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Aim To determine the social acceptance of children with strabismus by their peers and to determine the age at which the negative impact of strabismus on psychosocial interactions emerges.
Methods Photographs of six children were digitally altered in order to create pictures of identical twins except for the position of the eyes (orthotropic, exotropic and exotropic) and the colour of the shirt. One hundred and eighteen children aged 3–12 years were asked to select, for each of the six twin pairs, one of the twins to invite to their birthday party. The grouping of the pictures and the composition of the twin pairs were determined by Latin squares.
Results Children younger than 6 years old did not make any significant distinctions between orthotropic children and children with strabismus. Respondents aged 6 years or older invited children with a squint to their birthday parties significantly less often than orthotropic children. The authors found no impact (p>0.1) of gender, of the colour of the shirt or of the type of strabismus, but did find a highly significant impact of age on the number of invited children with strabismus.
Conclusions Children aged 6 years or older with a visible squint seem to be less likely to be accepted by their peers. Because this negative attitude towards strabismus appears to emerge at approximately the age of 6 years, corrective surgery for strabismus without prospects for binocular vision should be performed before this age.
- Strabismus
- exotropia
- esotropia
- discrimination
- children
- muscles
- cosmesis
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Introduction
Strabismus is known to have a negative psychosocial impact on adults. Several studies have demonstrated that adults with ocular misalignment are more likely to have psychosocial problems,1–5 problems finding an employment6–9 and problems finding a partner.10
Questions arise as to the social acceptance of children with strabismus and at what age the negative impact of strabismus on psychosocial interactions emerges. Few studies have approached this subject.
Harper's11 study, based on previous literature, showed that children with visible physical differences, such as orthopaedic impairments, facial disfigurement and obesity, often experience a hostile social milieu. Thereby, children younger than 12 years old and girls are generally more positive than older children and boys towards peers with physical differences. The acceptance depends also on the type of contact an individual has had with a particular disability, the attitude of the family towards the disability, how a child views the causality of how the disability happened, the duration of a disability and the cultural environment of a child. In this sense, Western countries differ from non-Western countries.
Uretmen et al12 investigated how 30 elementary school teachers view 10 personal characteristics in children with noticeable strabismus. Using digitally altered photographs of two boys and two girls aged between 8 and 10 years, they found that children with a squint were perceived as less healthy, less happy and having a lower capacity for hard work. Esotropic children were thereby rated more negatively than children with exotropia. The authors concluded that teachers have a negative social bias against children with significant strabismus that could have a negative effect on a child's education and socialisation.
In order to study the attitude towards strabismus in 34 children aged 3 to 7 years, Paysse et al13 altered three identical dolls so that one was orthotropic, one esotropic and one exotropic. They found that children aged 5¾ years or older were significantly more likely than younger children to report a dislike of the strabismic dolls when asked. Based on the fact that the youngest children did not notice the strabismus in the dolls, and children between 4½ and 5¾ years noticed a difference but did not have a preference, the authors concluded that dislike and hostility towards ocular deviations are acquired responses.
Johns et al14 could not confirm these findings. In their study, they analysed the impact of strabismus on the selection of playmates showing photographs of children arranged in pairs of one orthotropic child and another child with strabismus. One hundred children aged 3 to 8 years were asked to select a playmate from each photograph pair until they had a choice of 15 playmates. Out of a total of 1500 playmates chosen, 49.7% were children with strabismus. Neither age nor the direction or magnitude of strabismus had a significant impact on the selection.
The present study is based on digitally altered pictures grouped in pairs of an orthotropic child and his strabismic twin in order to investigate the effect of strabismus on the selection of children to be invited to a birthday party. In order to determine the age at which a negative attitude towards strabismus may emerge, children aged 3 to 12 years were included in the study.
Methods
A total of 118 children aged 3 to 12 were consecutively shown six pairs of photographs of the faces of two children differing only in the colour of their shirts (dark and light) and in the position of their eyes (normal, esotropic and exotropic). The esotropic and exotropic eyes were obtained by digitally altering the original pictures of three boys and three girls (figure 1). The alterations were made using Adobe Photoshop 6.0 (Adobe Systems, San Jose, California) by using the techniques of merging and erasing. The squint angles corresponded to 50 prism dioptres. The squint angles were chosen to allow a better comparison between studies, since the majority of previous studies used that angle.6–8 10
Example of photographs of twin pair: on right side orthotropic; on left side left esotropia.
