Ocular Effects of

Behavior Management Medications

Angela Howell, OD
Paragould, Arkansas

Abstract
Background: Medications are often recommended for patients to control unwanted behaviors. Treatment with
prescription drugs for autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and
acquired brain injury (ABI) has benefits and side effects. Gains may be made in attention and mental focus while
accommodation and eye tracking may be compromised. Benefits versus side effects must be considered when
managing these conditions with drugs.
Case Summary: A five-year-old girl presented for preschool evaluation. She destroyed the tape in the audio tape
player in the waiting room, broke several legos, tore pages from the childrens books and magazines and spilled a
soda before being called back for her exam. History was positive for Retts syndrome. No medications were taken.
All examination parameters were within normal limits.
The following year she returned complaining of difficulty reading and focusing at near. She managed to sit quietly in
the waiting area and play with a puzzle before her eye exam began. The history revealed that she had started taking
Prozac orally during the school year. Her mother reported that she read constantly. Reading material was constantly
held close. She became aggressive when challenged to move it away. Exam findings showed distance visual acuities
at 20/20 and near acuities reduced to 20/50. Accommodative testing showed reduced amplitude. A near prescription
of +1.00 OU was recommended to assist in her reading focus.
Conclusion: Behavior modifying medications were used to help this child and manage behavior in the classroom.
Reduced accommodation is a known side effect of many commonly used drugs in the treatment of disorders such as
ASD, ADHD, and ABI. Awareness of these medications and their side effects is warranted by eye care providers.
Key Words
acquired brain injury, attention deficit hyperactivity disorder, autism spectrum disorder, behavior management
medications, traumatic brain injury

Background Each year, an estimated 1.7 million people sustain a TBI.

