DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Mental health of children with vision impairment at 11 years of

age
JOHN HARRIS 1 | CHRIS LORD 2
1 Royal London Society for Blind People (RLSB), London; 2 National Centre for Social Research (NatCen), London, UK.
Correspondence to John Harris at RLSB, 11 Belgrave Road, London SW1V 1RB, UK. E-mail: [email protected]

This article is commented on by Hatton on pages 660–661 of this issue.

PUBLICATION DATA AIM The purpose of the study was to compare the risk of psychiatric disturbance among
Accepted for publication 4th November sighted and vision-impaired children aged 11 years.
2015. METHOD Scores from the parent and teacher versions of the Strengths and Difficulties
Published online 7th March 2016. Questionnaire (SDQ) were used to compare sighted children with: vision-impaired children;
vision-impaired children with no other reported disabilities or special educational needs; and
ABBREVIATIONS children with vision impairment and additional disabilities or special educational needs.
MCS Millennium Cohort Study Logistic regression was used to measure the associations between the independent variables
SDQ Strengths and Difficulties Ques- and SDQ scores, and to test for significance of the observed differences.
tionnaire RESULTS Both parents and teachers scored vision-impaired children significantly higher on
SEND Special educational needs and the SDQ compared with sighted children (p≤0.000) and a significantly higher proportion of
disability the vision-impaired children had SDQ scores in the abnormal range (p≤0.000). Children with
vision impairment and other disabilities or special educational needs were rated as being at
greatest risk of psychiatric disorder by both parents (30%) and teachers (22%).
INTERPRETATION Vision impairment among children as young as 11 years of age is
associated with an increased risk of psychiatric disorder.

A growing body of research using nationally representative range of instruments to measure the psychological well-
samples of children suggests that children with develop- being of children and young people aged 12 to 19 years of
mental delay, long-standing illness or disability, and those age.7 However, the authors found relatively few studies of
with special educational needs are more likely than chil- children under the age of 12, and no significant differences
dren without disabilities to display a range of behaviours were reported in respect of this age group. Across all age
associated with psychiatric disturbance, including ‘internal- groups, considerably more differences were reported from
izing’ and ‘externalizing’ behaviours.1–4 studies that used vision-specific measures of psychological
Vision impairment affects young children’s developmental well-being compared with those that used global measures.
progress across a number of domains, for example, concept In respect of younger participants, a Finnish study12
development, communication, language development, mobil- found no evidence of depression or distress among sight-
ity,5,6 well-being,7 social interaction,8 and participation in impaired 14-year-olds after comparing their scores on a
age-typical activities.9 These effects are likely to arise partly checklist of 17 physical and psychological symptoms of dis-
from the limitations that vision impairment imposes on chil- tress, a modified version of the Beck Depression Inventory,
dren’s ability to interact with the environment, and partly by and a self-esteem scale with scores obtained by 385 sighted
the way in which parents and other adults respond to them.10 children. However, they did find that self-esteem was lower
In addition, a high proportion of children diagnosed with among females with vision impairment compared with the
vision impairment have associated non-ophthalmic disorders sighted controls, and the sight-impaired females more often
or impairments that are likely to affect developmental pro- reported feelings of loneliness. They also reported that the
gress.11 In the light of these developmental challenges, the sight-impaired young people of both sexes had fewer friends,
psychological adjustment of children with vision impairment greater difficulty in making friends, and fewer dating experi-
in middle and later childhood is of particular interest. ences compared with their sighted peers.
Previous research on this topic has sought to identify A more consistent picture has emerged from studies
adjustment difficulties among vision-impaired children and using the Strengths and Difficulties Questionnaire (SDQ)4
young people by comparing their scores on a variety of dif- although to date results have only been reported for chil-
ferent measures with the scores of sighted children of a dren aged 15 years or older.
similar age. A recent meta-analysis reported significant dif- Pinquart and Pfeiffer13 found that self-reports and teacher
ferences, with small effects sizes, for studies using a wide ratings on the SDQ for 16-year-olds indicated significant

