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Not Autistic or Hyperactive. Just Seeing Double at Dr. Atul Gawande on Paying for a Health Care
Times Overhaul
December 8, 2009, 10:31 AM
By LAURA NOVAK A Workout in a Shoe
Published: September 11, 2007 December 7, 2009
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As an infant, Raea Gragg was withdrawn and could not make eye Spotting Depression in Adolescents
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sniff them and touch their cheeks.”

Specialists conducted a battery of
tests. The possible diagnoses
Thor Swift for The New York Times
Raea Gragg, 9, needed therapy to mounted: autism spectrum disorder, neurofibromatosis,
help her eyes work together. attention-deficit hyperactivity disorder, anxiety disorder.

A behavioral pediatrician prescribed three drugs for attention deficit and depression.
The only constant was that Raea, now 9, did anything she could to avoid reading and
writing.

Though she had already had two eye exams, finding her vision was 20/20, this year a
school reading specialist suggested another. And this time the optometrist did what no
one else had: he put his finger on Raea’s nose and moved it in and out. Her eyes jumped
all over the place.

Within minutes he had the diagnosis: convergence insufficiency, in which the patient
sees double because the eyes cannot work together at close range.

Experts estimate that 5 percent of school-age children have convergence insufficiency.
They can suffer headaches, dizziness and nausea, which can lead to irritability, low self-
esteem and inability to concentrate.

Doctors and teachers often attribute the behavior to attention disorders or seek other
medical explanations. Mrs. Gragg said her pediatrician had never heard of convergence
insufficiency.

Dr. David Granet, a professor of ophthalmology and pediatrics at the University of
California, San Diego, said: “Everyone is familiar with A.D.H.D. and A.D.D., but not with
eye problems, especially not with convergence insufficiency. But we don’t want to send
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Not Autistic or Hyperactive. Just Seeing Double at Times - New York Times 12/8/09 1:20 PM

eye problems, especially not with convergence insufficiency. But we don’t want to send
kids for remedial reading and education efforts if they have an eye problem. This should
be part of the protocol for eye doctors.”

In 2005, Dr. Granet studied 266 patients with convergence insufficiency. Nearly 10
percent also had diagnoses of attention deficit or hyperactivity — three times that of the
general population. The reverse also proved true: examining the hospital records of 1,700
children with A.D.H.D., Dr. Granet and colleagues found that 16 percent also had
convergence insufficiency, three times the normal rate.

“When five of the symptoms of A.D.H.D. overlap with C.I.,” he said, “how can you not
step back and say, Wait a minute?”

Dr. Eric Borsting, an optometrist and professor at the Southern California College of
Optometry who has also studied the links between vision and attention problems,
agreed. “We know that kids with C.I. are more likely to have problems like loss of
concentration when reading and trouble remembering what they read,” he said. “Doctors
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Dr. Stuart Dankner, a pediatric ophthalmologist in Baltimore and an assistant clinical What's your limit? »
professor at Johns Hopkins, said that children should be tested for convergence
difficulty, but cautioned that it was not the cause of most attention and reading
problems.
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Dr. Dankner recommended an overall assessment by a psychologist or education
specialist. “An eye exam should be done as an adjunct,” he said, “because even if the
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child has convergence difficulty, they will usually also have other problems that need to
be addressed.”

Doctors recommend a dilated eye exam and a check of eye teaming and focusing skills.
Testing includes using a pen or finger to test for the “near point of convergence,” as well MOST POPULAR - HEALTH

as a phoropter, which uses lenses and prisms to test the eyes’ ability to work together. E-MAILED BLOGGED

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There is no consensus on how to treat convergence insufficiency. Next spring, the
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measuring the benefits of vision therapy in a doctor’s office versus home-based therapy. Help
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For Raea Gragg, the treatment was relatively simple. For nine months she wore special Vitamins
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vision therapy. She has just entered fourth grade and is reading at grade level.
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Go to Complete List »
An article in Science Times on Sept. 11 about convergence insufficiency, in which a
patient sees double because the eyes cannot work together at close range, misidentified
the specialty of the doctor who diagnosed and treated the problem in Raea Gragg. The

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Not Autistic or Hyperactive. Just Seeing Double at Times - New York Times 12/8/09 1:20 PM

the specialty of the doctor who diagnosed and treated the problem in Raea Gragg. The
doctor, Carl Hirsch, who was not identified in the article, is an optometrist, not an
ophthalmologist.

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Past Coverage
Not Autistic or Hyperactive. Just Seeing Double at Times (September 11, 2007)
REALLY? (July 4, 2006)
Assemblyman Takes Aim At City Rules on 3rd Graders (April 20, 2004)
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