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: John.Harris@RLSB.org.uk

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
samples of children suggests that children with develop-
mental delay, long-standing illness or disability, and those
with special educational needs are more likely than chil-
dren without disabilities to display a range of behaviours
associated with psychiatric disturbance, including ‘internal-
izing’ and ‘externalizing’ behaviours.1–4
Vision impairment affects young children’s developmental
progress across a number of domains, for example, concept
development, communication, language development, mobil-
ity,5,6 well-being,7 social interaction,8 and participation in
age-typical activities.9 These effects are likely to arise partly
from the limitations that vision impairment imposes on chil-
dren’s ability to interact with the environment, and partly by
the way in which parents and other adults respond to them.10
In addition, a high proportion of children diagnosed with
vision impairment have associated non-ophthalmic disorders
or impairments that are likely to affect developmental pro-
gress.11 In the light of these developmental challenges, the
psychological adjustment of children with vision impairment
in middle and later childhood is of particular interest.
Previous research on this topic has sought to identify
adjustment difficulties among vision-impaired children and
young people by comparing their scores on a variety of dif-
ferent measures with the scores of sighted children of a
similar age. A recent meta-analysis reported significant dif-
ferences, with small effects sizes, for studies using a wide
range of instruments to measure the psychological well-
being of children and young people aged 12 to 19 years of
age.7 However, the authors found relatively few studies of
children under the age of 12, and no significant differences
were reported in respect of this age group. Across all age
groups, considerably more differences were reported from
studies that used vision-specific measures of psychological
well-being compared with those that used global measures.
In respect of younger participants, a Finnish study12
found no evidence of depression or distress among sight-
impaired 14-year-olds after comparing their scores on a
checklist of 17 physical and psychological symptoms of dis-
tress, a modified version of the Beck Depression Inventory,
and a self-esteem scale with scores obtained by 385 sighted
children. However, they did find that self-esteem was lower
among females with vision impairment compared with the
sighted controls, and the sight-impaired females more often
reported feelings of loneliness. They also reported that the
sight-impaired young people of both sexes had fewer friends,
greater difficulty in making friends, and fewer dating experi-
ences compared with their sighted peers.
A more consistent picture has emerged from studies
using the Strengths and Difficulties Questionnaire (SDQ)4
although to date results have only been reported for chil-
dren aged 15 years or older.
Pinquart and Pfeiffer13 found that self-reports and teacher
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
sighted controls in respect of SDQ total score and two sub-
scales that measure internalizing problems: emotional symp-
toms and peer problems. Using Goodman’s criteria4 to
identify children at risk of psychiatric disorder, the authors
identified 13.5% of their sight-impaired sample as having
scores in the abnormal range compared with only 5.1% of
the controls. They also reported that teacher responses pro-
vided significantly lower scores than self-reports of the
young people in respect of total difficulties score, emotional
symptoms, conduct problems, and hyperactivity.
Pinquart and Pfeiffer14 described changes over a period
of 2 years in self-report SDQ scores for 182 vision-
impaired young people with a mean age of 15 years and a
larger group of sighted controls. At the start and at the
end of the study, young people with vision impairment
scored significantly higher on the SDQ total difficulties
score, and both the internalizing (emotional symptoms,
peer problems) and externalizing (conduct problems,
hyperactivity) sub-scales compared with the controls.
When the cut-off criteria for identifying those at risk of a
diagnosis of psychiatric disorder were applied, 39% of the
young people with sight impairment had abnormally high
scores on at least one of the SDQ scales at the start of the
study, compared with 30% of the sighted young people.
After 2 years, these figures had declined so that 28% of
the young people with sight impairment were rated at high
risk of psychiatric disorder on one or more of the SDQ
scales compared with 22% of the sighted young people.
In the light of these findings, further research is needed
to identify at what age children with vision impairment
first present behaviours that are indicative of psychiatric
disturbance. The purpose of this study was twofold: to use
a large nationally representative data set to investigate
whether vision impairment is associated with an increased
risk of psychiatric disorder among 11-year-old children;
and to consider whether the presence of special educational
needs and disability (SEND) in addition to vision impair-
ment represents an additional risk factor.
The study is of interest for several reasons. It suggests
that children aged 11 years with vision impairment are at
greater risk of psychiatric disturbance compared to their
sighted peers, and that many will present challenges to
their parents and teachers over and above those directly
related to their difficulties with vision. Child and adoles-
cent mental health services should consider how those chil-
dren at high risk can be identified and what forms of
treatment are most likely to be effective. The study also
highlights the need for further research on the influence of
vision impairment during development and how it might
be implicated in psychological adjustment during child-
hood and adolescence.
METHOD
Sample
The sample was drawn from Wave 5 of the Millennium
Cohort Study (MCS), a UK-wide longitudinal study of
What this paper adds
• Vision-impaired children aged 11 years are at risk of psychiatric disorder.
• Vision-impaired children with additional special educational needs and dis-
abilities are at greatest risk.
