Age of the Emergence of Negative Attitudes

Journal of AAPOS December 2001 361 dolescents and adults with ocular misalignment believe that strabismus negatively affects their self-image, self-confidence, self-esteem, and interpersonal relationships with others. 1 Many people view strabismic adults as less intelligent, less sincere, and poorly communicative. 2 Strabismus may also negatively affect employers when making hiring decisions. 3 The age at which prejudice toward strabismus emerges in the general population is unknown. Better understand- ing about when and why children first recognize strabis- mus may help guide the appropriate timing of medical and surgical intervention and may help parents better cope with strabismus in their young child. The purpose of this study was to determine the age at which a negative attitude toward strabismus first emerges through an experimental study that used dolls whose eyes had been altered to create esotropia or exotropia. SUBJECTS AND METHODS A prospective observational study was conducted. This study was performed in accordance with the ethical stan- dards of the institutional review board at Baylor College of Medicine and T exas Children’ s Hospital, Houston, and with the Declaration of Helsinki. Appropriate informed consent was obtained from the parents of all study subjects before participation. The eyes of 3 identical dolls (Dragon Ball Z, Irwin T oys, T oronto, Ontario, Canada) were altered to create esotropia in one doll and exotropia in another , leaving the third doll orthotropic (Figure 1). Moderate esotropia or exotropia was created in the strabismic dolls. This doll was chosen for this study because (1) the eyes of this doll were prominent and able to be easily altered to create strabis- mus, and (2) a pilot study at our institution where children were exposed to various doll types demonstrated that both boys and girls would equally interact with this doll. Most other dolls tested demonstrated a gender-specific prefer- ence in that males or females were found to be unwilling to play with dolls stereotyped for the opposite sex. The 3 dolls were placed in a room in which they were the only toys with which to play . They were placed on an Age of the Emergence of Negative Attitudes T oward Strabismus Evelyn A. Paysse, MD, a,b Eric A. Steele, MD, a Kathr yn M. Brady McCr eer y , MD, a Kirk R. W ilhelmus, MD, a and David K. Coats, MD a,b Introduction: Strabismus impacts a variety of psychosocial variables in both children and adults. Poor self- esteem, lack of confidence, altered interpersonal relationships, and difficulty with employment procurement have been reported. The purpose of this study was to determine the age at which children perceive strabismus in dolls and to evaluate their reactions. Methods: Three identical dolls were altered so that one was orthotropic, one esotropic, and one exotropic. Thirty-four naïve children between 3 and 7 years of age were individually placed in a waiting room with the 3 dolls as the only toys with which to play . A one-way mirror allowed a hidden observer to tabulate the number of positive and negative behaviors exhibited toward each doll. After a 10-minute observation period, the children were asked a short series of questions about their preferences and attitudes toward the dolls. Odds ratios were then determined for both the observed behaviors and the expressed responses to the strabismic dolls compared with the orthotropic dolls. Results: Children aged 5 3 ⁄ 4 years and older were 73 times more likely than younger children to express a negative feeling about the strabismic dolls when asked ( P = .003). Additionally , when comparing the strabismic dolls with the orthotropic doll, children aged 3 to 4 1 ⁄ 4 years did not notice a differ- ence, children aged 4 1 ⁄ 2 to 5 1 ⁄ 4 years tended to describe the eyes as “different,” and children aged 5 3 ⁄ 4 years or older almost uniformly gave a negative description of the strabismic dolls. Conclusions: A negative attitude toward stra- bismus appears to emerge at approximately 6 years of age. The biopsychosocial determinants of dislike and hostil- ity toward ocular deviations are apparently acquired, learned responses. (J AAPOS 2001;5:361-6) From the Cullen Eye Institute, Baylor College of Medicine, Departments of Ophthalmology a and Pediatrics, b T exas Children’ s Hospital, Houston, T exas. Presented at the 27th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus, Orlando, Florida, March 21-25, 2001. Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc, New Y ork, New Y ork. Submitted April 2, 2001. Revisions accepted August 1, 2001. Reprint requests: Evelyn A. Paysse, MD, Baylor College of Medicine, T exas Children’ s Hospital, 1102 Bates, No. 300, MC3-2700, Houston, T exas 77030 (e-mail: epaysse@bcm.tmc.edu). Copyright © 2001 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2001/$35.00 + 0 75/1/119243 doi:10.1067/mpa.2001.119243 A appropriate child-sized table with a chair in random order for each child. The study consisted of two parts: (1) observed play and (2) expressed response. All children included in the study were children attending our pediatric ophthalmology clinic or their siblings. For the first limb of the study , 34 naïve children between the ages of 3 and 7 years were individually placed in the study room with their parent(s). Sixteen (47%) of the children had a diagnosis of strabismus. One investigator , hidden behind a one-way mirror , observed each child for a 10-minute period while the child played with the dolls. Parents were advised not to comment on the dolls or on their child’ s reaction to the dolls until after their child had completed the study . The hidden observer made a notation for each positive or neg- ative behavior displayed toward each doll. Positive and negative behaviors were defined before the study . Positive 362 Paysse et al Journal of AAPOS V olume 5 Number 6 December 2001 FIG 1. Dolls with (A) esotropia, (B) exotropia, and (C) orthotropia. A B C FIG 2. Questions asked of each child after play . behaviors included cradling, caressing, kissing, or verbally complimenting the doll. Negative behaviors included throwing, striking, or verbally disparaging a doll. Following the 10-minute observation period, the child was removed from the study room and asked to answer a brief questionnaire (Figure 2). Data from the behaviors observed and answers to the questionnaire were then tabulated and analyzed. T o facili- tate statistical analysis of the behaviors observed during play , a numeric overall negative response (ONR) for each doll for each subject was needed. The ONR was defined in the fol- lowing manner before beginning the study . The number of positive and negative behaviors exhibited toward a doll was tabulated for a child. The number of positive behaviors was then subtracted from the number of negative behaviors to arrive at the corrected negative score (CNS) for each doll. The CNSs for each doll for a child were then compared. For a doll to receive an ONR from the child, the doll had to have a CNS of at least 3, and the CNS had to be at least 70% of the highest CNS of the 3 dolls for that child. The absolute CNS of 3 was chosen because we believed it demonstrated some consistent negative behavior toward that specific doll and not just random accidental acts or clumsiness in the child. Seventy percent of the highest CNS was chosen because we believed that this value demonstrated that the specific CNS being analyzed is close enough in value to the highest CNS and so most likely represented true negative behavior toward that specific doll and not mere chance. For example, if a child kissed each doll twice (positive behaviors) and hit the orthotropic doll 3 times, the eso- tropic doll 27 times, and the exotropic doll 14 times (neg- ative behaviors), the CNS for the dolls would be 1, 25, and 12 for the orthotropic, esotropic, and exotropic dolls, re- spectively . The esotropic doll would then qualify as having received an ONR. The exotropic doll, on the other hand, would not qualify for an ONR because even though it had a CNS of more than 3, its CNS of 12 was not 70% of the highest CNS score (25 for the esotropic doll). Therefore, in this example, only the esotropic doll would be consid- ered to have received an ONR. If the child had had a CNS for the exotropic doll of 18 or more, then both the esotropic and exotropic dolls would have been considered to receive an ONR from the child because these totals are at least 70% of the highest CNS score. Odds ratios and 95% confidence limits (CL) were then determined for both the observed behaviors during play and the expressed responses to the questions by using the statistical program, Stata 6.0 (College Station, T exas). RESUL TS Thirty-four naïve children ranging in age from 36 (3 years) to 92 months (7 8 ⁄ 12 years) participated in the study . The mean age of the children was 60 months (5 years), and 15 (44%) were female. Sixteen (47%) children had a diagno- sis of strabismus. Nineteen (56%) children were white, 4 (12%) were Hispanic, and 11 (32%) were African American. T able 1 tabulates the patient demographics, strabismus status, CNSs, and ONRs for each doll for each subject. T able 2 summarizes the odds ratios, based on age, gender , and presence of strabismus, of the behaviors observed dur- ing play , and the expressed responses