Associations between Attention-Deficit/Hyperactivity Disorder and Ocular Abnormalities in Children: A Population-based Study

Vision-related quality of life and near-work visual symptoms in patients with attention-deficit/hyperactivity disorder

CLINICAL RELEVANCE

Attention-deficit/hyperactivity disorder (ADHD) has been associated with visual symptoms that may impact daily activities such as near-work tasks and social interactions. Addressing these visual issues is important for improving the overall quality of life and functional outcomes in individuals with ADHD, particularly in academic and social settings.

PURPOSE

To investigate the relationship between vision-related quality of life and near-work visual symptoms in patients with ADHD patients.

METHODS

A cohort of 37 individuals with ADHD was compared to age- and sex-matched healthy controls (n = 37). The 25-Item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) and the Convergence Insufficiency Symptoms Survey (CISS) were used to assess vision-related quality of life and near-work visual symptoms.

RESULTS

Mean NEI VFQ-25 scores were not significantly different between the ADHD and control groups. However, individuals with ADHD scored lower on the near activities (p = 0.032; Cohen's d = -0.511), social functioning (p = 0.045; Cohen's d = -0.481) and driving (p = 0.007; Cohen's d = -0.124) subscales. The CISS scores were significantly higher in the ADHD group (23.43 ± 11.22) than in the control group (14.02 ± 9.36; p < 0.001; Cohen's d = 0.910), indicating a significant relationship between ADHD and the presence of symptomatic subjects (p < 0.001; Cramer's V = 0.541). Medication did not affect NEI VFQ-25 or CISS scores. Female gender was associated with an increased number of symptomatic subjects based on their CISS scores (p = 0.043; Cramer's V = 0.396). Symptomatic ADHD individuals had lower NEI VFQ-25 scores (85.02 ± 12.68 vs. 96.02 ± 4.63, p = 0.008; Cohen's d = -0.969), indicating compromised vision-related quality of life.

CONCLUSIONS

Patients with ADHD experienced a reduced vision-related quality of life and increased near-work visual symptoms, suggesting potential repercussions on academic performance and social adaptability. This study underscores the importance of addressing visual issues in the ADHD population to enhance their overall well-being and functional outcomes.

Impact of stimulant treatment on refractive errors and pupil diameter in attention deficit hyperactivity disorder

PURPOSE

The relationship between attention deficit hyperactivity disorder (ADHD) and visual impairment remains poorly understood, and the impact of visual impairment on the development of ADHD is uncertain. The aim of this study was to investigate the refractive profile and ocular biometric characteristics in patients diagnosed with ADHD and compare them with a control group. Additionally, we aimed to explore the potential influence of sex and medication intake.

METHODS

A cohort of 100 participants, including 50 individuals with ADHD and 50 age- and sex-matched control subjects, was included in this study. Ocular biometric parameters were measured, and refractive error was assessed using cycloplegic and non-cycloplegic autorefraction. Subgroup analyses were performed within the ADHD group based on sex, medication intake and age to investigate potential associations with the ocular findings.

RESULTS

We observed no statistically significant differences in axial length, corneal topography parameters or anterior chamber characteristics between ADHD and control subjects. However, subgroup analysis within the ADHD group revealed that the prevalence of ametropia under cycloplegia was significantly higher in unmedicated (69.6%) compared to medicated (37.5%) (X2(2) = 7.320, p = 0.026) participants. Pupil diameter was significantly larger in medicated (3.91 mm) compared to unmedicated (3.58 mm; p = 0.017) individuals. Males had flatter (p = 0.004) and thicker (p = 0.008) corneas than females. Older ADHD participants had higher refractive error (p = 0.008 for non-cycloplegic and p = 0.0.003 for cycloplegic), axial length (p = 0.002) and corneal astigmatism (p = 0.049).

CONCLUSIONS

Our study provides compelling evidence that individuals diagnosed with ADHD exhibit a similar incidence of refractive errors and ocular parameters compared to normal subjects. Nonetheless, the prevalence of refractive errors appears to be higher in unmedicated ADHD patients, suggesting the potential benefit of stimulant treatment. Additionally, stimulant use is associated with an increase in pupil diameter.

Hearing Impairment and Severe Attention Deficit/Hyperactivity Disorder: A Nationwide Study

BACKGROUND

The association between hearing impairment and attention-deficit/hyperactivity disorder (ADHD) is unclear. Therefore, we aimed to assess this association in Israel's national sample of over 1.1 million adolescents.

METHODS

We conducted a nationwide, population-based, cross-sectional study of all Israeli adolescents (n = 1,175,534, 58% males; mean age, 17 yrs) who were examined before mandatory military service during 2004 to 2020. Board-certified specialists confirmed diagnoses of hearing impairment and severe ADHD.