774 DOI: 10.1111/dmcn.13032 © 2016 Mac Keith Press

differences between the sight-impaired young people and What this paper adds
sighted controls in respect of SDQ total score and two sub- • Vision-impaired children aged 11 years are at risk of psychiatric disorder.
scales that measure internalizing problems: emotional symp- • Vision-impaired children with additional special educational needs and dis-
toms and peer problems. Using Goodman’s criteria4 to abilities are at greatest risk.
identify children at risk of psychiatric disorder, the authors • Health services should consider how to identify and treat vision-impaired
children at risk of psychiatric disorder.
identified 13.5% of their sight-impaired sample as having
scores in the abnormal range compared with only 5.1% of approximately 19 000 children born between September
the controls. They also reported that teacher responses pro- 2000 and January 2002. Wave 5 data was collected
vided significantly lower scores than self-reports of the between January 2012 and January 2013.15 Research ethics
young people in respect of total difficulties score, emotional approval for the various elements of the MCS has been
symptoms, conduct problems, and hyperactivity. obtained.16 The MCS sample is clustered geographically
Pinquart and Pfeiffer14 described changes over a period and stratified to ensure appropriate representation of
of 2 years in self-report SDQ scores for 182 vision- demographic characteristics that are of particular interest
impaired young people with a mean age of 15 years and a such as deprivation and ethnicity. Wave 5 data are avail-
larger group of sighted controls. At the start and at the able for 13 287 children aged 11 years, of whom 50.3%
end of the study, young people with vision impairment were male and 49.6% female.15 Children were identified as
scored significantly higher on the SDQ total difficulties vision-impaired if they met one or more of the following
score, and both the internalizing (emotional symptoms, criteria: a parent reported a sight-related impairment that
peer problems) and externalizing (conduct problems, limited the child’s activities (67% of sight-impaired chil-
hyperactivity) sub-scales compared with the controls. dren); a parent reported in this or any previous wave of the
When the cut-off criteria for identifying those at risk of a MCS that the child was registered sight impaired or
diagnosis of psychiatric disorder were applied, 39% of the severely sight impaired (51%); a teacher reported that the
young people with sight impairment had abnormally high child was receiving extra help in the classroom or had a
scores on at least one of the SDQ scales at the start of the statement of special educational need because of a ‘prob-
study, compared with 30% of the sighted young people. lem with sight’ (31%); a parent reported that the child was
After 2 years, these figures had declined so that 28% of receiving extra help in the classroom (12%); or had a state-
the young people with sight impairment were rated at high ment of special educational need because of a ‘problem
risk of psychiatric disorder on one or more of the SDQ with sight’ (10%).
scales compared with 22% of the sighted young people. Children with an additional disability or special educa-
In the light of these findings, further research is needed tional need (other than arising from a vision impairment)
to identify at what age children with vision impairment were also identified if the parent reported: a non-sight-
first present behaviours that are indicative of psychiatric related impairment that limited the child’s activities; that
disturbance. The purpose of this study was twofold: to use the child had a statement for non-sight-related reasons; if
a large nationally representative data set to investigate the parent or teacher reported that the child was in receipt
whether vision impairment is associated with an increased of additional classroom support; or had special educational
risk of psychiatric disorder among 11-year-old children; needs for non-sight-related reasons.
and to consider whether the presence of special educational
needs and disability (SEND) in addition to vision impair- Measures
ment represents an additional risk factor. Included in the MCS are both the parent and teacher
The study is of interest for several reasons. It suggests report forms of the SDQ.4 The purpose of the SDQ is to
that children aged 11 years with vision impairment are at provide a simple, quick, and economical procedure to iden-
greater risk of psychiatric disturbance compared to their tify children and young people who are likely to meet the
sighted peers, and that many will present challenges to criteria for diagnosis of psychiatric disorder. Complete
their parents and teachers over and above those directly SDQ data permitting calculation of total scores were pro-
related to their difficulties with vision. Child and adoles- vided by parents of 189 children with vision impairment
cent mental health services should consider how those chil- and 10 436 sighted children. Comparable data from teach-
dren at high risk can be identified and what forms of ers were available for 138 vision-impaired children and
treatment are most likely to be effective. The study also 6328 sighted children. Data required to calculate individual
highlights the need for further research on the influence of sub-scale scores were available for slightly more children
vision impairment during development and how it might in each category.
be implicated in psychological adjustment during child- Although initially based on psychiatric constructs used
hood and adolescence. in the Rutter Questionnaires,17 the items themselves and
their organization into sub-scales have been refined
METHOD through factor analysis, frequency distributions, informal
Sample trials, and professional feedback.4 Items are divided into
The sample was drawn from Wave 5 of the Millennium five sub-scales, each of which generates scores from 0 to
Cohort Study (MCS), a UK-wide longitudinal study of 10. The emotional symptoms and peer problems sub-scales

