Vision is complex and each person’s combinations of problems and circumstances is unique. Vision doesn’t function in isolation. It is represented in more areas of the brain than any other sense. It is involved in almost everything we do. How we see the world is an integral part of who we are. It follows that enhancing essential visual functions;
-eye alignment and movement,
-object perception, spatial perception, and guidance of movement
is messy and complex and that it is naïve to think that therapy is not influenced by the patient’s mindset, age, conflicts, and prior experiences.
All of this must be taken into consideration to treat patients. Computerized programs cannot do this but they can be useful to stimulate attention and motivation. It also requires more than a list of techniques. Doctors and therapists need to be ready and able to modify plans to match the patient’s current visual abilities. Optometric vision therapy is provided by doctors and therapists with specialty qualifications. Certified doctors are Fellows in the College of Optometrists in Vision Development (FCOVD). Certified therapists earn the title, Certified Optometric Vision Therapists (COVT). The College of Optometrists in Vision Development is the certifying body for this specialty.
Relationships between providers, patients, and their families are integral to the success of all healthcare, especially incremental care. Atul Gawande wrote about one of thirteen centers for treating patients with cystic fibrosis in the US in his book Better. One center had much better outcomes than all of the others even though the centers all followed the same protocol. The difference was that the director in one center got to know his patients personally. The better understanding and communication that resulted from these personal relationships fostered improved compliance. Atul Gawande also addresses this in his article on The Heroism of Incremental Care.
Therapy is an interplay between treatment and assessment as the patient progresses. The doctor and therapist continue to learn about patients from the way each patient responds. Dwight D. Eisenhower stated in reference to war that “Plans are useless, but planning is indispensable.” This also applies to other complex, messy situations.
Vision therapy is not easy and can be frustrating. Plasticity in Sensory Systems makes therapy possible. While neuroplasticity declines with age, it continues throughout life. Motivation can recruit surprising amounts of plasticity. The Power of Habit balances our ability to change. Habit enables us to function without consciously thinking through everything we do, which is not possible, but it can also cause us to err when conditions change. Therapy develops new visual habits. Focused rehearsal under a variety of circumstances facilitates supplanting existing habits with new skills and makes them more automatic than the dysfunctional patterns that they are replacing.
Optometric vision therapy takes advantage of neuroplasticity and the messiness in our visual system to make change possible. Therapy creates new visual patterns to be more efficient, more comfortable, and less taxing. Patients must achieve this for themselves, but appropriate feedback at the right time can be powerful, which is why doctors and therapists are indispensable in this process. Daniel Coyne provides example which demonstrate this in The Talent Code as does Norman Doidge in The Brain that Changes Itself. Humans are endowed with amazing abilities to learn and to adapt.
Distortion of the news, the power of advertising, and the control of minds are not new concerns. What is new is how: electronics has made these influences ubiquitous; the media are controlled by fewer and fewer people; and computing has refined how to get around “our better selves” and insidiously capture our attention. The news that is most effective to do this is emotional and appeals to our baser instincts. It stimulates polarization. It views issues as unresolvable extremes and makes us angry and adamant, or anxious and depressed, not hopeful and energized. It is good for the electronic media whose primary goal is to attract our attention and capture markets. It does not enrich our lives and make them more meaningful. It distracts us from acting on our values and even distracts us from thinking about what our values are. Time and attention are limited resources. Electronics have the ability to be an efficient resource for information, but they can also be used to direct our thoughts without being aware that we are being manipulated.
James Williams has a background which is well-suited to this discussion. He worked for Google committed to their mission “to organize the world’s information and make it accessible and useful.” He left Google when he “came to understand that the cause in which I’d been conscripted wasn’t the organization of information at all, but of attention.” Realizing “that there’s a deep misalignment in the goals we have for ourselves and the goals our technologies have for us”, he left Google to attend Oxford University to study philosophy. The title of the book is from a story about a philosopher, Diogenes, who refused an offer by Alexander the Great to give to him anything that he wanted. His response was to “get out of my light” i.e., don’t distract my attention from what is important in life.
As information has become abundant, the resource which has become scarce is attention. Our attention, like our memory, is an important part of who we are. It is being usurped. Technology and its messages shape our environment which shapes our thoughts and behavior. Persuasion has become industrialized with the assistance of digital technologies.