MAIN OUTCOMES AND MEASURES

We compared the prevalence of severe ADHD in adolescents with and without hearing impairment. Associations were analyzed using logistic regression models and sensitivity analyses accounting for hearing impairment type (sensorineural vs. conductive) and severity.

RESULTS

Of the 8,769 adolescents with hearing impairment, 57 were diagnosed with severe ADHD (prevalence = 0.65%). Of the 1,166,765 adolescents without hearing impairment, 3,936 were diagnosed with severe ADHD (prevalence = 0.29%). We found a significant association between hearing impairment and severe ADHD (odds ratio = 1.93 [95% confidence interval, 1.47-2.49]), which persisted in a multivariable model adjusted to age, sex, socioeconomic status, educational status, cognitive performance, and immigration status (odds ratio = 1.70 [95% confidence interval, 1.29-2.20]). The association also persisted when stratified by hearing impairment type (sensorineural vs. conductive) and severity.

CONCLUSIONS

Adolescents with hearing impairment had 70% increased odds of severe ADHD. Study findings suggest that active screening of patients with hearing impairment for ADHD should be considered.

Researching Eyesight Trends IN ADHD (RETINA)

BACKGROUND

There has been limited exploration of the relationship between ADHD and vision impairment, especially in relation to ADHD medication regimens and age. This study aims to examine trends in visual disorders in young patients with ADHD.

METHODS

We analyzed deidentified patient records from TriNetX database. Patients under 22 years old were divided into cohorts based on ADHD status and medication regimen. We compared prevalence of vision disorders between cohorts.

RESULTS

We studied over 1 million patients. The ADHD cohort had higher rates of all visual disorders than their non-ADHD peers. Medication usage was found to have a slight impact, with non-stimulants associating with higher rates for all outcomes.

DISCUSSION

Our findings suggest that the higher occurrence of visual disorders in ADHD is not primarily due to misdiagnosis or medication effects. There is a need for regular eye care in ADHD patients and further investigation into the role of ADHD medications in eye health.

Frequencies and patterns of symptoms in Chinese adults with accommodative and binocular dysfunctions

PURPOSE

Recent studies have found that children with convergence insufficiency experience higher frequencies of performance-related symptoms (e.g., losing concentration), but data on performance-related symptoms among adults with accommodative dysfunctions (ADs) and/or binocular dysfunctions (BDs) are lacking, which might cause misdiagnosis, diagnostic confusion, or exacerbation of attention deficits. We aimed to describe frequencies and symptom patterns in adults with ADs and/or BDs who were treated at optometric clinics and explore any correlations between visual symptoms and clinical findings.

METHODS

This cross-sectional study divided 235 participants (age: 23.7 ± 2.9 years) into three groups: ADs, BDs, and normal binocular vision (NBV) groups. Convergence Insufficiency Symptom Survey (CISS), refractive examinations, and binocular tests were administered to all participants. After 1-to-1 propensity score matching, outcomes were assessed using Mann‒Whitney U test and Pearson's correlation analysis among three groups.

RESULTS

In this sample, the number (frequency) of individuals with ADs and/or BDs was 117 (49.8%). ADs and BDs groups experienced significantly more performance-related symptoms (feeling sleepy, losing concentration, trouble remembering, reading slowly, losing place, and having to re-read; all P < 0.05) than the NBV group. Significant correlations were observed between performance-related symptoms and clinical findings, including accommodative amplitude (r =  - 0.294), accommodative facility (r =  - 0.452), near phoria (r =  - 0.261), near point of convergence (r = 0.482), and positive fusional vergence (r =  - 0.331) (all P < 0.001).

CONCLUSION

ADs and/or BDs are commonly present in adults treated at optometric clinics, and adults diagnosed with ADs and/or BDs exhibit more performance-related symptoms than participants with NBV.

Neurodevelopment at 6 years of age in children with atopic dermatitis

BACKGROUND

Few studies have reported an association between atopic dermatitis and cognitive impairment in children. Therefore, we evaluated the association between atopic dermatitis (AD) and neurodevelopmental dysfunction in children.

METHODS

We analyzed 2,395,966 children born between 2008 and 2012 in Korea. All data were acquired from the databases of the Korean National Health Insurance System. AD was defined as five or more diagnoses before age 24 months. The outcome was suspected neurodevelopmental dysfunction in the gross motor skill, fine motor skill, cognition, language, sociality, and self-care domains of the Korean Developmental Screening Test for Infants and Children at age 6 years. The positive control outcome was defined as attention deficit hyperactive disorder (ADHD). The associations were assessed using ordinal logistic regression, adjusting for asthma and allergic rhinitis.