Children with Vision Impairment John Harris and Chris Lord 775
measure internalizing problems, while conduct problems measure revealed consistent differences in respect of the
and hyperactivity sub-scales measure externalizing prob- scale scores and the risk ratings for the SDQ total score
lems. A fifth sub-scale measures pro-social behaviours. The and the peer problems sub-scale. Significantly fewer vision-
total SDQ score and the four sub-scales representing psy- impaired children, compared with sighted children, were
chosocial difficulties can be assigned to one of three bands identified as ‘low risk’ on the emotional symptoms and
that indicate the likelihood of a disorder being diagnosed conduct problems sub-scales, although a direct comparison
following psychiatric assessment: normal/low risk; border- of scores on these two measures did not reveal significant
line/moderate risk; and abnormal/high risk. Cut-offs were differences. In contrast, comparisons using the teacher
chosen so that roughly 80% of cases are normal, 10% bor- measure revealed only one significant difference on the
derline, and 10% abnormal.4 scale score for the conduct sub-scale. Since cell sizes for all
The SDQ appears to function effectively as a screening the comparisons using the teacher measure were below 50,
tool18 and has satisfactory psychometric properties in the power of the statistical tests used in this analysis was
respect of internal consistency, test–test reliability, inter- very much reduced.
rater agreement, construct, and concurrent validity.19 When the scores of children with vision impairment and
other SEND were compared with those of sighted chil-
Analysis dren, there was a much greater degree of consistency
Preliminary analysis confirmed that the data were normally between the parent and teacher measures. For all compar-
distributed. Teacher and parent SDQ scores for children isons (apart from the pro-social sub-scale parent measure
with and without vision impairment were then compared of the proportion of children rated ‘low risk’) there were
using the following tests for statistical significance. We first significant differences in respect of the scale scores and the
tested for differences in the SDQ scores using Complex proportion of children rated ‘low risk’ of a psychiatric dis-
Samples General Linear Regression. This technique calcu- order. On the parent measure, 21% to 36% of children
lates standard errors that reflect the sampling design and were at high risk of psychiatric disorder, while on the tea-
weighting procedures used in the MCS to obtain more reli- cher measure the figures ranged from 6% (on the emo-
able significance results. We then compared the number of tional symptoms sub scale) to 26% (on the hyperactivity
children in each group obtaining scores signifying beha- sub-scale).
vioural disturbance and tested for statistical significance.
We used Complex Samples Binary Logistic Regression to DISCUSSION
compare the distribution of children with low-risk scores to The present study provides comparative data on psychiatric
children with borderline and high-risk scores. Again this disturbance from a nationally representative group of chil-
takes the complex survey design into account and adjusts dren with and without vision impairment. The children are
the standard errors when measuring statistical significance. considerably younger than those included in previous stud-
The analysis was repeated in order to compare SDQ scores ies of vision-impaired children using the SDQ. The results
obtained for vision-impaired children with and without strongly suggest that sight impairment is associated with
additional special educational needs. For this last level of children’s psychosocial adjustment by the age of 11 years
analysis, case numbers per cell for the teacher-reported data and that 20% to 30% of children with sight impairment
were <50 for children with sight impairment but no other may be in need of professional advice and support. An
SEND, thus reducing the power of statistical tests and their important variable is the presence or absence of an addi-
sensitivity to underlying differences. These values are shown tional SEND: fewer problems are identified by both teach-
within square brackets in the figures and Table I. ers and parents among children with vision impairment but
no other SEND; conversely, the presence of SEND results
RESULTS in higher scale scores and more children being identified as
The SDQ l scores are shown in Table I. being at risk of psychiatric disorder compared to sighted
On both parent and teacher measures, the vision- children.
impaired children obtained significantly higher total scores When SDQ scores for sighted children were compared
than the sighted children. There were also significant dif- with scores for children with vision impairment but no
ferences in the proportion of vision-impaired children cate- other SEND, there were a higher number of statistically
gorized as being at low, medium, or high risk of a significant differences in respect of data from parents com-
psychiatric disorder compared with sighted children. On pared to teachers. This most likely reflects the lower num-
the parent measure, 18% to 29% of vision-impaired chil- ber of report forms completed by teachers, compared to
dren were identified as being at high risk of psychiatric dis- parents, and hence the reduced power of the statistical
order, compared with 7% to 10% of sighted children. tests.
Similarly, teachers identified 6% to 20% of vision- The high number of ‘difficulties’ reported by parents
impaired children as being at high risk compared with 4% and teachers is of concern for a number of reasons. It sug-
to 7% of sighted children. gests that for many children sight problems in early child-
When the children with vision impairment but no other hood have important long-term implications over and
SEND were compared with sighted children, the parent above the practical difficulties associated with learning and

