A 6-year-old boy presented at the request of his teacher. He's been "acting up" in class and his teacher and his mother are wondering if he's distracted because he can't see the board. I performed a full exam and found the child sees 20/20 and has no amblyopia, convergence insufficiency, binocular vision or accommodation problems.

“This is a very common scenario in the first few months of the school year—particularly when a child is moving from preschool to kindergarten or first-grade, when more is expected of children,” says Andrea Gregory, MD, a pediatrician at Self Regional Healthcare in Greenwood, SC.  

“Sensory deficits—both visual and auditory—are high on the differential for children with behavior concerns, and should be the first to be ruled out if concerns arise,” Dr. Gregory says. 

However, she adds, other possible causes include specific learning disabilities, language disorder, attention-deficit/hyperactivity disorder (ADHD), substance abuse (in older children/adolescents), family stressors, lack of sleep, thyroid disorder, adverse effects of medication, autism spectrum disorders and psychiatric disorders. 

“It’s important to know whether the concerning behaviors are occurring in more than one setting,” Dr. Gregory says. “If those behaviors occur only at school, problems such as sensory deficit or learning disorders are higher on the differential. If they are only at home, family stressors and lack of adequate boundaries may be more likely.”

However, she adds, “if the child is bouncing off the walls of your office and it’s difficult to get through the exam—and this is the norm according to the parents—then ADHD should be strongly considered.”

Is this child hyperactive, vision impaired or just a "busy bee"? Take a closer look.

Epidemiologic studies of ADHD indicate that 3% to 8% of children in the US are affected, mostly boys.1 There is no known cause of ADHD, but neuroimaging studies have shown differences in brain structure and function between people with ADHD and those without. Specifically, areas of the brain associated with executive function (problem solving and goal orientation) seem to be less active in patients with ADHD.2 

ADHD is not a simple diagnosis to make, Dr. Gregory says. Several criteria are required: 

• The child must exhibit six of nine symptoms of inattention (things like “often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities,” “often does not seem to listen when spoken to directly” and “often has difficulty organizing tasks and activities”).

• Or, the child must show six of nine symptoms of hyperactivity or impulsivity (“often fidgets with hands or feet or squirms in seat,” “often interrupts or intrudes on others” and “often talks excessively”). 

A few simple questions can help determine if the child could benefit from further evaluation by his pediatrician (whether or not the child is found to have a visual deficit): 

• How is the behavior at home or out in public? 

• Does he seem easily distracted when trying to complete a task? 

• Does he act as if he is “driven by a motor”? 

“An emphatic referral to the child’s primary physician, along with a note with your findings and concerns, can be invaluable,” Dr. Gregory says. 

She adds, “Many children fall behind academically if they are left undiagnosed and untreated, so it’s important to start the evaluation and possible treatment as early as possible. This is especially true for older children and adolescents who may go years without seeing their physician—but may see you annually to get their eyes examined.” n 

1. Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics. 2012 Jul;9(3):490-9. 
2. Sowell ER, Thompson PM, Welcome SE, et al. Cortical abnormalities in children and adolescents with attention-deficit hyperactivity disorder. Lancet. 2003 Nov 22;362(9397):1699-707.