The impact of visual impairment on children’s mental health

It affects visual impairment and blindness. 2.2 billion people worldwideincluding 19 million children. For these children, visual impairment has a significant impact on their lives, including their education and mental health.

Two studies conducted in collaboration with the eye care non-profit Orbis International concluded that providing children with free glasses improves their ability to learn in school and that addressing visual impairment in children can reduce depression and anxiety. Both studies fill important research gaps and provide important directions for future interventions and research.

Glasses and education for children

of First study Published in BMJIt was conducted in rural areas of western China, where only 15 percent of children who need glasses have them.

The study was a cluster-randomized controlled trial (RCT), double-masked, and cross-arm cross-contamination by selecting 1 school per city. Primary schools in 2 neighboring provinces, Gansu and Shaanxi, were considered for eligibility. Areas sampled included low- and middle-income urban settlements in each state.

A total of 252 schools were selected – 1 per city, and 1 fourth and fifth grade from each school. Children in these selected classes were eligible to participate in the study if their uncorrected visual acuity (UCVA) was £6/12 in both eyes and could be improved to ³6/12 in both eyes by wearing spectacles.

The researchers began by administering questionnaires to children, parents, and math teachers. Questionnaires asked of children about their vision and personal information. Questionnaires for parents and teachers about resources and blackboard use, respectively.

Visual acuity was assessed for each child at the beginning of the study. Then, UCVA was performed in children with £6/12 for automated comparison with subject screening. Mathematics scores were assessed at the beginning and end of the study with timed and designed tests appropriate for each class. Eyeglass wear was assessed by direct examination and self-report at the end of the study.

The schools were randomized to receive 1 of 3 interventions: free glasses, vouchers for free glasses, or a prescription (control group). Children in the voucher and control groups received free glasses at the conclusion of the study if necessary, but were not told about this at the beginning.

The schools were divided into 2 groups: those who received instructional incentives (such as watching a video, receiving a brochure, or classroom discussion) or those who received no instruction.

All data were created to show that myopia is common in China, that glasses are a very safe and effective treatment, and that wearing glasses does not harm children’s eyes.

Finally, 3,177 children in 251 schools were eligible to participate in the study. Only 15% of eligible children wore glasses. At the end of the study, 41% of the children in the glasses-free group wore glasses, while 68% self-reported. In comparison, 26% was observed and 37% of self-feeding clothes in the control group.

Giving kids free glasses equates to half a semester of extra tuition and improved math test scores. In particular, half or more of the teaching tasks showed improvement when using blackboards (a reliable result because these children are mostly imaginative and are particularly disadvantaged when reading from a distant blackboard, as opposed to a textbook on their desk).

The provision of free glasses had a greater effect on test scores than parental education and family wealth. This effect was observed despite imperfect compliance (about 40% in this case), but an additional incentive to wear glasses is expected to increase the effect.

This study provides a rationale for cost-effective government programs to provide free eyeglasses to school children. The low cost of wholesale glasses increases the reach of government programs, and as a result of this research, a pilot program of free glasses for children has been launched in Gansu and Shaanxi provinces. The study helped shape China’s 2018 National Myopia Control Program, announced by none other than Xi Jinping.

Visual impairment and mental health

of Second study Published in Eye treatmentIt has been shown that children with visual impairment have more depression and anxiety than their peers without visual impairment.

Myopic children, in particular, have higher depression and anxiety scores, and those with other causes of visual impairment have higher anxiety scores. Additionally, children who receive corrective strabismus surgery have been shown to have improved symptoms of depression and anxiety.

This study provides clear evidence that can lead governments to take action on children’s vision, especially when the cost is prohibitive for glasses and insurance coverage for corrective strabismus surgery.

Depression and anxiety in children pose a greater risk if they are not recognized and treated promptly. The lifetime burden of children affected by these conditions is very high.

Orbis research shows that children with visual impairments experience negative mental health because they tend to participate in less physical activity, have lower academic performance and are socially excluded.

Additionally, negative attitudes toward strabismus appear to emerge as early as age 6, and early detection and treatment can have a significant impact on children’s mental health.

This study reports a systematic review and meta-analysis to examine whether visual impairment, eye disease, and their treatments are associated with mental health problems.

The study analyzed 36 articles from 9 different databases. These articles analyzed studies involving children and adults with visual impairment (visual impairment <6/12) or the mental health findings of adults with childhood eye disease.

In addition, the study reviewed 23 observational studies related to depression and anxiety, eight observational studies related to strabismus, and 7 intervention studies. In total, nearly 700,000 participants were enrolled in these studies. Of the 36 studies, 22 were from low- to middle-income countries, and 9 of them focused on myopia in China.

While there is a large body of work focusing on the impact of visual impairment on depression and anxiety in adults, studies examining mental health in children with visual impairment are few and have not been reviewed in this comprehensive way before.

This research has important implications for health care planners as they allocate resources and design interventions to prevent visual impairment. For example, in some countries, strabismus surgery is seen as a cosmetic procedure and is excluded from insurance coverage, forcing families to pay out of pocket. These barriers can prevent patients of low socioeconomic status from seeking treatment and from accessing the mental health benefits of corrective surgery.

More accessible eye care treatments improve children’s mental health and overall well-being.

Research applications

These studies provide valuable information on the impact of preventable visual impairment and blindness on children’s educational outcomes and mental health.

Uncorrected refractive error remains the leading cause of vision loss worldwide. The effects of nearsightedness and poor vision on academic performance can be a source of stress and depression, especially in high-pressure educational environments such as China, where more than half of children aged 6 to 18 have myopia.

Finally, the results of both studies provide policymakers and health care planners with useful information for intervention design and resource allocation, highlighting the negative effects of visual impairment and the positive effects of treatment.

Nathan Condon is Director of Research at Orbis International.

Emily Rich, MPH, is a recent international health graduate from Queen’s University Belfast in Belfast, Northern Ireland and currently a volunteer faculty member at Orbis International. She can be contacted ataterich01@qub.ac.uk