Self-perception in Preschool Children With Deprivation Amblyopia and Its Association With Deficits in Vision and Fine Motor Skills

Key Points

Question

Is visual deprivation amblyopia associated with lower self-perception in children ages 3 to 6 years?

Findings

In a cross-sectional study, children with visual deprivation amblyopia (n = 15) had lower peer acceptance and physical competence scores for the Pictorial Scale of Perceived Competence and Acceptance for Young Children compared with control children (n = 20); self-perception of cognitive competence and maternal acceptance did not differ between groups. Using a standardized motor skills test, self-perception of peer acceptance and physical competence were moderately associated with motor skills scores.

Meaning

Lower self-perception of peer acceptance and physical competence was associated with early monocular visual deprivation.

Abstract

Importance

Although the development of self-perception and self-esteem has been investigated in children with strabismic and anisometropic amblyopia, we know little about how self-perception is affected in deprivation amblyopia. Deprivation amblyopia from a dense, unilateral cataract is the least common and typically most severe form of amblyopia. After cataract extraction, optical correction, and patching treatment for amblyopia, visual acuity almost always remains abnormal, and except in rare cases, stereoacuity is nearly always nil.

Objective

To determine whether deprivation amblyopia is associated with altered self-perception in preschool children and to determine whether any differences in self-perception are associated with vision or motor skill deficits.

Design, Setting, and Participants

Cross-sectional study conducted from 2016 to 2019 at a pediatric vision research laboratory. Children aged 3 to 6 years were enrolled, including 15 children with deprivation amblyopia and 20 control children.

Main Outcomes and Measures

Self-perception was assessed using the Pictorial Scale of Competence and Acceptance for Young Children, which includes 4 specific domains: cognitive competence, peer acceptance, physical competence, and maternal acceptance. Fine motor skills were evaluated with the Manual Dexterity and Aiming & Catching Scales of the Movement ABC-2 test. Visual acuity and stereoacuity also were assessed.

Results

Of the 35 children included, 13 of 35 were girls (37%) and 28 of 35 were non-Hispanic White (80%). Children with deprivation amblyopia had significantly lower peer acceptance and physical competence scores compared with control children (mean [SD], 2.80 [0.44] vs 3.25 [0.33]; mean difference, 0.45; 95% CI for difference, 0.19-0.71; P = .002 and 2.94 [0.45] vs 3.41 [0.37]; mean difference, 0.47; 95% CI for difference, 0.19-0.75; P = .002, respectively). Among children with amblyopia, moderate associations were found between self-perception domain scores and motor skills, including peer acceptance and manual dexterity (r = 0.68; 95% CI, 0.26-0.89; P = .005), peer acceptance and aiming (r = 0.54; 95% CI, 0.03-0.82; P = .03), and physical competence and aiming (r = 0.55; 95% CI, 0.06-0.83; P = .03).

Conclusions and Relevance

Lower self-perception of peer acceptance and physical competence were associated with early visual deprivation in children in their everyday life.

This study evaluates whether deprivation amblyopia is associated with altered self-perception in preschool children and to determine whether any differences in self-perception are associated with vision or motor skill deficits.

Introduction

Children’s self-perception begins developing during the preschool years.¹ While preschool children are unable to assess their overall global self-worth, they can make judgments about early building blocks of self-concept including competence (cognitive capability and physical skills) and social acceptance by peers and family.¹ Strabismic and anisometropic amblyopia are associated with lower self-perception of physical competence and peer acceptance in children ages 3 to 7 years compared with age-similar control children.² Self-perception of physical competence was associated with aiming and catching skills and with stereoacuity.² The differences in self-perception scores compared with control children were similar in magnitude to that found for age-similar children with other pediatric conditions, including developmental coordination disorder³ and chronic health conditions.^4,5

Deprivation amblyopia from a dense, unilateral cataract is the least common and typically most severe form of amblyopia.⁶ However, we know little about how self-perception is affected in deprivation amblyopia. This is a group of children who, as with children with strabismic and anisometropic amblyopia, have normal vision in 1 eye. After cataract extraction, optical correction, and patching treatment for amblyopia, visual acuity almost always remains abnormal and, except in rare cases, stereoacuity is nil.⁶ Impaired motor skills are also present.⁷ The aims of this study were to determine whether deprivation amblyopia is associated with altered self-perception in preschool children and whether altered self-perception is associated with visual acuity and motor skills deficits.

Participants

Fifteen preschool children, ages 3 to 6 years, with deprivation amblyopia following extraction of a dense congenital or infantile unilateral cataract, and a convenience sample of 20 age-similar control children (no eye conditions, normal visual acuity, and stereoacuity) were enrolled at 1 site. None of the children were born at younger than 32 weeks’ gestational age, had coexisting systemic/syndromic conditions, or a history of congenital infection or malformation. Written informed consent was obtained from a parent. Participants received a $25 gift card. All procedures and the protocol were approved by the University of Texas Southwestern Medical Center institutional review board, followed the tenets of the Declaration of Helsinki, and complied with the requirements of the US Health Insurance Portability and Accountability Act of 1996.

Vision

Each participant had a comprehensive eye examination performed by a pediatric ophthalmologist who diagnosed deprivation amblyopia. Monocular best-corrected visual acuity (BCVA) was obtained for each eye using an opaque occluder patch and the Amblyopia Treatment Study HOTV protocol.⁸ Stereoacuity was evaluated using the Randot Preschool Stereoacuity Test and the Stereo Butterfly (Stereo Optical Company Inc).

