Multiple-Choice Answer Form Completion Time in Children With Amblyopia and Strabismus

Key Points

Question

Do fine motor deficits found in amblyopia and strabismus affect performance on an academic-related motor skill—marking answers with a pencil on a multiple-choice answer form?

Findings

In this cross-sectional study of 85 children, children with amblyopia or strabismus were approximately 28% slower than control children at marking answers on a multiple-choice answer form.

Meaning

Children with amblyopia and strabismus may not perform to their full academic potential if they take longer to complete a multiple-choice answer form, which is typically used in timed, standardized tests.

This cross-sectional study assesses an academic-related fine motor outcome—multiple-choice answer form completion time—in children with amblyopia and strabismus.

Abstract

Importance

Abnormal binocular experience during infancy or childhood from strabismus and/or anisometropia results in visual acuity deficits (eg, amblyopia) and impaired stereoacuity. These pediatric eye conditions have also been linked to slow reading and fine motor impairment.

Objective

To assess an academic-related fine motor outcome—multiple-choice answer form completion time—in children with amblyopia and strabismus.

Design, Setting, and Participants

In this cross-sectional study completed between May 2014 and November 2017 at a nonprofit eye research institute, 47 children with amblyopia treated for strabismus, anisometropia, or both, 18 children with nonamblyopic strabismus, and 20 normal controls were enrolled.

Exposures

Children were asked to transfer the correct answers from a standardized reading achievement test booklet to a multiple-choice answer form as quickly as possible without making mistakes or reading the text.

Main Outcomes and Measures

The time to complete the task was recorded and analyzed between groups.

Results

Of the 85 included children, 40 (47%) were female, the mean (SD) age was 10.09 (0.91) years, and the last mean (SD) grade completed was 3.42 (0.92). Compared with children in the control group (mean [SD] time to completion, 230 [63] seconds), children with amblyopia (mean [SD] time to completion, 297 [97] seconds; difference, 63 seconds; 95% CI, 24-102; P = .001) and children with nonamblyopic strabismus (mean [SD] time to completion, 293 [53] seconds; difference, 68 seconds; 95% CI, 21-115; P = .002) required approximately 28% (95% CI, 20-37) more time to fill out a multiple-choice answer form. Completion time was not associated with etiology, visual acuity, or stereoacuity.

Conclusions and Relevance

Multiple-choice answer forms typically accompany standardized testing in schools in the United States. Longer completion time in children with amblyopia or strabismus may affect a child’s performance on tests using multiple-choice answer forms and may hinder academic success.

Introduction

Abnormal binocular experience during infancy or early childhood associated with strabismus, anisometropia, or both often results in deficits in visual acuity (eg, amblyopia) and stereoacuity that persist throughout childhood. Even with extensive treatment, 15% to 50% of children with amblyopia have residual amblyopia.¹ Amblyopia is the most common cause of monocular vision impairment among children, affecting 2% to 4% of children in the United States. Previously, we have shown that amblyopia, regardless of type (eg, strabismic or anisometropic), is associated with slow reading and more eye movements during reading in school-aged children,^2,3 which is likely to hinder academic performance on timed, standardized tests. Other studies have shown that compared with normal controls, children and adults with amblyopia and strabismus perform poorer on fine motor tasks, such as placing pegs in holes, threading beads, and pouring water into a container.^4,5,6,7 Fine motor function has been linked to academic success in school-aged children.^8,9,10 Here, we assessed whether the fine motor deficits previously found in children treated for strabismus and/or anisometropia translate into a real-world academic situation—using a pencil to mark answers on a Scantron form (Scantron Corporation), a bubble sheet frequently used by standardized multiple-choice achievement tests (http://www.scantron.com/~/media/Scantron/Files/solutions/K-12%20Assessment%20Infographic.ashx). We also assessed whether Scantron completion time was associated with etiology, visual acuity, or stereoacuity.

Methods

The research protocol observed the tenets of the Declaration of Helsinki, was approved by the institutional review board of the University of Texas Southwestern Medical Center, and conformed to the requirements of the United States Health Insurance Portability and Privacy Act. Written informed consent was obtained from a parent or legal guardian, and written assent was obtained from children 10 years or older prior to testing and after explanation of the nature and possible consequences of the study.

