looking at it. It might even make you have a headache or feel queasy or uncomfortable.

So if we're having a hard time getting information in, it's really hard to retain that information. And gosh, it's a lot more easy to be distracted by sounds that are happening around us or wanting to get up and check out what our peers are doing, or just close the book and say, "I don't like reading, I'm not good at reading and I'm just never going to be good at it. So I'm just going to take ownership of it". 

And that's really where we come in. We're looking at and weeding out a lot of these kiddos who come in and usually the first complaint the parents will say is, "you know, they don't like reading, I just want them to like reading as much as I do. And I don't know whether it's their eyes or whether it's, you know, their inability to actually do it and pay attention".

And that's where a developmental exam really comes into play because we're weeding out things like, can they see well, can we evaluate their tracking system and see how those two eyes work together to get input in so we don't lose our place while we read or skip sentences or skip lines. Can they actually look across the room and copy from the board and then look up close? Because if that's hard to do, imagine what your notes are gonna look like at the end of the day, trying to review.

So if we can weed out visual function and understand what roadblocks are happening there, then we can better treat to help address those aspects. And then we can better understand what we can address from an attention perspective separately.

Veronica: Is there any typical outcome that one might expect or does it really vary case by case so much? Or what have you seen in your practice as a result?

Dr. Knapp: Yeah, there can definitely be some burying, especially dependent on the severity. And also even the age of the child.

As you had your own experience, you know, your children were different ages as they were coming through the vision therapy program and also had different needs. So, you know, as we're working through some of these visual difficulties, a lot of times, most of these kiddos are coming in also under the care of OT and even have 504s or IEPs in place at school, or if they're getting other support, whether it's reading support, their family doctor, pediatrician's involved.

So really working through to minimize as much frustration to really make them as receptive to all of these interventions as much as possible. So a lot of times I'll have OTs working on self-regulation and really being able to be self-aware and describe what they're feeling. And then we're working on the visual component to minimize all of those difficulties that make it hard for us to attend in the first place.

So if we can weed out some of those pieces, we're really opening ourselves up for more success. But it can vary. There have been some, you know, certainly cases that, you know, ADHD has been a major component and initiating therapy can be a challenge when we have a really hard time. Even the most basic activity can be very challenging and frustrating.

So a goal of our therapists and our clinicians in the office is really everything should be catered to the patient. I can't treat two children exactly the same, even though we might have parallel goals, it's two separate streets to get to the next block. We really have to work to make sure that we're doing activities that are going to speak to that particular child, which another kiddo the same exact age, same gender, same abilities, you know, may not be able to perform the same way because they're more easily frustrated or easily distracted.

Veronica: What does it, what does it look like? Can you just describe some of the exercises or what is when we say vision therapy, people may or may not have an idea that comes to mind.

Dr. Knapp: Yeah, most definitely. So, you know, I always feel like when you walk into a vision therapy room, there's that feeling of, what exactly goes on in here? We've got balls hanging from the ceiling and spinning pegboards and touchscreen TVs. And, you know, it kind of feels like this occupational therapy type setting kind of intermingled with, you know, almost what feels like almost magic happening back there because how could a swinging ball, you know, really help us get to our finish line?

So in a most basic sense, everything that we're doing is foundation. So we're layering on all these visual skills so that we can get to a higher level of performance. So we've got stamina. So we've got the endurance to get through that visual task, but we've got to start small.

So if I have a child come in and, you know, instantly it's just, let's work on depth perception and let's make you, you know, just the best set of eyes that anyone could have. It's generally not successful. We've got to start with really the roots.

So a lot of things we're working on are smooth movements of our eyes, and we're not doing such an a such basic form, but when you think of that ball, that would be swinging side to side and having to keep our eyes on it as it moves, we're working on a smooth movement, fixation understanding where we are in space and all of those things are gonna help with our visual security, but also help us feel less frustrated and more in control.

Looking between targets - because if we're looking between two targets, that represents a lot like what we do when we're reading, we're jumping words, we're looking at what's up on the board at school and looking back, now in a virtual world, maybe it's our computer screen and then our keyboard or our notebook.

So working on all of those really straightforward skills since tracking is a great place to really start weeding out some of that real frustration with reading, if we can improve how well we can keep our eyes on a target, how well we move our eyes with that target, and jump between targets, that's our great foundation.