to questions regard- ing preferences between the strabismic and orthotropic dolls. Gender and the presence or absence of strabismus in the participant did not affect the child’ s behavior toward or preferences for the dolls in either limb of the study . During play , children 5 3 ⁄ 4 years or older were 4.4 (95% CL, 0.70, 28.08) times more likely to display an ONR to the strabismic dolls compared with children younger than 5 3 ⁄ 4 years ( P = .12). Because of the small number of subjects, separate analysis for orthotropic, esotropic, and exotropic dolls was not possible. However , an abrupt change in the amount of negative behaviors displayed toward the dolls divided by strabismus status was noted at age 5 3 ⁄ 4 years (Figure 3). When asked about their personal preferences in the questionnaire, children 5 3 ⁄ 4 years and older were 73 (95% CL, 4.33, 1291.2) times more likely to report a dislike of the strabismic dolls compared with children younger than 5 3 ⁄ 4 years ( P = .003). In response to the question “What do you think of the action figures’ eyes?,” a gradual change in response was noted as the age of the child increased (Figure 4). Children younger than 4 1 ⁄ 2 years did not notice Paysse et al 363 Journal of AAPOS V olume 5 Number 6 December 2001 FIG 3. Combined percentages of negative behaviors displayed toward each doll. Note that children younger than 5 3 ⁄ 4 years displayed rough- ly equal amounts of negative behaviors toward each doll and children 5 3 ⁄ 4 years and older displayed negative behaviors exclusively toward the strabismic dolls. Ortho, Orthotropia; ET , esotropia; XT , exotropia. FIG 4. Response to the question: “What do you think of the action fig- ures’ eyes?” a difference between the dolls. Children aged 4 1 ⁄ 2 to 5 1 ⁄ 4 years tended to describe the eyes as “different” but still did not express an opinion for one over the other . Children aged 5 3 ⁄ 4 years or older almost uniformly gave a negative description of the strabismic dolls during the questionnaire. DISCUSSION Physical appearance, including facial features, has been shown to play an important role in social interactions. 4 Once a person is perceived as having a physical abnormal- ity , it is almost impossible for him/her to escape the social 364 Paysse et al Journal of AAPOS V olume 5 Number 6 December 2001 T ABLE 1. Demographics, strabismus status, corrected negative scores, and overall negative responses for each subject CNS ONR Subject No. Age (mo) Sex Strab (Y/N) Ortho doll ET doll XT doll Ortho doll ET doll XT doll 13 6 F Y 0 0 0 N N N 23 6 M N 0 0 0 N N N 33 8 M Y 1 0 8 7 Y Y Y 43 8 F N 0 0 0 N N N 54 0 F Y – 5 – 4 – 4 N N N 64 1 M N 1 1 1 N N N 74 2 F N 6 5 5 Y Y Y 84 4 M Y 1 1 4 1 2 Y N Y 94 8 M Y 4 1 6 6 N Y N 10 49 F N 19 16 19 Y Y Y 11 51 M N 0 0 0 N N N 12 54 M N 5 4 4 Y Y Y 13 54 F Y –3 –1 –1 N N N 14 54 M Y 8 14 22 N N Y 15 58 M Y 11 13 15 Y Y Y 16 59 M Y 5 10 5 N Y N 17 61 M N 0 0 1 N N N 18 62 M N 0 0 0 N N N 19 62 F N 0 0 16 N N Y 20 63 F N 0 0 0 N N N 21 63 M Y 29 42 21 N Y N 22 65 M N 10 12 3 Y Y N 23 69 F N 0 0 0 N N N 24 71 M N 0 0 0 N N N 25 72 F N 0 13 14 N Y Y 26 74 F Y –1 21 22 N Y Y 27 75 M Y 2 2 2 N N N 28 75 F N 1 18 1 N Y N 29 78 M N 2 13 9 N Y N 30 80 F Y 0 0 0 N N N 31 80 M Y 0 7 7 N Y Y 32 83 M N 1 17 24 N Y Y 33 91 F Y 0 8 31 N N Y 34 92 F Y 2 7 6 N Y Y Strab, Strabismus; N, no; Y, yes; CNS, corrected negative score; ET , esotropia; ONR, overall negative resonse; XT , exotropia. T ABLE 2. Factors associated with a child’ s observed or expressed negative reaction to either an esotropic or exotropic doll compared with the orthotropic doll, using multivariable logistic regression models Observed negative reaction to strabismic doll Expressed negative response to strabismic doll Patient characteristic OR (95% CL) P value OR (95% CL) P value Age 5 3 ⁄ 4 years or older 4.42 (0.70, 28.08) .12 72.99 (4.13, 1291.2) .003 Sex 2.04 (0.44, 9.39) .36 1.45 (0.21, 10.08) .71 Strabismus 1.86 (0.43, 8.17) .41 0.22 (0.02, 2.15) .19 stigma, even if the physical abnormality is ultimately repaired. Strabismus is an easily recognizable facial abnormality that has many adverse consequences for the affected patient. 1-3,5-7 Satterfield et al 1 found that 63% of strabismic late adolescents and adults surveyed believed that their strabismus resulted in adverse consequences. In general, patients believed that the condition resulted in adverse consequences throughout life, including child- hood. Furthermore, their study patients felt that these psychosocial difficulties intensified in the teenage and adult years. Coats et al 3 demonstrated the probability that a woman with strabismus would have difficulty in obtaining employ- ment compared with a woman with straight eyes. Olitsky et al, 2 using similar methodology , demonstrated significant psychosocial prejudice against adults with strabismus. Adult strabismus patients also heralded major improve- ments in the quality of their own psychosocial functioning and self-esteem following strabismus surgery . 