• Health services should consider how to identify and treat vision-impaired
children at risk of psychiatric disorder.
approximately 19 000 children born between September
2000 and January 2002. Wave 5 data was collected
between January 2012 and January 2013.15 Research ethics
approval for the various elements of the MCS has been
obtained.16 The MCS sample is clustered geographically
and stratified to ensure appropriate representation of
demographic characteristics that are of particular interest
such as deprivation and ethnicity. Wave 5 data are avail-
able for 13 287 children aged 11 years, of whom 50.3%
were male and 49.6% female.15 Children were identified as
vision-impaired if they met one or more of the following
criteria: a parent reported a sight-related impairment that
limited the child’s activities (67% of sight-impaired chil-
dren); a parent reported in this or any previous wave of the
MCS that the child was registered sight impaired or
severely sight impaired (51%); a teacher reported that the
child was receiving extra help in the classroom or had a
statement of special educational need because of a ‘prob-
lem with sight’ (31%); a parent reported that the child was
receiving extra help in the classroom (12%); or had a state-
ment of special educational need because of a ‘problem
with sight’ (10%).
Children with an additional disability or special educa-
tional need (other than arising from a vision impairment)
were also identified if the parent reported: a non-sight-
related impairment that limited the child’s activities; that
the child had a statement for non-sight-related reasons; if
the parent or teacher reported that the child was in receipt
of additional classroom support; or had special educational
needs for non-sight-related reasons.
Measures
Included in the MCS are both the parent and teacher
report forms of the SDQ.4 The purpose of the SDQ is to
provide a simple, quick, and economical procedure to iden-
tify children and young people who are likely to meet the
criteria for diagnosis of psychiatric disorder. Complete
SDQ data permitting calculation of total scores were pro-
vided by parents of 189 children with vision impairment
and 10 436 sighted children. Comparable data from teach-
ers were available for 138 vision-impaired children and
6328 sighted children. Data required to calculate individual
sub-scale scores were available for slightly more children
in each category.
Although initially based on psychiatric constructs used
in the Rutter Questionnaires,17 the items themselves and
their organization into sub-scales have been refined
through factor analysis, frequency distributions, informal
trials, and professional feedback.4 Items are divided into
five sub-scales, each of which generates scores from 0 to
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
and hyperactivity sub-scales measure externalizing prob-
lems. A fifth sub-scale measures pro-social behaviours. The
total SDQ score and the four sub-scales representing psy-
chosocial difficulties can be assigned to one of three bands
that indicate the likelihood of a disorder being diagnosed
following psychiatric assessment: normal/low risk; border-
line/moderate risk; and abnormal/high risk. Cut-offs were
chosen so that roughly 80% of cases are normal, 10% bor-
derline, and 10% abnormal.4
The SDQ appears to function effectively as a screening
tool18 and has satisfactory psychometric properties in
respect of internal consistency, test–test reliability, inter-
rater agreement, construct, and concurrent validity.19
Analysis
Preliminary analysis confirmed that the data were normally
distributed. Teacher and parent SDQ scores for children
with and without vision impairment were then compared
using the following tests for statistical significance. We first
tested for differences in the SDQ scores using Complex
Samples General Linear Regression. This technique calcu-
lates standard errors that reflect the sampling design and
weighting procedures used in the MCS to obtain more reli-
able significance results. We then compared the number of
children in each group obtaining scores signifying beha-
vioural disturbance and tested for statistical significance.
We used Complex Samples Binary Logistic Regression to
compare the distribution of children with low-risk scores to
children with borderline and high-risk scores. Again this
takes the complex survey design into account and adjusts
the standard errors when measuring statistical significance.
The analysis was repeated in order to compare SDQ scores
obtained for vision-impaired children with and without
additional special educational needs. For this last level of
analysis, case numbers per cell for the teacher-reported data
were <50 for children with sight impairment but no other
SEND, thus reducing the power of statistical tests and their
sensitivity to underlying differences. These values are shown
within square brackets in the figures and Table I.
RESULTS
The SDQ l scores are shown in Table I.
On both parent and teacher measures, the vision-
impaired children obtained significantly higher total scores
than the sighted children. There were also significant dif-
ferences in the proportion of vision-impaired children cate-
gorized as being at low, medium, or high risk of a
psychiatric disorder compared with sighted children. On
the parent measure, 18% to 29% of vision-impaired chil-
dren were identified as being at high risk of psychiatric dis-
order, compared with 7% to 10% of sighted children.
Similarly, teachers identified 6% to 20% of vision-
impaired children as being at high risk compared with 4%
to 7% of sighted children.
When the children with vision impairment but no other
SEND were compared with sighted children, the parent
776 Developmental Medicine & Child Neurology 2016, 58: 774–779
measure revealed consistent differences in respect of the
scale scores and the risk ratings for the SDQ total score
and the peer problems sub-scale. Significantly fewer vision-
impaired children, compared with sighted children, were
identified as ‘low risk’ on the emotional symptoms and
conduct problems sub-scales, although a direct comparison
of scores on these two measures did not reveal significant
differences. In contrast, comparisons using the teacher
measure revealed only one significant difference on the
scale score for the conduct sub-scale. Since cell sizes for all
the comparisons using the teacher measure were below 50,
the power of the statistical tests used in this analysis was
very much reduced.