But we also like to make sure that since our visual system guides all our motor, that we really work on all of those pieces too. So especially in younger children, as we're working on our bilateral integration and how both sides of our brain and our body speak to one another really helping them understand that they can smoothly follow across without feeling like there's a concrete wall here at the center, they've got to jump, really having them understand space. We've got on trampolines and walking rails and understanding right from left and really trying to help them connect what our eyes give us in terms of knowledge.

There's a lot of vision therapy that, I'll say, just feels fun because if you think of things like the board games and the activities that we do, like playing checkers or memory or connect four, all of those tap into our visual skills.

And it's really easy for a child to skip some of those activities, like putting our wooden puzzle pieces into the board, because we're not good at that manipulation, but that manipulation is twofold: our eyes give us the information to change the shape and how our fine motor acts on it.

So we do a lot of things that involve our physical movements with gross motor, fine motor, obviously working with those eyes in our general movements, but also using things like lenses to help us understand when things are clear versus blurry and glasses that help us see 3d. So we can really appreciate where we point our eyes and how we get good information.

So it really is a very diverse setting and really individualized. We're getting as much response from that patient as possible.

So for example, if I have a little girl who's in the office, who's five years old, maybe asking her to read letters off the chart is not going to be ideal, but having her tell me who Disney princesses are, as she's jumping back and forth is still executing what I need from a visual perspective, but speaks to her because she's able to, you know, be excited and you know, which princess is she on? And she knows all about those princesses. So superheroes, princesses letters or numbers, all kind of gets the job done.

Veronica: And then what are some of the potential outcomes? Like what can you, what's the goal or what are some of the goals that you look to achieve?

Dr. Knapp: Yeah. So in its most obvious sense, our, my personal goal is always to, I'll say, eliminate the symptom.

So if one of the things that, you know, as a parent, you know, coming in and having that discussion of so much loss of place when we're reading or double vision or headaches, especially the biggest thing that really matters the most is reducing all of those symptoms.

So keeping things clear while we're reading, making sure that we're able to remember what we're reading, all of those things are really what we're looking for. In some of the more obvious cases, you know, there'll be a true eye drift. So seeing that eye look aligned has that cosmetic improvement is always a nice thing, but it's really what the neurological aspect is in terms of success.

So we really try to measure that frequently to make sure that our therapists are aware of and pushing for the same progress we're asking of, making sure the parents are involved so that you have the opportunity to express, you know, now our tracking's better, but you know what I'm realizing her spelling is really crummy, or she doesn't know right from left, or he really has a hard time going up and down the stairs.

So really working on things that weed themselves out, along the way, but still really come back to our symptoms. So that's the ultimate. Sometimes what happens is, you know, we're kind of that starting platform, as we're weeding out the visual concerns, then we can really get help from that reading tutor or occupational therapy or physical therapy to work a little bit more on the whole self, but ultimately being able to be more in control and less frustrated is the key. That'd be the best point of success.

Veronica: Awesome. So why do you think it ends up being a controversial subject, like talking about at the beginning with a pediatrician, for example? 

Dr. Knapp: Yep. So a few reasons, one, I think we are in a society where particularly medically trained physicians love the idea of a medication being able to treat, or a surgery being able to treat. Especially from a standpoint of, you know, if you think of something like you go to the doctor and you have, you know, a sore throat, you know, what arethe things that you typically do? You get prescribed that antibiotic, you get treated, you take your medication, you recognize your symptoms improve and voila, we're all happy.

But the thing is, is that just like we accept occupational therapy, vestibular, any of these things that are a different way of approaching the problem or helping the healing process or helping the body learn and recover, vision therapy is much more like that.

So because of all this controversy, there've been a lot of studies done to understand what the effective in office optometric vision therapy is versus even home therapy, or I'll say the placebo as opposed to really doing anything.

So we know for certain conditions, particularly one called convergence insufficiency, which generally is mostly a near point concern. So if we look at something up close, it really is a difficulty of those two eyes to follow that target inward. And usually there's some double vision, some blur, headaches after reading, there have been studies conducted to show the efficacy of vision therapy.