6,7 Use of the terms “socially significant strabismus” and “vocationally significant strabismus” has been advocated to emphasize these important aspects of strabismus. 3 Indeed, such strong evidence now exists substantiating the potentially harmful psychosocial and vocational effects of strabismus on aspects of patients’ lives that improvement of psy- chosocial functioning is now an accepted indication for strabismus surgery , in addition to improvement of binocu- lar fusion, elimination of diplopia, and improvement of the binocular visual field. 8 Studies examining other physical characteristics, such as obesity and skin color , have shown that awareness and pref- erences for these physical traits appear at an early age. This awareness starts as early as 3 years of age and is uniformly present by age 6. 9-11 A wareness of these physical findings strongly concurs with our findings in this study regarding strabismus. Before this study , the age at which people begin to develop negative attitudes toward strabismus was unknown. Some useful anecdotal and observational data, however , were available. Infantile esotropia was shown to negatively affect the parent-child relationship at a critical time in child development. 12 Mruthyunjaya et al 13 recently reported that parents of children with strabismus believed that after strabismus surgery , 61% of the children younger than 4 years had improved eye contact and 55% of the chil- dren between 4 and 6 years of age enjoyed better self- esteem and confidence. These findings seem to imply that a negative feeling about strabismus may be emerging at an early age, at least among children with strabismus. V ery little has been published regarding the attitudes of children with normal ocular alignment toward people with strabismus. In an observational study of 10 children between the ages of 5 and 15 years with uncorrected esotropia, Lion et al 14 reported that no interpersonal problems with other children occurred until age 6. At age 6, however , children with normal ocular alignment began to use disparaging name-calling and display other negative behaviors toward Paysse et al 365 Journal of AAPOS V olume 5 Number 6 December 2001 the strabismic children. Our results are similar to these find- ings and are consistently demonstrated in both limbs of the study: (1) observed play and (2) expressed responses to ques- tions about preferences. Whether the strong dislike of stra- bismic dolls is transferable to negative feelings about strabis- mic people has not been proven, but combined with the find- ings of Lion et al, the evidence is compelling. Our results should be considered preliminary for the following reasons. First, the participants in the study were patients attending an ophthalmology clinic or their sib- lings. Some of the participants had strabismus, and those who did not may have been more aware of this condition and subsequently viewed it differently than children who had never been to an ophthalmologist. W e could not, how- ever , find any effect of a subject’ s ocular alignment on the observed or expressed reactions. Next, the study design involved translating subjective behaviors into objective notations for the purposes of analysis. Although it may seem appropriate to count throwing a doll against a wall as a negative behavior , it was impossible to know the child’ s actual motivations and thoughts about the doll at that moment. Finally , a child’ s behaviors and attitudes toward strabismic dolls may not directly translate into his/her atti- tudes toward strabismic people. Despite these limitations, the findings of the study are strengthened by the fact that positive and negative behaviors and the analytic definitions of CNS and ONR were strictly defined before initiating the study . Further investigation that duplicates this study protocol by using a larger sample size of children not attending an ophthalmology clinic is warranted. The results of this study are very provocative. For the first limb of the study (observed behavior during play), children aged 5 3 ⁄ 4 years and older were about 4.4 times more likely than the younger children to display negative reactions to the strabismic dolls. The same dichotomy was seen during the second limb of the study (the participants’ verbal responses to the questionnaire). The responses to the open-ended question “What do