When the scores of children with vision impairment and
other SEND were compared with those of sighted chil-
dren, there was a much greater degree of consistency
between the parent and teacher measures. For all compar-
isons (apart from the pro-social sub-scale parent measure
of the proportion of children rated ‘low risk’) there were
significant differences in respect of the scale scores and the
proportion of children rated ‘low risk’ of a psychiatric dis-
order. On the parent measure, 21% to 36% of children
were at high risk of psychiatric disorder, while on the tea-
cher measure the figures ranged from 6% (on the emo-
tional symptoms sub scale) to 26% (on the hyperactivity
sub-scale).
DISCUSSION
The present study provides comparative data on psychiatric
disturbance from a nationally representative group of chil-
dren with and without vision impairment. The children are
considerably younger than those included in previous stud-
ies of vision-impaired children using the SDQ. The results
strongly suggest that sight impairment is associated with
children’s psychosocial adjustment by the age of 11 years
and that 20% to 30% of children with sight impairment
may be in need of professional advice and support. An
important variable is the presence or absence of an addi-
tional SEND: fewer problems are identified by both teach-
ers and parents among children with vision impairment but
no other SEND; conversely, the presence of SEND results
in higher scale scores and more children being identified as
being at risk of psychiatric disorder compared to sighted
children.
When SDQ scores for sighted children were compared
with scores for children with vision impairment but no
other SEND, there were a higher number of statistically
significant differences in respect of data from parents com-
pared to teachers. This most likely reflects the lower num-
ber of report forms completed by teachers, compared to
parents, and hence the reduced power of the statistical
tests.
The high number of ‘difficulties’ reported by parents
and teachers is of concern for a number of reasons. It sug-
gests that for many children sight problems in early child-
hood have important long-term implications over and
above the practical difficulties associated with learning and
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
on the other may be more difficult in the case of sight-
impaired children, especially if they have additional SEND.
While there is widespread recognition that families benefit
from peer and professional support when sight problems
are first diagnosed, these findings suggest that such help
may be beneficial at least up until the age of 11 years and
possibly beyond.
Elevated scores on the SDQ have been reported in pre-
viously published research on older children,13,14 which
suggests that the risk of psychiatric disturbance is likely to
persist over time. More research is needed to understand
the relationship between vision impairment and internaliz-
ing and externalizing behaviours so that preventive strate-
gies and treatments can be developed.
Given the limited availability of child and adolescent
mental health services for children and young people in
England23 there are concerns about how easily vision-
impaired children with behavioural and emotional difficul-
ties are able to access appropriate professional support.
LIMITATIONS
The method of selecting the sample led to the identifica-
tion of approximately 2% of the MSC sample as vision-
impaired, and is therefore likely to include those with less
severe sight impairment compared to previous studies that
have access to optometric records. Only data provided by
parents and teachers is presented because the young age of
the children in this study precluded the use of the self-
report form of the SDQ. The analysis did not include pro-
cedures to control for false positive findings associated
with multiple comparisons.
CONCLUSION
As part of the MCS, parents and teachers of 11-year old
children were invited to complete the SDQ, a rating scale
used to detect the presence or absence of behaviours
indicative of psychiatric disturbance. The results indicate
that on the basis of parental ratings, sight-impaired chil-
dren are significantly more likely than sighted children to
present behaviours that are a cause for concern on all
SDQ scales, with 18% to 29% falling into the high-risk
category on one or more of the SDQ scales. There were
significant differences on two of the SDQ scales when
comparisons were made between sighted children and
those with sight impairment, but no other SEND, and
the number rated as high risk fell to 10% to 25%. Tea-
cher ratings were available for fewer children than paren-
tal ratings, and this is likely to have affected the number
of significant differences reported between sighted chil-
dren and children with vision impairment but no other
SEND.
On both parent and teacher ratings, children with vision
impairment and other SEND scored significantly higher
than sighted children on all the SDQ scales. In terms of
the likelihood of a diagnosis of psychiatric disorder, 21%
to 30% were rated as high risk by parents and 6% to 26%
by teachers.
These results highlight the effects of sight impairment
on children’s psychosocial development, and suggest
that children as young as 11 years of age and their par-
ents are likely to benefit from specialist advice and sup-
port.
A CK N O W L E D G E M E N T
Thanks to Cheryl Lloyd from the National Centre for Social
Research for advice on the statistical analysis and to Sue Keil
from the Royal National Institute for Blind People (RNIB) for
her helpful comments on the manuscript. The project was jointly
funded by the Royal London Society for Blind People and RNIB.
The authors have stated that they had no interests that might be
perceived as posing a conflict or bias.

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