In addition to heightening our awareness, James Williams outlines what may be done to address this problem. This goes beyond increasing our willpower. Research has made it clear that willpower, like attention, is a limited resource. If you have exhausted your willpower at work or dealing with your children, you are less likely to stick to your goals, especially when your willpower has to compete with an entire industry designed to capture our attention. We need time and quiet to think and to put things in perspective, not just react to the next piece of data. And to have perspective and to figure life out at any age, people need the freedom to be exposed to different ideas, other people, develop an appreciation of the value of the humanities, and to spend time in nature.
“The ADHD Diagnosis Problem” appeared in the December 4, 2018 issue of The Wall Street Journal based on research that was reported in The New England Journal of Medicine last week. Children whose birthdays are in August have a 32% higher rate of ADHD diagnosis than those who are born in September in states in which the cutoff date for entering school is September 1. This is another example of the differences that exist, on average, between being one of the oldest and one of the youngest in class. In New York, the cutoff date for starting school is December 1. Children who are 4 years and 9 months old may be reading, but that does not mean that it is reasonable to expect all children to be reading at that age.
The article does not mention that there were similar findings a few years ago for ice hockey players in Canada. Looking at their date of birth was the best way to predict who would become an elite hockey player. The oldest had an advantage in the beginning and their success bred success. Learning to play ice hockey and learning in school are both dependent on a child’s developmental age which correlates with their chronological age. Instead of being ignored, it should be expected. Parents recognize this and redshirt their children for school and for sports. It should also be recognized that numerous factors make it difficult for children to catch-up; to start to learn faster or grow faster than others in their grade.
Similar research was reported in the Journal of Child Psychology and Psychiatry in October which studied 13 countries. The same age correlation held in all the countries other than Denmark whose parents commonly delay their children’s entrance into school by one year. While the WSJ article is focused on the age of starting school, the critical message is that we need to pay more attention to child development. Expectations should not be structured on when we want children to have certain skills, but on when most children are ready. Children differ in their rates of development. Many children develop asynchronously. It used to be routine to assess child development. It is now assumed that all children are the same or that the school can make them the same. If these are not the assumptions, what is the rationale? Children who naturally read early have advantages, but that doesn’t mean pushing children creates the same love of reading. It is more likely to have the opposite effect.
Our focus is visual development, but vision does not develop in isolation and all areas of development are important; language, social skills, physical abilities, self-control, and focus. We see the effects of academic acceleration in the office. Most of the children with vision-related school problems who were brought into the office in the past were in third and fourth grade. Most of them are now in first or second grade. Many are in kindergarten because they are not reading and they are having difficulty with the visual motor control needed to write. Their parents, with similar skills at the same age, would have been judged OK. May the pendulum start to swing back towards an appreciation of child development.
Here’s to the Value of Appropriate “READ“shirting!
ADHD Nation is as important for understanding the evolution of the diagnosis and treatment of attention disorders, the role of Big Pharma, and how attention disorders have been mismanaged as are the books NeuroTribesand In a Different Keyfor understanding the evolution of our understanding of autism.
Alan Schwarz is an award-winning investigative journalist whose work made public the seriousness of concussions in the NFL. Like concussions in sports, the potential side-effects of ADHD medications have been largely ignored. Big Pharma and the scientists they support have been complicit in this omission.
ADHD medications have the potential to improve attention, motivation, and energy which is not dependent on having ADHD. When used properly, the drugs can help many people and the side-effects are minimized. But the statistics make it clear that the condition is being over-diagnosed in this country. The drugs are also being used (and misused) by many high school and college students and by others who feel that they need a boost and have never been diagnosed. The causes of their problems are not being investigated nor are other possible means of treatment. Consider the following…
In the 1930s, a drug was developed with the goal of treating asthma or nasal congestion which, serendipitously, was found to make people feel good. Smith, Kline, & French “licensed it before knowing exactly what medical condition the stuff might actually treat. Finding out was a lot easier then than it is today: Lax federal regulations did not require any proof of safety, let alone efficacy, before a drug was released for public experimentation. So SKF sent boxes of what it called ‘Benzedrine sulfate’ to any doctor willing to try the drug on patients with various ills, from asthma to postpartum depression.”
Due to known problems with amphetamines, a close cousin to amphetamines was developed to have the same effects with fewer side effects. “CIBA termed the chemical formulation of this drug ‘methylphenidate’. The company released it to the American market in 1956 as Ritalin, a treatment for narcolepsy, chronic fatigue, depression, and erratic behavior caused by senility. (Again, only in adults; the medication was untested in children.)”