776 Developmental Medicine & Child Neurology 2016, 58: 774–779

Table I: Teacher and parent Strengths and Difficulties Questionnaire scores for sighted and vision-impaired children

Vision-impaired Vision impaired Vision impaired/

Sighted children children only SEND

SDQ Par Teach Par Teach Par Teach Par Teach

Total score n 10436 6328 189 138 87 46 102 92

Mean score 7.2 5.1 12a 8.7a 9.8a [5.6] 13.6a,b 10.1a,b
p values A Ref. Ref. 0.000 0.000 0.010 0.652 0.000 0.000
p values B Ref. Ref. N/A N/A N/A N/A 0.000 0.000
Low risk (%) 88 88 63a 72a 72a [87] 56a,b 65a,b
Borderline (%) 5 7 16 11 18 [5] 14 13
High risk (%) 7 5 21 18 10 [8] 30 22
p values A Ref. Ref. 0.000 0.000 0.005 0.921 0.000 0.000
p values B Ref. Ref. N/A N/A N/A N/A 0.038 0.016
Emotional symptoms n 11184 6480 211 141 94 46 117 95
Mean score 1.8 1.3 3.1a 2.3a 2.4 [1.9] 3.5a,b 2.4a
p values A Ref. Ref. 0.000 0.001 0.041 0.302 0.000 0.000
p values B Ref. Ref. N/A N/A N/A N/A 0.021 0.373
Low risk (%) 83 92 63a 82a 68a [83] 60a 82a
Borderline (%) 7 4 13 11 18 [9] 11 12
High risk (%) 10 4 23 6 14 [8] 29 6
p values A Ref. Ref. 0.000 0.002 0.023 0.104 0.000 0.002
p values B Ref. Ref. N/A N/A N/A N/A 0.425 0.883
Peer problems n 11090 6499 202 142 91 46 111 96
Mean score 1.3 1.1 2.3a 1.9a 2.1a [1.4] 2.4a 2.1a
p values A Ref. Ref. 0.000 0.001 0.000 0.317 0.000 0.001
p values B Ref. Ref. N/A N/A N/A N/A 0.380 0.054
Low risk (%) 83 90 64a 74a 70a [88] 60a 68a,b
Borderline (%) 7 4 8 5 5 [1] 10 7
High risk (%) 10 5 28 20 25 [11] 30 25
p values A Ref. Ref. 0.000 0.000 0.031 0.644 0.000 0.000
p values B Ref. Ref. N/A N/A N/A N/A 0.285 0.018

Conduct n 11175 6499 209 142 92 46 117 96

Mean score 1.3 0.6 2.0a 1.1a 1.6 [0.3a] 2.3a,b 1.4a,b
p values A Ref. Ref. 0.000 0.007 0.207 0.046 0.000 0.001
p values B Ref. Ref. N/A N/A N/A N/A 0.003 0.000
Low risk (%) 83 92 64a 85a 71a [97] 59a,b 80a,b
Borderline (%) 9 3 18 6 16 0 20 8
High risk (%) 8 5 18 9 13 [3] 21 12
p values A Ref. Ref. 0.000 0.011 0.028 0.266 0.000 0.002
p values B Ref. Ref. N/A N/A N/A N/A 0.041 0.045
Hyperactivity n 11101 6517 207 143 92 46 115 97
Mean score 3.0 2.1 4.7a 3.6a 3.8a [1.9] 5.3a,b 4.3a,b
p values A Ref. Ref. 0.000 0.000 0.040 0.524 0.000 0.000
p values B Ref. Ref. N/A N/A N/A N/A 0.000 0.000
Low risk (%) 85 89 62a 75a 75 [94] 54a,b 67a,b
Borderline (%) 6 4 9 6 6 [4] 11 8
High risk (%) 9 7 29 19 19 [3] 36 26
p values A Ref. Ref. 0.000 0.000 0.089 0.335 0.000 0.000
p values B Ref. Ref. N/A N/A N/A N/A 0.005 0.002
Pro social n 11251 6499 211 141 92 45 119 96
Mean score 8.8 82 8.2a 7.5a 8.7 [8.2] 7.9a,b 7.3a,b
p values A Ref. Ref. 0.005 0.002 0.694 0.877 0.001 0.000
p values B Ref. Ref. N/A N/A N/A N/A 0.001 0.011
Low risk (%) 96 8.7 91 81a 97 [90] 87 78a
Borderline (%) 3 7 4 8 3 [5] 5 9
High risk (%) 2 6 5 11 0 [5] 8 13
p values A Ref. Ref. 0.063 0.032 0.645 0.567 0.057 0.001
p values B Ref. Ref. N/A N/A N/A N/A 0.126 0.078
a
Significant difference (p≤0.05), sighted children versus vision-impaired with and without SEND. bSignificant difference (p≤0.05), vision-
impaired children with SEND versus vision-impaired children without SEND. n, responses for SDQ scale; p values A, scores of sighted chil-
dren compared with scores of vision-impaired children with and without SEND; p values B, scores of vision-impaired-children with SEND
compared with scores of vision-impaired children without SEND; Ref, reference group. Figures in square brackets indicate case numbers
per cell <50. SDQ, Strengths and Difficulties Questionnaire; Par, parent data; Teach, teacher data; SEND, special educational needs and dis-
ability.