Unwanted behaviors secondary to Autism Spectrum
Disorders (ASD), Attention Deficit Hyperactivity Disorder
(ADHD), and Acquired/Traumatic Brain Injury (ABI, TBI)
are often treated with pharmaceutical agents. These conditions
are prevalent in both adult and pediatric populations.
ASD occurs in all racial, ethnic, and socioeconomic groups,
but is four times more likely to occur in males than females.
The United States Center for Disease Control (CDC) estimates
that between 1 in 80 and 1 in 240, with an average of 1 in 110
children, have an ASD.1
ADHD is estimated to affect 3% to 7% of school aged
children. As of 2007, approximately 9.5% or 5.4 million
children four to 17 years of age have been diagnosed with
ADHD. Boys (13.2%) were more likely than girls (5.6%) to
have been diagnosed with ADHD. Prevalence of ADHD has
increased at a greater rate among older teens as compared to
younger children. The highest rates of parent-reported ADHD
diagnosis were noted among children covered by Medicaid
and multiracial children. Prevalence of parent-reported ADHD
diagnosis varies by state. Nevada has the lowest rate at 5.6%
and North Carolina has the highest rate of 15.6%.2,3
Journal of Behavioral Optometry
Children aged zero to four years, older adolescents aged 15 to
19 years, and adults aged 65 years and older are most likely
to sustain a TBI. Almost half a million (473,947) emergency
department visits related to TBI are made annually by children
aged zero to 14 years. Adults aged 75 years and older have the
highest rates of TBI-related hospitalization and death.4
Medications may be added to the treatment plan for long
or short term management of undesired behaviors. A survey
of over 3,000 families in North Carolina found that 46% of
respondents reported that their family member with ASD
was prescribed psychotropic medication for behavioral
symptoms.5,6 Another recent study documented that 13.5%
of children in the welfare system were using psychotropic
medications. This is two to three times the rate of other
children in the community.7 Pharmaceutical agents may allow
time for patients and their families to learn behavioral and
discipline strategies to keep negative actions and emotional
outbursts to a minimum. As verbal communication skills
improve, management with prescription medications may be
minimized or eliminated.
Volume 23/2012/Number 3/Page 73
 Pharmaceutical treatment for ASD, ADHD, and ABI/TBI
has benefits and side effects. Managing excessive activity may
allow some success in academic and social settings, but can
cause unwanted side effects. Increased focus of attention may
be undermined by distress to the accommodative/convergence
system. This case illustrates the beneficial and detrimental
effects of medication to manage behavioral issues.
Case Summary
A five-year-old girl presented to the clinic for preschool
evaluation. She destroyed the tape in the audio tape player
in the waiting room, broke several legos, tore pages from the
childrens books and magazines in the waiting room, and spilled
a soda before she was called back for her exam. She threatened
to kill the doctor and staff, saying, All doctors are evil, and
you should die! History was positive for Retts syndrome
(a form of autism spectrum disorder).8 No medications were
taken. The mother shared that the child did not sleep at night
and was difficult everywhere she went. Visual acuities were
20/20 in each eye at distance and near. Retinoscopy was +1.50
in each eye with bright clear reflexes. Cover test showed low
exophoria at distance and near. Ocular health was normal. No
prescription for glasses was recommended and follow up was
set up for one year.
The following year she returned for vision evaluation.
She was complaining of difficulty reading and focusing
at near. She managed to sit quietly in the waiting area and
played with a puzzle before her eye exam began. The history
revealed that she had started taking Prozac orally during the
last school year. Her mother reported that she had learned to
read and read constantly. Reading material was constantly held
close, and she became aggressive when challenged to move it
away. Examination findings showed distance visual acuities
at 20/20 and near acuities reduced to 20/50. Accommodative
testing showed reduced amplitude of accommodation, with
PRA at -1.00 and NRA at +2.00. She was diagnosed with
accommodative insufficiency. A near prescription of +1.00 OU
(single vision), was recommended to assist her when reading.
The parents were educated about this condition and were
supportive of the treatment plan. The importance of regular
follow up visits was stressed, especially if the medication was
changed or if dosage was increased.
Discussion
Behavior modifying medications were used to help this
child attend school and manage behavior in a classroom
setting. Reduced accommodation is a known side effect of
many commonly used drugs to treat disorders such as ADHD.
Problems with accommodation are noted with tricyclic
antidepressants and low potency antipsychotics.9, 10
Behavior management medications are frequently used
to manage ADHD. A customized treatment plan must be
formed with careful observation of behavior by parents and
physicians.11 As of 2007, 2.7 million youths aged 4-17 years
(66.3% of those with a current diagnosis) were receiving
treatment in the form of medications for the disorders.1 Many
different categories of medication have been used in Federal
Drug Administration (FDA) approved treatments and off