Dr. Keith Connors, author of the Connors Rating Scale, is the best-known researcher in the field of ADHD. “Connors needed no questionnaire to assess the effects of Ritalin on himself. Late one afternoon, following an exhausting day in the lab, he had to attend an eight-p.m. lecture by Harry Harlow, a behavioral psychologist famous for locking young monkeys away from their mothers and studying their emotional demise. Knowing he’d never stay conscious for the whole thing, Connors found the tub of Ritalin capsules so generously donated by CIBA and took one. Within thirty minutes he snapped awake and thought to himself, ‘This is fantastic!’ He kept working until eight. He skipped dinner. He zoned in on the lecture, chatted with folks afterward, and stayed up until three in the morning. Just one dose felt so beguiling, that he never tried the stuff again for the rest of his life.”
In the early 1990s, Obetrol was an amphetamine which was prescribed for weight control but it was not a financial success. After a pediatrician discovered that it worked for some children who did not respond well to Ritalin, Obetrol was remarketed as Adderall.
“Psychiatry journals teemed with more than a thousand studies on ADHD conducted by Biederman, Barkley, and other pharma-sponsored scientists. The Food and Drug Administration relied on them when green-lighting medications as safe and effective. Their findings served as the backbone for the lectures that drug companies’ key opinion leaders delivered on world tours. The whirlwind created a self-affirming circle of science, one that quashed all dissent.”
“While almost all other developed nations immediately closed the loophole that Metadate had exploited – expressly banning direct-to-consumer advertising of controlled substances, usually through legislation – the United States sat back and let the market take over. To this day, the United States is only one of two developed nations that allow advertising of ADHD medications to the general public.”
“Appallingly, some children have heightened anxiety interpreted not as a side effect of medication, meaning the drug should be reconsidered, but a new condition needing additional treatment…. Diagnosing young children with several overlapping psychiatric conditions became de rigueur in the 2000s, resulting in what some call a ‘medication cascade’. No doctor was more responsible for the trend than Joe Biederman up at Harvard, who evaluated dozens of drugs on behalf of his Big Pharma benefactors and almost invariably declared them safe and appropriate for children with multiple diagnoses like ADHD and bipolar disorder. Yet neither he nor anyone else tested the performance or risks of these drugs in combination – no pharmaceutical company would ever sponsor such a study, considering it too risky to their product’s reputation.” “Adderall and methylphenidate have always been among the most addictive substances in medicine. Weird as it may sound, stimulants are dangerous by being not dangerous enough – the drugs have found a sweet spot in which their advantages are more common and immediately obvious than their more latent risks, lulling all involved into complacency.”
“Today, misuse of ADHD medications by high school students is far more widespread that most anyone realizes. About a million high school kids nationwide use Adderall, Concerta, Vyvanse, and others without a doctor’s prescription, getting them either from friends or from dealers for a few dollars a pill.”
“Dozens of studies since the 1990s have estimated that about 8 to 35 percent of undergraduates take stimulant pills illicitly to try to improve their grades; a reasonable estimate among high-pressure colleges is probably 15 to 20 percent. Most students, of course, don’t experience terrible outcomes – if they did, the dangers would already be better recognized. But many do. One 2006 study found that about one in ten adolescents and young adults who misused ADHD medications became addicted to them, with some of them becoming psychotic or suicidal.”
“A different study found that teachers suspected ADHD far more often in elementary school children whose birthdays made them one of the youngest in their grade – just a tick over six, say, when the rest of their classmates were nearing seven. Therefore, many kids were being diagnosed merely because they were born in the wrong month: ‘The youngest children in fifth and eighth grades,’ it concluded starkly, ‘are nearly twice as likely as their older classmates to regularly use stimulants prescribed to treat ADHD.”
At the end of his working career, Dr. Keith Connors sent a letter to a colleague and closed with the following: “Beware the simple & sovereign explanation.” That is good advice to all of us.
Alan Schwarz includes in the book a mock doctor/patient interview from a certified continuing education program purported to teach physicians how to diagnose ADHD. From the start of the conversation to the writing of the Rx was six minutes. Also, it was not revealed that there was a possible conflict of interest but the following was discretely printed at the end: “Supported by an independent educational grant from Shire.”