acquiring skills for independence. The behaviours that It indicates that parenting children with sight problems
contribute to the SDQ, if unresolved, are likely to affect presents challenges over and above those faced by parents
mental health20 and the ability to forge a strong self-con- of sighted children. Achieving a balance between promot-
cept that embraces sight impairment.21,22 ing independence, self-efficacy, and autonomy on the one

Children with Vision Impairment John Harris and Chris Lord 777
hand and the provision of practical and emotional support used to detect the presence or absence of behaviours
on the other may be more difficult in the case of sight- indicative of psychiatric disturbance. The results indicate
impaired children, especially if they have additional SEND. that on the basis of parental ratings, sight-impaired chil-
While there is widespread recognition that families benefit dren are significantly more likely than sighted children to
from peer and professional support when sight problems present behaviours that are a cause for concern on all
are first diagnosed, these findings suggest that such help SDQ scales, with 18% to 29% falling into the high-risk
may be beneficial at least up until the age of 11 years and category on one or more of the SDQ scales. There were
possibly beyond. significant differences on two of the SDQ scales when
Elevated scores on the SDQ have been reported in pre- comparisons were made between sighted children and
viously published research on older children,13,14 which those with sight impairment, but no other SEND, and
suggests that the risk of psychiatric disturbance is likely to the number rated as high risk fell to 10% to 25%. Tea-
persist over time. More research is needed to understand cher ratings were available for fewer children than paren-
the relationship between vision impairment and internaliz- tal ratings, and this is likely to have affected the number
ing and externalizing behaviours so that preventive strate- of significant differences reported between sighted chil-
gies and treatments can be developed. dren and children with vision impairment but no other
Given the limited availability of child and adolescent SEND.
mental health services for children and young people in On both parent and teacher ratings, children with vision
England23 there are concerns about how easily vision- impairment and other SEND scored significantly higher
impaired children with behavioural and emotional difficul- than sighted children on all the SDQ scales. In terms of
ties are able to access appropriate professional support. the likelihood of a diagnosis of psychiatric disorder, 21%
to 30% were rated as high risk by parents and 6% to 26%
LIMITATIONS by teachers.
The method of selecting the sample led to the identifica- These results highlight the effects of sight impairment
tion of approximately 2% of the MSC sample as vision- on children’s psychosocial development, and suggest
impaired, and is therefore likely to include those with less that children as young as 11 years of age and their par-
severe sight impairment compared to previous studies that ents are likely to benefit from specialist advice and sup-
have access to optometric records. Only data provided by port.
parents and teachers is presented because the young age of
the children in this study precluded the use of the self- A CK N O W L E D G E M E N T
report form of the SDQ. The analysis did not include pro- Thanks to Cheryl Lloyd from the National Centre for Social
cedures to control for false positive findings associated Research for advice on the statistical analysis and to Sue Keil
with multiple comparisons. from the Royal National Institute for Blind People (RNIB) for
her helpful comments on the manuscript. The project was jointly
CONCLUSION funded by the Royal London Society for Blind People and RNIB.
As part of the MCS, parents and teachers of 11-year old The authors have stated that they had no interests that might be
children were invited to complete the SDQ, a rating scale perceived as posing a conflict or bias.

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Children with Vision Impairment John Harris and Chris Lord 779