Self-perception

Self-perception was assessed with the Preschool-Kindergarten Pictorial Scale of Perceived Competence and Social Acceptance for Young Children.¹ Details of test design and administration were described in our earlier study of children with strabismic and anisometropic amblyopia.¹ Briefly, there are 2 versions, one for girls and one for boys. There are 6 pairs of pictures for each of the 4 domains. For each pair, the tester read a standardized description of the 2 pictures (eg, “This boy is pretty good at climbing. This boy isn’t very good at climbing”). The tester then asked the child “Which picture is most like you?” Once the child made this initial choice, the tester asked “Are you a lot like the child in the picture or just a little like the child in the picture?” Responses to these 2 questions provide a 4-point response scale, with higher scores indicating higher perceived competence or acceptance. Mean scores, ranging from 1 to 4, were calculated for each domain: cognitive competence, physical competence, peer acceptance, and maternal acceptance.

Motor Skills

Children with deprivation amblyopia were tested with the Manual Dexterity and Aiming & Catching subscales of the Movement Assessment Battery for Children, second edition (Pearson Clinical Assessment).⁹ Manual dexterity tasks included putting coins in a slot, threading beads onto a string, and staying inside the lines of a drawing trail. Aiming and catching tasks included catching a beanbag and aiming to throw a beanbag onto a target. Raw scores per task were combined, and tables in the test manual were used to convert raw scores to standard scores, with higher scores indicating better performance. Motor skills data from some of these children was included in a prior report.⁷

Statistical Analysis

Independent 2-tailed t tests were used to compare self-perception domain scores of children with deprivation amblyopia and control children (Bonferroni correction, P ≤ .01). For the group with deprivation amblyopia, Pearson r was used to evaluate associations of BCVA, manual dexterity, and aiming and catching with self-perception.

Results

Among children with deprivation amblyopia (n = 15), 5 were female and 13 were non-Hispanic White; mean (SD) age was 4.6 (1.0) years (range, 3.1-6.1 years). Amblyopic eye BCVA ranged from 0.4 to 2.0 logMAR (20/50 to 2000) and fellow eye from −0.1 to 0.2 logMAR (20/15 to 30). All had nil stereoacuity. Among children in the control group (n = 20), 8 were female and 15 were non-Hispanic White; mean (SD) age was 5.0 (1.0) years (range, 3.0-6.4 years). Visual acuity in each eye ranged from −0.1 to 0.2 logMAR (20/15 to 30) and stereoacuity from 100 to 40 arcseconds.

Mean self-perception domain scores for children with deprivation amblyopia and control children are summarized in the Figure. Self-perception of peer acceptance and physical competence were significantly lower among children with deprivation amblyopia compared with control children (t₃₃ = 3.46; P = .002 and t₃₃ = 3.39; P = .002, respectively), but a difference in self-perception of cognitive competence or maternal acceptance between groups was not identified. Correlations between self-perception domain scores and amblyopic eye BCVA failed to reveal any association. Moderate correlations were found between self-perception domain scores and motor skills, including peer acceptance and manual dexterity (r = 0.68; 95% CI, 0.26-0.89; P = .005), peer acceptance and aiming (r = 0.54; 95% CI, 0.03-0.82; P = .03), and physical competence and aiming (r = 0.55; 95% CI, 0.06-0.83; P = .03).

Figure. Mean (SE) Domain Scores From the Pictorial Scale of Perceived Competence and Social Acceptance for Young Children for Children With Deprivation Amblyopia (n = 15) and Control Children (n = 20).

Discussion

Deprivation amblyopia was associated with lower self-perception of peer acceptance and physical competence in preschool children aged 3 to 6 years compared with age-similar control children. Lower scores in both domains may lessen a child’s social interactions and participation in physical activities. Lower self-perception was moderately associated with manual dexterity and aiming, as assessed in a standardized test of motor skills. The same 2 domain scores were reduced relative to control children in children aged 3 to 7 years with strabismic and anisometropic amblyopia, and physical competence was associated with stereoacuity.² A previous study¹⁰ of self-perception in 7 older children (mean [SD] age 9.1 [0.9] years) with deprivation amblyopia reported reduced scores for the social acceptance domain. We were unable to assess associations of self-perception with stereoacuity because all children with deprivation amblyopia in our study had nil stereoacuity.

Limitations and Strengths

A limitation of our study was that the sample studied was relatively small, and the study was conducted at a single nonprofit eye research institute, which may limit the generalizability of our results. However, our amblyopia research programs receive referrals from 19 Dallas–Fort Worth, Texas, area ophthalmologists who serve a wide spectrum of families. Strengths of our study were that we evaluated the self-perception of children themselves, not via proxy responses obtained from a parent, and motor skills were evaluated with the standardized testing, not by indirect report.

Self-perception has been identified as an important contributor to quality of life.^11,12 Child interviews conducted as part of the development of the PedEyeQ, designed to assess visual function and quality of life in children with eye conditions, identified visual abilities and social interactions as the 2 concerns most often cited by children.¹³ Proxy reports for young children (age 2-7 years) with a history of surgery for secondary cataract,¹⁴ and self-report of older children (aged 8 years and older) with a history of surgery for primary unilateral cataract¹⁵ both reported reduced quality-of-life scores relative to control children.

Conclusions

It is evident that even at the very young age of 3 to 6 years, there is a marked association of visual deprivation amblyopia not only with vision but also with self-perception and quality of life.