So we have the studies to prove it. We've also got the history of vision therapy, which is not something that is new, therapy techniques have been around for more than 50 years at this point. But I also think there's insecurity even within optometry as a profession, my greatest referral sources are other parents and other OTs, child study teams, reading tutors, it's not necessarily from my own colleagues.

There seems to be even some, you know, disbelief even within our own profession. But I think there's also concern of, you know, you refer a patient to a colleague and want to ensure that you're going to get that patient back.

So, you know, in, especially in a small business world right now, we're, you know, we're all kind of in a little bit of a pandemic crisis in terms of, you know, keeping our businesses open and thriving, you know, there's insecurity that's definitely driven there.

One thing we try to do to I'll say combat that a bit is communicate with our referring optometrist and referring doctors as much as possible. We don't sell product to our patients. So we're not an eyeglass, you know, sales center. We really want to make sure that we are seeing you for this difficulty and onwards you go.

And I think that line does get blurred. You know, at times I think it's easy to do, and it's definitely more work to, you know, say to someone, you know, I've loved caring for you and I'm going to miss you terribly, but you have a great doctor and you know, you're in good hands there, so you certainly  can go back and be cared for.

I also think, you know, there's also a lot of just, in general, because it feels as if, you know, when we think of vision, I think people immediately, you know, look right to, oh, but I already see 20/20. And this is past that. This is not just, oh, I see clear, so I couldn't have anything wrong or couldn't be a problem. There are so many layers beyond that from your depth perception, your color vision, to how your two eyes work together that matter well beyond how well you're seeing.

And I think when we say vision therapy, we really equate it to, but I don't need glasses or contacts and I can see fine, so what could it possibly do for me? So, you know, maybe, you know, the goals of the next several years can be to help evolve that name. But, you know, vision is past that, there's always that phrase, in vision therapy, vision's beyond 20/20. And it's so much more than that.

Veronica: Yeah. We've been going through and looking a little bit about how the different systems interact with each other. And I find it utterly fabulous how the human body just really builds on itself to be able to accomplish those higher level learning skills, right?

As we're about to wrap up, for parents, any last things you'd like to say or recommendations around vision therapy and how can they find a practitioner such as yourself and where could we find you?

Dr. Knapp: So to find a practitioner near you, one of the best resources is a website, www.covd.org, the website has a practitioner locator. So you type in your zip code and that'll be able to populate the optometrists that provide vision therapy or developmental optometry near you.

One thing I would make the recommendation of is finding one of those physicians that is a fellow in the college of optometry in optometrists and vision development. It's an extra level of training, really focusing on that learning related and visual processing aspect. So above and beyond our traditional optometric training, it's many hours of completion and examinations and oral exam that really show that ability to treat and to care for those patients.

So that would be the first, I'll say piece of criteria, I would say. I, myself, practice in Fairlawn, New Jersey, and we are, I'll say fortunate enough to see patients from all through the state, all through really the tri-state area. We've been really lucky to have patients come to see us from Guatemala and Australia and even co-managing with Israel, and it's just been kind of a real compliment to the history of the practice and, you know, the reputation that is there.

So I am more than happy at any point to answer questions. You can certainly feel free to share our contact information. Our website has a contact us. So if there's any questions or, you know, looking for any information I'm happy to.

And another two great resources on Facebook, Vision Therapy Parents Unite, is also a great one to understand what other families are going through. And a lot of them are also, you know, exploring things like auditory processing, and speech concerns, and working with child study teams, so it's really a great platform to realize that, you know, this is not an uncommon concern.

One in four children in a classroom has a vision related difficulty. So it's certainly not unheard of, and it's a good place to, you know, remind yourself that as a parent, you're not alone and, you know, in a perfect world, when you know, we're in even a doctor's waiting room, I like the idea that even as our patients come in, they see, you know, I'm not the only one coming here for this, there's, there's more than one of a software that has some hiccups with how are our eyes and our brain are working together.

And one more really good resource, if I may, a great book, The Hidden Link Between Vision and Learning, is a great one in terms of discussion for ADHD, as well as, vision therapy and kind of really linking those pieces together. So it's a really, I'll say, really well shared book amongst developmental optometrists as well.

Veronica: Awesome. Thank you so much, Dr. Knapp for being here today and sharing just your wisdom, knowledge, expertise, and where we can go find help.