label treatments.12 Off label treatments involve the use of an
approved medication to treat a non-approved condition, or the
use of the medication for treatment of a child younger than that
for which FDA approval has been granted.
Volume 23/2012/Number 3/Page 74
Behavior modification along with medication has shown
to have more positive results than medication alone for
ASD.13 Behavioral treatment combined with antipsychotic
medication was the most effective approach to reducing
aggressive behaviors in youths with ASD.14 Commonly used
classes of medications include anti-psychotics, neuroleptics,
anti-depressants, anti-anxiety agents, stimulants, anti-
hypertensives, anti-convulsants, mood stabilizers, and
norepinepherine re-uptake inhibitiors. Optometrists should be
familiar with the desired effects and negative side effects of
these pharmaceutical agents Table 1.
Wide arrays of transmitter systems that may contribute
to ASD include serotonin, dopamine, acetylcholine, and
brain-derived neurotropic factor.15 Serotonin, dopamine,
acetylcholine, oxytocin, and amino acid neurotransmitters are
among the neurochemicals being investigated with regard to
the development and expression of ASD. Evidence that acute
depletion of the dietary precursor of serotonin (tryptophan)
increases the symptoms of ASD is stimulating further research
on serotonin.15
Selective serotonin reuptake inhibitors (SSRIs) including
Prozac (fluoxetine), Paxil (paroxetine), and Celexa
(citalopram), have been reported to be the most prescribed
psychotropic medications for those with autism. They are
effective in managing behaviors such as compulsions,
stereotypes, and self-injury.3 Dopamine is a catecholamine that
is synthesized from the dietary amino acid tyrosine. Dopamine
function in the brain involves systems that contribute to
movement control, emotion, stimuli reinforcement, memory,
and higher-order functioning.16 Dopamine blockers, such as
antipsychotics, have been observed to alleviate symptoms of
ASD, including hyperactivity, various stereotypical behaviors,
aggression, and self-injury.17,18 Dopamine antagonists were
found in one study to decrease accommodative ability and
the rate of accommodative recovery after discontinuing
medication use.19
Social impairment is a primary symptom of ASD.
Researchers have begun to investigate whether or not the
hormone oxytocin is produced or processed in a dysfunctional
manner in individuals with ASD. Recent studies suggest
oxytocin deregulation may play a role in ASD.20,21 Oxytocin is
associated with lactating mothers and is thought to be involved
with the mother-child bonding process. Disruption of the
bodys oxytocin may be at the root of issues with empathy, eye
contact, and ability to form and maintain social relationships.22
Brain derived neurotropic factor (BDNF) is a protein
found in the brain that plays a significant role in long-term
neuronal development and survival. BDNF is commercially
available as a dietary supplement without a prescription. The
levels of BDNF have been found to be significantly decreased
in individuals with ASD when compared to age matched
controls.23
Neuroleptic medications are used in patients with ASD
and ABI/TBI. Commonly used epileptic medications are
Carbechol (carbamazepine), Zarontin (ethosuximide), Felbatol
(felbamate), Gabitril (tiagabine), Keppera (levetiracetam),
Lamictal (lamotrigine), Lyrica (pregabalin), Neurontin
(gabapentin), Dilantin (phenytoin), Topamax (topiramate),
Trileptal (oxycarbazepine), Depakene (valproate),
Depakote (valproic acid), Zonegran (zonisamide), and
Journal of Behavioral Optometry
 Table 1. Common Behavior Medications
CLASS DRUGS BENEFIT SIDE EFFECTS
Anti-psychotics or Haldol, Mellarill Reduce agitation, anxiety, Addiction
Neuroleptics Stelazine, Thorazine aggression, hyperactivity, stereo- Blurred vision
typic and self-stimulatory behaviors,
and temper outbursts Dyskinesia, Psychosis
Sedation, Tremors
Typical Abilify, Clozaril Reduce aggression, agitation, self- Agitation, Increased appetite
Neuroleptics Geodon, Risperdal injurious behavior Lowers white blood cell count
Seroquel, Zyprexa Tardive dyskinesia
Anti-depressants Anafranil, Celexa Raise serotonin levels Arhythmias
Elavil, Lexapro Reduce anxiety Blurred vision
Luvox, Paxil, Prozac Reduce obsessive-compulsive & Constipation, Dry mouth
Tofranil, Wellbutrin ritualistic behaviors Dizziness
Zoloft Hyperactivity & Impulsivity
Lowered threshold for seizures
Sleep disturbances
Anti-anxiety agents Ativan, Buspar Reduce anxiety Abnormal eye
Klonapin, Valium movements
Xanax Crying, Disinhibition
Irritability
Stimulants Adderall, Cylert Affect dopamine Depression
Daytrona patch Improve focus and Increase in perseveration &
Dexedrine, Focalin regulation repetitive behaviors
Ritalin Monitor arousal system Irritability, Palpitations
Decrease impulsivity Sleep disturbance
Anti-hypertensives Clonidine, Tenex Calm and improve sleep Irritability, Lower blood pressure
Decrease hyperactivity & impulsivity Sedation
Anti-convulsants/ Depakote, Dilantin Calm behavior Affects kidney function
Mood stabilizers Keppra, Phenobarbitol Lessen mood swings, outbursts Vision impairments such as rapid
Tegretol, Trileptal eye movements
Norepinephrine Strattera Reduces inattention, hyperactivity & Possibly bipolar disorder
re-uptake inhibitor impulsivity
Reprinted with permission: Lemer P. Envisioning a Bright Future. Interventions that Work for Children and Adults with Autism Spectrum Disor-
ders. Santa Clara, CA: Optometric Extension Program Foundation, 2008.