you think of the action figures’ eyes?” showed a similar change in attitude at the same age of 5 3 ⁄ 4 years (Figure 3). Children 5 3 ⁄ 4 years or older were 73 times more likely to report a dislike of the strabismic dolls compared with children younger than 5 3 ⁄ 4 years ( P = .003). Also intriguing is the attitude pro- gression to this question, which was shown by the youngest children not noticing the strabismus in the dolls at all, children between 4 1 ⁄ 2 and 5 3 ⁄ 4 years noticing a differ- ence but not having a preference, and children 5 3 ⁄ 4 and older having a definite bias against the strabismic dolls. These findings have important implications regarding optimal timing of strabismus surgery in children. Surgery should be performed at the age that will produce the best functional benefit with regard to binocular vision. How- ever , in patients with sensory strabismus in whom there is no possibility for restoration of binocularity and the likeli- hood of recurrence of ocular misalignment is high, it may be more appropriate to defer surgical intervention until just before 4 1 ⁄ 2 years when awareness of “difference” and certainly negative attitudes toward strabismus may not yet be present. In summary , we demonstrated in an experimental study that a negative attitude toward strabismus appears to emerge at approximately 5 3 ⁄ 4 years of age, and awareness of a difference between the eyes of strabismic and normally aligned dolls begins at approximately 4 1 ⁄ 2 years of age. The biopsychosocial determinants of dislike and hostility toward ocular deviations are apparently acquired, learned responses. These findings suggest that corrective surgery for all strabismus should optimally be performed at an early age to avoid the psychosocial stigma associated with this condition. References 1. Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of stra- bismus study . Arch Ophthalmol 1993;111:1100-5. 2. Olitsky SE, Sudesh S, Graziano A, Hamblen J, Brooks SE, Shaha SH. The negative psychosocial impact of strabismus in adults. J AAPOS 1999;3:209-11. 3. Coats DK, Paysse EA, T owler AJ, Dipboye RL. Impact of large angle horizontal strabismus on ability to obtain employment. Ophthalmo- logy 2000;107:402-5. 4. T idwell MC, Reis HT , Shaver PR. Attachment, attractiveness, and social interaction: a diary study . J Pers Soc Psychol 1996;71:729-45. 5. Reinecke RD, Sterling R, Wizov S. Accuracy of judgments of the presence or absence of eccentric (non-primary) gaze and the pres- ence or absence of strabismus. Binocular Vis Q 1991;6:189-96. 6. Burke JP , Leach CM, Davis H. Psychosocial implications of strabismus surgery in adults. J Pediatr Ophthalmol Strabismus 1997;34:159-64. 7. Hengstler LK. The eye of the beholder . J Pediatr Ophthalmol Strabismus 1991;28:301-2. 8. Keltner JL. Strabismus surgery in adults: functional and psychosocial implications. Arch Ophthalmol 1994;112:599-600. 9. Gunthrope WW . Skin color recognition, preference, and identifica- tion in interracial children; a comparative study . Lanham (MD): USA University Press of America, Inc; 1998. p. 39-58. 10. Kenney KE. A wareness of and preference for physical characteristics among Caucasian kindergarten children. Dissertation Abstracts Int 1998;59(4-A):1073. 11. Cramer P , Steinwert T . Thin is good, fat is bad: how early does it begin? J Appl Dev Psychol 1998;19:429-51. 12 . Lipton EL. Remarks on the psychological aspect of strabismus. Sight-Saving Rev 1971;41:129-38. 13. Mruthyunjaya P , Simon JW , Pickering E, Lininger LL. Subjective and objective outcomes of strabismus surgery in children. J Pediatr Ophthalmol Strabismus 1996;33:167-70. 14. Lion EG, O’Neill C, Prager RE. Strabismus and children’ s person- ality reactions. Am J Orthopsychiatry 1943;13:121-4. 366 Paysse et al Journal of AAPOS V olume 5 Number 6 December 2001 An Eye on the Arts – The Arts on the Eye I am twelve. When relatives come to visit I hide in my room. My cousin, Brenda, just my age, whose father works in the post office and whose mother is a nurse, comes to find me. “Hello,” she says. And then she asks, looking at my recent school picture, which I did not want taken, and on which the “glob,” as I think of it, is clearly visible, “Y ou still can’ t see out of that eye?” “No,” I say , and flop back on the bed over my book. That night, as I do almost every night, I abuse my eye. I rant and rave at it, in front of the mirror . I plead with it to clear up before morning. I tell it I hate and despise it. I do not pray for sight. I pray for beauty . —Alice W alker (from Beauty: When the other dancer is the self )

Age of the Emergence of Negative Attitudes

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