All participants were children aged 3 to 12 years attending the Department of Ophthalmology at the Eye Clinic in St Gallen, or their siblings. Children with physical impairments, children with low visual acuity on the better eye, children with a squint or having persons with a squint among their family members and friends as well as children not speaking German were excluded from this study.
For all six twin pairs, the children were asked which of the twins they would invite to their birthday party. Three groups of photographs consisting of six pairs of pictures were made. Each group included: two pairs of twins, of which one twin was orthotropic and the other exotropic; two pairs of twins, of which one twin was orthotropic and the other esotropic; and two pairs with an esotropic and an exotropic twin. The order of the blocks within each task (order of pictures and twin pairs shown) was pseudorandomised (using a Latin Square design).
After having seen the six pairs of photographs, children were asked if they had noted anything in particular. If a child had noted nothing related to the eyes, they were asked again if anything was unusual with the eyes of the photographed twins.
The number of children with a squint invited to the party and the selection between exotropic and esotropic children were analysed for each age group using t tests.
A regression analysis was performed to determine whether the age and gender of the interviewed children or the colour of the shirts of the photographed children had any impact on the number of selected children with strabismus or on the choice between exotropic and esotropic children.
All statistics were performed with R Version 2.9.1 (http://www.r-project.org/).
The study was approved by The Ethics Commission of the Canton St Gallen, and written informed consent was obtained from the parents of the participating children and of the children shown on the photographs.
Results
A total of 118 (64 girls and 54 boys) children (mean (SD) age 7.02 (1.99) years) participated in the study.
For their birthday party, each child was asked to choose four times between an orthotropic twin and one with strabismus. They therefore could invite between zero and four squinting children. If strabismus had no impact on the choice, an average of two invited squinting children would be expected. The t test showed no significant differences from this expected average for children younger than 6 years old. In children aged 6 years or more, children with a squint were invited significantly less often to the birthday party than orthotropic children (table 1).
Number of strabismic children selected to participate in the birthday party
When the children were asked to select between an esotropic and exotropic twin, no significant difference (p=0.1746) was found between the two types of squint (table 2).
Number of esotropic children selected to participate in the birthday party and percentage of children making comments about the eyes of the photographed twins
When asked if they had noted anything in particular regarding the twins, the percentage of children who made specific comments about the eyes increased with age. Approximately 19% of children aged 4 to 6 years commented on eye alignment without being asked to pay attention to the eyes. After being asked to pay attention to the eyes, the number of children saying something concerning them increased to 39%. For children aged 6–8 years, the percentage of children commenting on eye alignment increased to 48% before and 77% after being specifically asked to pay attention to the eyes. Eighty-three per cent (91%) of children aged 8–10 years noted something in particular about the eyes of the pictures. Children's comments included remarks that the eyes were crossed, strange, turned, squinting, looking in different directions, like chameleons, different from each other or not straight.
The regression analysis showed no impact of gender or of the colour of shirts of the children presented in the photographs but showed a highly significant impact of age on the number of strabismic children invited to the party (p=6.99e–06, adjusted R2=0.1501). Age, gender and the colour of the shirts did not have any impact (p>0.1) on the choice between esotropic and exotropic children.
Discussion
Strabismus is a visible facial abnormality that has been shown to have adverse psychosocial consequences in adults.1–10 15 It has been demonstrated also that visible differences in general have a negative impact on how children are perceived by peers.11 Furthermore, a negative social bias on the part of teachers against schoolchildren with strabismus has been demonstrated.12
Concerning the attitude of children towards strabismus, two studies have reached contradictory conclusions. Johns et al found that the presence of strabismus did not have a significant impact on the peer acceptance of children aged 3–8 years.14 Contrary to this, Paysse et al13 found that a negative attitude towards strabismus arises in children at approximately 6 years of age. Both studies did not include children older than 8 years.