Table 2. Stimulant Group

Trade Name Generic Name Approved Age

Adderall (XR) amphetamine 3 and older
Concerta methylphenidate (long acting) 6 and older
Daytrana methylphenidate patch 6 and older
Desoxyn methamphetamine hydrochloride 6 and older
Dexedrine dextroamphetamine 3 and older
Dextrostat dextroamphetamine 3 and older
Focalin (XR) dexmethylphenidate 6 and older
Metadate ER methylphenidate (extended release) 6 and older
Metadate CD methylphenidate (extended release) 6 and older
Methylin methylphenidate (oral solution and chewable tablets) 6 and older
Ritalin methylphenidate 6 and older
Ritalin SR methylphenidate (extended release) 6 and older
Ritalin LA methylphenidate (long acting) 6 and older
Strattera atomoxetine 6 and older
Vyvanse lisdexamfetamine dimesylate 6 and older

Adapted from http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/complete-

index.shtml
Journal of Behavioral Optometry Volume 23/2012/Number 3/Page 75
Valium (diazepam).24 These medications are used alone or
in combination to control seizures in about 70% of patients.
Higher rates of epilepsy have long been reported in patients
with ASD. Prevalence estimates vary from as little as 5% to
as much as 46%.25,26 One of the best-known associations with
central nervous system dysfunction is the high risk of epilepsy.
It has been reported to occur in one third of the individuals with
ASD. Autism spectrum disorder is also increased in epilepsy
populations, with as high as 32% meeting diagnostic criteria.
Treatment of children with ASD and epilepsy is guided by
the principles of treating childhood epilepsy. Anti-epileptic
drugs (AEDs) are chosen based on seizure type, and clinicians
strive for maximum seizure control with minimum side
effects. The practicalities of certain treatment choices are very
important in ASD. Factors such as available formulations
(liquid vs. tablets vs. capsules), dosing schedules, need for
blood monitoring, and, most importantly, behavioral side
effects must be considered. It is important to note that treating
epilepsy does not usually have a major impact on the ASD
symptomatology. Some children may show improvement in
cognition, communication, or behavior, but the ASD diagnosis
does not change.26
Risperdal falls into the category of typical neuroleptic
medication. Risperidone is used in the treatment of irritability
and mood instability associated with autism, including
symptoms of aggression, deliberate self-injury, and temper
tantrums in children ages five to 16. Currently, risperidone
is the only medication that has specific FDA approval to
treat individuals with ASD.27 Other drugs prescribed for the
treatment of ASD symptoms fall into the off label category.
Although using antidepressants to treat ADHD and ASD is off
label, clinically it is commonly practiced.
Most of the psychotropic medications prescribed are FDA
approved for some conditions and some ages, but may not be
approved specifically for ASD. Antidepressant medications
include SSRIs and have been the most commonly prescribed
medications in ASD. Zoloft (fluoxetine), Paxil ( paroxetine),
and Celexa (citalopram) are effective in managing compulsions,
sterotypes, and self injurious behavior.5 Dopamine blockers,
considered atypical antispychotics, including Clozaril
(clozapine), Risiperdal, Zyprexa (olanzapine), Seroquel
(quetiapine), and Geodon (ziprasidone) have been observed to
alleviate symptoms of hyperactivity, stereotypical behaviors,
aggression, and self-injury.17
The most commonly used category of medication to treat
ADHD is the stimulant group. The mechanism of action is
to stimulate the central nervous system, thereby allowing
concentrated focus of attention. Stimulant medications come
in different forms, such as pill, capsule, liquid, or skin patch.
Some medications come in short-acting, long-acting, or
extended release varieties. Table 2 illustrates the medication
use for ADHD by trade name and the approved age for
treatment.11 Of the medications listed, Concerta, Adderall XR,
Vyvanse, and Focalin XR were among the top two hundred
products in the market by sales for 2009.28
Nutritional alternatives to FDA approved medication
need further investigation to document their role in assisting
with management of undesired behaviors. A study to
compare vitamins and minerals versus standard medication
management showed there were some advantages to treatment
Volume 23/2012/Number 3/Page 76
with micronutrients, including lower activity level, less social
withdrawal, less anger, better spontaneity with the examiner,
less irritability, lower intensity, markedly fewer adverse
events, and less weight gain. Advantages of medication
management were insurance coverage, fewer pills, and less
frequent dosing.29
Complementary and alternative medical treatments are
often used by families. The popularity of these treatments
is in part attributed to the chronicity of symptoms of ASD
and the absence of effective medical treatments. Popular
biological based treatments include supplements, specialized
diets, immune therapies, gastrointestinal treatments, chelation,
and withholding immunizations. Other non-biological
treatments include manipulative and body-based treatments
like craniosacral manipulation, auditory integration, and
mind- and body-based therapies like yoga. So far, few studies
have addressed safety and effectiveness of most of these
treatments. Practitioners should support families as they assess
the effectiveness, risks, and costs of treatments and assist in
monitoring potential side effects.30,31
Summary
Medications to control unwanted behaviors are clinically
prevalent. These medicines have positive intended effects and
negative unintended effects. The primary care optometrist