Children with strabismus, anisometropia, or combined mechanism amblyopia (n = 47; 21 female [45%]; mean [SD] age, 9.9 [0.9] years; range, 8.6-12.1 years), children with nonamblyopic strabismus (n = 18; 10 female [56%]; mean [SD] age, 10.2 [0.9] years; range, 8.9-12.1 years), and similarly aged normal control children (n = 20; 9 female [45%]; mean [SD] age, 10.4 [1.0] years; range, 8.4-12.4 years) were enrolled. Patients with amblyopia, strabismus, and anisometropia were treated according to the American Academy of Ophthalmology Preferred Practice Pattern,¹¹ ie, with spectacle correction, strabismus surgery, and/or patching/atropine. Children with strabismus were initially diagnosed with esotropia but were aligned to within 4 prism diopters of orthotropia at near at enrollment.

Amblyopia was defined as an interocular difference in visual acuity of 0.2 logMAR or worse and a best-corrected visual acuity in the nonpreferred and preferred eye of 0.2 logMAR or greater and 0.1 logMAR or better, respectively. Children with nonamblyopic strabismus had an interocular difference less than 0.2 logMAR and a best-corrected visual acuity in the nonpreferred and preferred eye of 0.2 logMAR or better and 0.1 logMAR or better, respectively. Children were tested with their habitual spectacle correction if required, which was confirmed by medical record review. Control children had normal visual acuity and stereoacuity and no history of vision disorders. All children had completed at least the second grade and, by report, had previous experience with standardized tests using Scantron multiple-choice answer forms. None of the children had been diagnosed with dyslexia nor were any children enrolled in school reading intervention programs.

Monocular visual acuity was obtained using the electronic Early Treatment Diabetic Retinopathy Study protocol.^12,13 Stereoacuity was assessed using the Randot Preschool Stereoacuity and Stereo Butterfly Tests (Stereo Optical Inc). Each child was seated in a quiet room and given a Scantron multiple-choice answer form F-19465-AS-L, a pencil, and a standard State of Texas Assessment of Academic Readiness 3rd grade reading achievement test booklet (publicly available 2013 version) with the 40 correct answers circled. The child’s task was to transfer those correct answers to the Scantron form as quickly and accurately as possible without reading the passages or questions and to say “stop” as soon as they had completed the task. The researcher timed the task with a stopwatch and stopped when the child indicated that they were finished. The time to complete the task was recorded. Scantron forms were categorized as having no errors (0) or having 1 or more error(s). Errors consisted of a wrong answer transferred, answers skipped, or answers shifted down.

Scantron completion time was compared among groups (children with amblyopia, children with nonamblyopic strabismus, and normal control children) using a 1-way analysis of covariance, controlling for last grade completed. Post hoc, separate variances independent t tests with Bonferroni-corrected α = .017 were conducted following a significant analysis of variance. Spearman correlations for children treated for strabismus, anisometropia, or both (with or without amblyopia) were conducted to determine whether completion time correlated with nonpreferred eye visual acuity or stereoacuity. A P value less than .05 was considered significant, and all P values were 2-tailed.

Results

Based on Kolmogorov-Smirnov tests, age, last grade completed, and Scantron time were normally distributed for all 3 groups. The Table shows group data on last grade completed, monocular visual acuity, and stereoacuity.

Table. Group Characteristics.

Characteristic	Mean (SD) [Range]
	Amblyopia (n = 47)	Nonamblyopic Strabismus (n = 18)	Normal Control (n = 20)
Last grade completed	3.3 (0.9) [2 to 5]	3.5 (1.0) [2 to 5]	3.7 (0.9) [2 to 5]
Nonpreferred eye BCVA, logMARa	0.4 (0.2) [0.2 to 1.5]	0.1 (0.1) [−0.1 to 0.2]	−0.1 (0) [−0.1 to 0.0]
Preferred eye visual acuity, logMAR	0.0 (0.1) [−0.1 to 0.1]	−0.1 (0.1) [−0.1 to 0.1]	−0.1 (0.1) [−0.1 to 0.1]
Stereoacuity, log arcsecondsb	3.2 (0.9) [1.6 to 4.0]	3.5 (0.9) [1.6 to 4.0]	1.5 (0.1) [1.3 to 1.8]
Race/ethnicity, No. (%)
Non-Hispanic white	32 (68)	13 (72)	13 (65)
Black/African American	3 (6)	2 (11)	2 (10)
Hispanic	6 (13)	1 (6)	2 (10)
Asian	6 (13)	0	2 (10)
Other/more than one	0	2 (11)	1 (5)

Abbreviation: BCVA, best-corrected visual acuity.