RESULTS

Among the eligible children, 89,452 and 30,557 were allocated to the control and AD groups, respectively. In the weighted data, the AD group showed a higher risk of suspected neurodevelopmental dysfunction in the total score (weighted adjusted odds ratio [95% CI] 1.10 [1.05-1.16]), gross motor skills (1.14 [1.04-1.25]), and fine motor skills (1.15 [1.06-1.25]) than the control group. The AD with steroids or hospitalization groups showed an increased risk of suspected neurodevelopmental dysfunction. In addition, the AD group showed a significant association with mental retardation, psychological development disorder, and behavioral and emotional disorders as well as ADHD.

CONCLUSIONS

AD before age 2 years may be associated with an increased risk of neurodevelopmental dysfunction including gross and fine motor skills in the young childhood period.

Association between ADHD and vision problems. A systematic review and meta-analysis

AIM

To conduct the first systematic review and meta-analysis assessing whether attention-deficit/hyperactivity disorder (ADHD) is associated with disorders of the eye, and/or altered measures of visual function.

METHOD

Based on a pre-registered protocol (PROSPERO: CRD42021256352), we searched PubMed, Web of Knowledge/Science, Ovid Medline, Embase and APA PsycINFO up to 16th November 2021, with no language/type of document restrictions. We included observational studies reporting at least one measure of vision in people of any age meeting DSM/ICD criteria for ADHD and in people without ADHD; or the prevalence of ADHD in people with and without vision disorders. Study quality was assessed with the Appraisal tool for Cross-Sectional Studies (AXIS). Random effects meta-analyses were used for data synthesis.

RESULTS

We included 42 studies in the narrative synthesis and 35 studies in the meta-analyses (3,250,905 participants). We found meta-analytic evidence of increased risk of astigmatism (OR = 1.79 [CI: 1.50, 2.14]), hyperopia and hypermetropia (OR = 1.79 [CI: 1.66, 1.94]), strabismus (OR = 1.93 [CI: 1.75, 2.12]), unspecified vision problems (OR = 1.94 [CI: 1.38, 2.73]) and reduced near point of convergence (OR = 5.02 [CI: 1.78, 14.11]); increased lag (Hedge's g = 0.63 [CI: 0.30, 0.96]) and variability (Hedge's g = 0.40 [CI: 0.17, 0.64]) of the accommodative response; and increased self-reported vision problems (Hedge's g = 0.63 [CI: 0.44, 0.82]) in people with ADHD compared to those without ADHD (with no significant heterogeneity). We also found meta-analytic evidence of no differences between people with and without ADHD on retinal nerve fiber layer thickness (Hedge's g = -0.19 [CI: -0.41, 0.02]) and refractive error (Hedge's g = 0.08 [CI: -0.26, 0.42]) (with no significant heterogeneity).

DISCUSSION

ADHD is associated with some self-reported and objectively ascertained functional vision problems, but not with structural alterations of the eye. Further studies should clarify the causal relationship, if any, between ADHD and problems of vision.

TRIAL REGISTRATION

PROSPERO registration: CRD42021256352.

A nationwide cohort study on the risk of ADHD in children with amblyopia mediated by fine motor skill impairment in East Asia

This national administrative investigation of Republic of Korea compared the risk of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorders(ASD) in preschool amblyopic children and identified factors that possibly mediate this association. After propensity score (PS) matching, 7762 amblyopic children and 31,030 non-amblyopic children were included. Amblyopia was associated with ADHD (aOR:1.687; 95% CI 1.444, 1.970) but not with ASD (aOR: 0.591; 95% CI 0.341, 1.026). Fine motor skill impairment was a mediating factor in association of amblyopia with ADHD, accounting for 4.2% (95% CI 1.7, 8.0). In conclusion, amblyopic children have a greater risk of ADHD, and deficits in fine motor skills mediate this association. We suggest increased attention given to fine motor skill underdevelopment in amblyopic children to prevent the development of ADHD.

The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder

BACKGROUND

Misconceptions about ADHD stigmatize affected people, reduce credibility of providers, and prevent/delay treatment. To challenge misconceptions, we curated findings with strong evidence base.

METHODS

We reviewed studies with more than 2000 participants or meta-analyses from five or more studies or 2000 or more participants. We excluded meta-analyses that did not assess publication bias, except for meta-analyses of prevalence. For network meta-analyses we required comparison adjusted funnel plots. We excluded treatment studies with waiting-list or treatment as usual controls. From this literature, we extracted evidence-based assertions about the disorder.

RESULTS

We generated 208 empirically supported statements about ADHD. The status of the included statements as empirically supported is approved by 80 authors from 27 countries and 6 continents. The contents of the manuscript are endorsed by 366 people who have read this document and agree with its contents.

CONCLUSIONS

Many findings in ADHD are supported by meta-analysis. These allow for firm statements about the nature, course, outcome causes, and treatments for disorders that are useful for reducing misconceptions and stigma.