must be aware of the interactions of these pharmaceutical
agents with accommodation, convergence, refractive shifts,
and diplopia. Blurred vision, asthenopia, light sensitivity, and
poor depth perception may be reported as both a symptom of
the disorder and a side effect of the medication. Astute clinical
judgments must be made in dealing with these challenges.
Communication with other members of the treatment team will
maximize desired outcomes and allow concurrent progress as
the management process continues.
References
1. Centers for Disease Control. ADHD facts. www.cdc.gov/ncbddd/adhd.
Last Accessed May 23, 2011.
2. Centers for Disease Control. Autism Facts. www.cdc.gov/ncbddd/autism/
facts.html. Last Accessed April 21, 2011.
3. Autism Society. http://www.autism-society.org/about-autism/. Last Ac-
cessed June 24, 2011.
4. Centers for Disease Control. TBI Statistics. www.cdc.gov/TraumaticBrain-
Injury/statistics.html. Last Accessed April 21, 2011
5. Langworthy-Lam KS, Aman MG, Van Bourgondien ME. Prevalence and
patterns of use of psychoactive medicines in individuals with autism in
the Autism Society of North Carolina. J Child Adolesc Psychopharmacol
2002;12; 311-22.
6. Rubin D, Feudtner C, Localio R, Mandell D. State variation in psychotro-
pic medication use by foster care children with autism spectrum disorder.
Pediatrics 2009;124:e305-12.
7. Raghaven R, Zima B, Andersen RM, Lebowitz AA, et al. Psychotropic
medication use in a national probability sample of children in the child
welfare system. J Child Adolesc Psychopharmacol 2005:15:97-106.
8. Koslowe K, Bergwerk K, Yinon U, Joav M. Ocular findings in Rett syn-
drome. J Behav Optom 2009;20:151-3.
9. Richa S, Yazbek JC. Ocular adverse effects of common psychotropic
agents: A review. CNS Drugs. 2010;24:501-26.
10. Rennie IG. Clinically important ocular reactions to systemic drug therapy.
Drug Saf 1993;9:196-211.
11. National Institute of Mental Health. www.nimh.nih.gov/health/publica-
tions/attention-deficit-hyperactivity-disorder/complete-index.shtml. Last
Accessed June 24, 2011.
12. Han E, Craig SB, Rutner D, Kapoor N, et al. Medications prescribed to
brain injury patients: A retrospective analysis. Optometry 2008:79:252-8.
Journal of Behavioral Optometry
13. Aman MG, McDougle CJ, Scahill L, Handen B, et al. Medication and 27. Lubesty MJ, Handen B. Medication treatment in autism spectrum disorder.
parent training in children with pervasive developmental disorders and se- Speakers Journal 2008;8.10:97-107.
rious behavior problems: Results from a randomized clinical trial. J Am 28. Bartholow M. Top 200 prescription drugs of 2009. www.pharmacytimes.
Acad Child Adolesc Psychiatry 2009;48:1143-54. com/publications/issue/2010/May2010/RxFocusTopDrugs-0510 Last Ac-
14. Frazier TW, Youngstrom EA, Haycock T, Sinoff A, et al. Effectiveness of cessed June 24, 2011.
medication combined with intensive behavioral intervention for reducing 29. Mehl-Madrona L, Leung B, Kennedy C, Paul S, et al. Micronutrients ver-
aggression in youth with autism spectrum disorder. J Child Adolesc Psy- sus standard medication management in autism: A naturalistic case-control
chopharmacol 2010;20:167-77. study. J Child Adolesc Psychopharmacol 2010;20:95-103.
15. Viola, SG, Maino DM. Brain anatomy, electrophysiology and visual func- 30. Levy S, Mandell D, Schultz R. Autism. Lancet. 2009;374:1627-38.
tion/perception in children within the autism spectrum disorder. Optom Vis 31. Huffman LC, Sutcliffe TL, Tanner IS, Feldman HM. Management of
Dev 2009;3:157-63. symptoms in children with autism spectrum disorders: A comprehensive
16. Roberts P, Woodruff G, Iversen L. Dopamine (Advances in Biochemical review of pharmacologic and complementary-alternative medicine treat-
Psychopharmacology). New York, NY: Raven Press, 1978. ments. J Dev Behav Pediatr 2011;32:56-68.
17. Young J, Kavanagh M, Anderson G, Shaywitz B, et al. Clinical neuro-
chemistry of autism and related disorders. J Autism Dev Dis 1982;12:147-
65. Corresponding author:
18. Taub MB, Russell BS. Autistic spectrum disorders: A primer for the op- Angela Howell, OD
tometrist. Rev Optom 2007;144:82-91. 219 West Main
19. Yeung L, Hung PT, Lin LL, Yang CH, et al. Effects of dopamine antago- Paragould, AR 72450
nists in human eye accommodation. J Ocul Pharmacol Ther 2001;17:11-7. drangelahowell@yahoo.com
20. Modahl C, Green L, Fein D, Morris M, et al. Plasma oxytocin levels in Date submitted for publication: 8 June 2011.
autistic children. Bio Psychiatry 1998:42:270-7. Date accepted for publication: 26 July 2011.
21. Hollander E, Novotny S, Hanratty M, Yaffe R, et al. Oxytocin infusion re-
duces repetitive behaviors in adults with autistic and Aspergers disorders.
Neuropsychopharm 2003:28:193-8.
22. Klin A, Jones W, Schultz R, Volkmar F, et al. Visual fixations patterns
during viewing of naturalistic social situations as predictors of social com- ADDITIONAL CONTENT AVAILABLE!
petence in individuals with autism. Arch Gen Psychiatry 2002;59:809-16.
23. Yip J, Oblak A, Blatt G. Decreased levels of brain derived neurotropic fac- The JBO Online version of this article
tor (BDNF) in the cerebellum of patients with autism. Society of Neurosci-
ence Annual Conference, San Diego 2007. features videos. Access JBO Online at:
24. Epilepsy Health Center. Epilepsy drugs to treat Seizures. Web MD. www.
webmd.com/epilepsy/medications-treat-seizures. Last Accessed May 26, www.oepf.org/journals or by
2011.
25. Maino DM, Viola, SG, Donati R. The etiology of autism. Optom Vis Dev
scanning this QR code with
2009:40:150-6. your smartphone!
26. Spence S, Schneider M. The role of epilepsy and epileptiform EEGs in
autism spectrum disorder. Pediatr Res 2009;65:599-606.