^aFor children with nonamblyopic strabismus, either the previously amblyopic eye or the right eye (if the child was never amblyopic) is listed for nonpreferred eye visual acuity. For normal control children, the right eye is listed for nonpreferred eye visual acuity.

^bNil stereoacuity was arbitrarily assigned a value of 4.0 log arcseconds.

There was a significant main effect of group for Scantron completion time (F_2,81 = 4.35; P = .02) but no main effect for last grade completed (F_2,81 = 0.76; P = .39). Compared with control children (mean [SD] time to completion, 230 [63] seconds), significantly increased Scantron completion time was found for children with amblyopia (mean [SD] time to completion, 297 [97] seconds; difference, 63 seconds; 95% CI, 24-102; P = .001) and children with nonamblyopic strabismus (mean [SD] time to completion, 293 [53] seconds; difference, 68 seconds; 95% CI, 21-115; P = .002). There was no difference between children with amblyopia and children with nonamblyopic strabismus (difference, 4 seconds; 95% CI, −34 to 42; P = .82). In other words, children with strabismus or anisometropia took an average of 5 minutes to transfer the 40 answers to the Scantron sheet, or 28% (95% CI, 20-37) longer, than normal control children, who required less than 4 minutes (Figure).

Figure. Mean Scantron Completion Time.

Error bars indicate the standard error of the mean.

No significant difference was found between children with anisometropia alone (n = 24) and children with a history of strabismus (with or without amblyopia or anisometropia; n = 41; t₆₃ = 1.07; P = .29). No significant association of Scantron completion time with nonpreferred eye visual acuity (n = 65; r = −0.12; P = .35) or stereoacuity (n = 65; r = −0.22; P = .08) was found. Scantron errors were infrequent in all groups (amblyopia, 3 of 47 [6%; 95% CI, 2-18]; nonamblyopic strabismus, 3 of 18 [17%; 95% CI, 5-40]; normal control, 1 of 20 [5%; 95% CI, 0-25]).

Discussion

We found slower Scantron completion time, on average, for children with a history of abnormal binocular experience during infancy or early childhood due to strabismus, anisometropia, or both, regardless of whether the child had amblyopia. No association was found between Scantron completion time and stereoacuity for children treated for strabismus, anisometropia, or both (with or without amblyopia). However, most children had severely subnormal or nil stereoacuity (35 of 65 had nil stereoacuity and 12 of 65 had a stereoacuity of 400 arcseconds or worse). Further research must be conducted to determine the underlying mechanisms associated with fine motor deficits. Findings from this research indicate that children with a history of abnormal binocular visual experience may perform more poorly academically because of their fine motor impairment, specifically in using a pencil to mark answers on a Scantron multiple choice answer form. Currently, academic accommodations (eg, extended test time) are unavailable for these children because they have good vision when viewing with 2 eyes.¹⁴ Our findings could be of value to parents and educators in showing how impaired fine motor skills may affect the academic performance of children with strabismus and amblyopia and may aid in developing new guidelines in academic accommodations for these children.

Limitations

This study had limitations. We did not test children to determine whether they had dyslexia. Instead, we relied on parental report for this exclusion criterion. The group of children with nonamblyopic strabismus included those with resolved amblyopia and those who have never developed amblyopia, and those 2 groups could differ in their ability to complete the Scantron task. The age of our children ranged from 8 to 12 years, and we did not assess the effect that age has on completing a Scantron form.

Conclusions

Multiple-choice answer forms are commonplace in standardized testing in US schools. Longer completion time in children with amblyopia or strabismus may affect a child’s performance on tests using these forms and could limit academic success.