The data presented in this study are based on children aged 3–12 years in order to analyse the impact of strabismus at different ages. These children had to choose between twins who were identical except for the colour of their shirt and the position of their eyes. Regression analysis showed no impact of the colour of the shirts of the twins or of the gender of the respondents on the choice of one of the twins. In contrast, age had a strong impact, where the number of children with a squint selected to be invited at the birthday party decreased significantly with increasing age. In general, for children older than 6 years, the number of selected children with strabismus was significantly lower than that of orthotropic children. Our results confirm those of Paysse,13 in that a negative attitude towards strabismus appears to emerge at approximately 6 years of age, and in that the perception that something is different in squinting compared with aligned eyes arises earlier.
These findings have important implications concerning the appropriate time for surgical intervention in children with visible strabismus without prospects for binocular vision. Surgery should be performed before negative attitudes towards strabismus emerge. Negative attitudes appear to be present in children older than 6 years. Although children between 4 and 6 years of age were often aware of a difference between an aligned and squinting eye, this difference was not valued negatively.
Johns et al14 found that a negative attitude towards strabismic children had not emerged by the age of 8 years. Our results show a significant impact beginning at the age of 6 years and increasing with age. We presume that the main reason why our results differed from those of Johns et al is that in their study, the authors paired different children in the photographs, with different personalities, hair styles and shirt colours. In their experiment, children were asked about their reason for selecting a playmate. The answers showed that respondents were more concerned about the perceived personality of the children in the photographs and about their clothing and hair than they were about the position of their eyes. This demonstrates that although strabismus seems to be an important element in choosing playmates, other aspects of a child, such as their personality, might be even more important. In our study, children were asked to select between identical twins except for the colour of their shirts and the position of their eyes. Because the colour of the shirt did not have an impact on the choice, we can conclude that the differences in the number of selected children with a squint at different age groups depend mainly on the changing perception of strabismus with increasing age. Although we controlled for the colour of the shirts and for the order and grouping of the pictures shown, our study is based on photographs, and not on real persons and situations. Therefore, we cannot exclude the possibility that social aspects, such as group dynamics or social environment, or personal aspects, such as the child's personality, could have an impact on the socialisation of children with strabismus. Finally, our results are based on data from Switzerland and may not be transferable to countries with different perceptions or acceptances of children with visible differences. This study did not investigate at what angle a squint becomes visible to other children because such a study design would have necessitated the inclusion of a considerably higher number of children. However, it would be important to clarify this issue in future studies.
The differences in the perception of strabismus between age groups can be explained by studies on the development of children in the recognition of faces and facial features. These studies show that children older than 6 years of age mostly process faces holistically, like adults. Children younger than 4 years use part-based processing, meaning that faces are categorised in terms of piecemeal characteristics. Therefore, younger children may not be able to realise that two eyes are not aligned.16
We did not investigate the role of glasses on the perception of a squint. Many children with strabismus wear glasses, and it is known that they can distract from visible strabismus. The results of studies investigating how children with glasses are perceived by peers remain controversial. Terry and Stockton17 found that glasses had a negative effect, and Walline et al18 found that they made children look smarter and slightly more honest.
Based on the answers and preferences of 118 participants aged 3–12 years, we found no negative attitudes towards strabismus in children younger than 6 years. Negative attitudes appear to emerge at approximately 6 years and increase with age. In our experimental study, children older than 6 years selected children with strabismus significantly less often than those with aligned eyes to be invited at their birthday parties. Neither gender nor the form of strabismus had any impact on the selection. Although, until 6 years, no preference for orthotropic children was shown, a large percentage of children between 4 and 6 years of age already noted that something was different with the eyes. Our results show that schoolchildren with strabismus seem to be less likely to be accepted by their peers, and so corrective surgery for strabismus should be performed before the age of 6 years, when negative social implications may arise. A similar conclusion was reached by Uretmen et al12 based on a more negative perception of schoolchildren with strabismus by elementary school teachers.
Acknowledgments
We would like to thank Paul Sensecall (http://www.pseditorialservices.com) for linguistic editing.