Wold SAFE Fund

2012 COVD Annual Meeting Student & Resident Travel Grants
The College of Optometrists in Vision Development
Annual Meeting Travel Grant is offered to encourage
and support optometry student and resident
participation at the meeting. The grants are provided
through the Wold SAFE Fund.
COVD members donate to this fund to support student
attendance at the meeting. The number and amount
of the grants given are based on monies available in
the fund each year. This year, thanks to our donors and
a $7,000 grant from The Vision Care Institute, LLC, up
to eighty-nine $200 grants are available for students
and residents.
To be eligible to receive a grant, an optometry student
or resident must:
Be a COVD member (if not already a member, join
for free)
Be enrolled in an optometry degree (OD) program at
a school or college of optometry.
Submit an application and current copy of your CV.
Be sure to include any posters or papers you are
presenting at the 2012 Annual Meeting.
After your application is received, you will be given
the title of an article to summarize.
Grant recipients will be selected based on a review of
their CV and article summary.

The 2012 COVD Annual Meeting is October 16-20, in Fort Worth, Texas. Deadline for submission of
applications is 11:59 pm on July 26, 2012. You will be given the title of an article to summarize on or
before August 2, 2012. The article summary and submission of your CV is due 11:59 pm on August 23,
2012. Decisions will be made on or before September 4, 2012.

Applications are available on the COVD website or by emailing info@covd.org.

Journal of Behavioral Optometry Volume 23/2012/Number 3/Page 77