There are many possible causes for ADHD behaviors other than primary “brain dysfunction”. Since there is no litmus test for ADHD like blood work or imaging, ADHD is primarily a diagnosis of exclusion. Other possible causes of ADHD should be investigated and ruled out prior to considering medication. Visual problems are one of the possible causes of these signs and symptoms but so are the accelerated curriculum, fewer recesses in school, less time playing outside, more stimulation from video games, more organized activities which reduce free time, instant communication and responses, less sleep, and more pressure. Children whose problems are not primarily due to attention, may also do better with medication, but their underlying problems are not being addressed and they may be being medicated unnecessarily. “The human brain has evolved over many thousands of years, yet only in the last hundred, a blip on that time line, have we demanded that each and every young one sit still and pay attention for seven hours a day.”
One of the country’s leading authorities on ADHD, Dr. Vincent Monastra holds a Ph.D. in clinical psychology and is the Director of the FPI Attention Disorders Clinic in Endicott, NY. I became aware of Dr. Monastra’s perspective on undetected and untreated vision problems compounding ADHD issues through our optometric colleague, Dr. Gary Williams, who has […]
Attention and embodied perception are themes of Matthew B. Crawford’s book The World Beyond Your Head. Who we are and what we can become are enabled by our attention and perception as they are by our environment.
The following article discusses some of the amazing abilities of our visual system. Vision and attention are inseparable. Visual skills need to be automatically adaptable to different environments for us to function effectively and safely. These are learned skills and their development can be enhanced through vision therapy. They vary between individuals, but they also vary within each of us based on the environment, fatigue, and the demands on us at that moment.
PRINCETON . ALUMNI. WEEKLY
Life of the Mind
Psychology: Your Attention, Please
Distractions in our visual environment can impede our brains’ ability to function
By Michael Blanding Published in the June 3, 2015, issue
“Lowering the shades while working or tidying one’s workspace can lead to more productivity, says Professor Sabine Kastner.”
If a cluttered desk is a sign of a cluttered mind,” Albert Einstein once cracked, “of what, then, is an empty desk a sign?” The answer, according to psychology professor Sabine Kastner, may be clear thinking. In 20 years of research on attention, Kastner has found that, despite the protests of Einstein, Steve Jobs, and other messy creative thinkers, visual clutter competes with our brain’s ability to pay attention and tires out our cognitive functions over time.
The journey to that conclusion started one day in 2008, when Kastner was crossing Washington Road on her way to Nassau Hall for a meeting. Realizing she was automatically scanning for cars before she crossed the street, she wondered how the brain so quickly differentiated cars from other things in the environment. When she researched the phenomenon, “it became apparent that this basic question had gone completely unanswered,” she says.
The problem for researchers was that they had difficulty replicating the chaos of our random world in the lab; they used simple, easily recognizable shapes in experiments to see how the brain reacted. Kastner exposed subjects to the full variation of a random environment by showing them a selection of street scenes and asking them to focus either on a person or a car, while a functional magnetic resonance imaging (fMRI) machine measured their brain activity.
The scans showed clear patterns of activity in the frontal cortex, indicating that the neurons were activated based not on what subjects were seeing, but rather what they were looking for. “Whatever you look for dominates your brain signals so much that all of the scene context gets suppressed,” she says. Once you think “car,” your brain automatically blocks out everything else and hones in on that specific shape.
Kastner’s subsequent studies found that the brain may not be good at blocking clutter. When she asked subjects to focus on one object while introducing another object into their visual field, Kastner detected a fuzzy version of that second object in the brain scan. In any environment, she concluded, there is both a “push” toward desired objects and a “pull” from objects competing for attention. The more objects in the visual field, the harder the brain has to work to filter them out, causing it to tire over time and reducing its ability to function.
Such a mechanism may shed light on the brains of those with attention deficit hyperactivity disorder (ADHD). “The way it is typically framed is that a child with ADHD has a problem focusing,” says Kastner. “Perhaps the real problem is that the child is overwhelmed by the clutter that gets in the way.” That is why strategies that reduce sensory overload, such as breaking tasks into discrete steps, are helpful to children with ADHD. But such techniques can help anyone who has trouble concentrating, Kastner says. Just lowering the shades while working or taking a few minutes to tidy one’s workspace can lead to more productivity, she advises. To reconsider Einstein, a clean desk may not signify an empty mind — rather, a cluttered desk may make a mind too full.