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Bullying and eye patching
The psychological impact that patching treatment for amblyopia might have on children and their families was highlighted in an influential review of amblyopia screening.1 A recent randomised trial investigating the efficacy of patching for amblyopia has reported that 4 year old and 5 year old children were significantly more upset by receiving patching and glasses than by receiving glasses only, as were the parents of the 4 year olds undergoing treatment, suggesting that patching treatment can be associated with some short term distress for the child and the family.2 However, most children in the study were reported as being happy and had normal behavioural scores. We have recently reported results from a birth cohort study suggesting that longer term psychosocial sequelae may be associated with patching treatment (the Avon Longitudinal Study of Parents and Children, ALSPAC3). A history of patching treatment and wearing glasses were both independent risk factors for children reporting that they had been bullied in the past at age 8.4 Repeated bullying victimisation is consistently associated with physical and emotional problems for the victims and may have long term adverse consequences.5,6
One argument for preschool screening is that patching treatment is more likely to have concluded before school starts, thus avoiding adverse reactions from peers. We aimed to test this hypothesis by comparing, prospectively, two groups of children: one that had been offered state provided preschool screening for amblyopia (aged 3 years and 1 month) and the other that had not. Both groups had been given a check by the school nurse in the first year of school (aged between 4–5), which if unsatisfactory resulted in a recommendation to see either an optometrist and/or a community orthoptist, after which patching was commenced if needed. The outcome measure was bullying victimisation by age 8 assessed with a structured standard interview.6 Children were asked whether they had repeatedly (at least four times a month) been the victims of bullying.4 We calculated the risk (odds ratio, 95% confidence interval) of reporting having been bullied for children who had been treated with patching in each group. For comparison, we calculated the same risk for children who had been given glasses at any time. We hypothesised that as the wearing of glasses usually continues once started, then preschool screening would be unlikely to reduce any risk of bullying associated with wearing glasses.
Usable data on having been bullied were available for 4473 children whose screening history was known and these are shown in table 1. There was an almost 50% reduction in children who reported having been bullied in the group that had been offered preschool screening, compared with the group who had not. By contrast, there was no difference in rates of perceived bullying for children who wore glasses, irrespective of previous screening. These results support the hypothesis that preschool vision screening may be associated with less bullying for children who need to have patching treatment. The specificity of the findings (that is, there was no such effect for children who wore glasses) argues against the results being the result of confounding factors that have not been accounted for, although as the data are observational, this possibility cannot be excluded.
Visual outcomes at 7 years of age were not improved with this model of preschool screening7 and school entry screening is currently recommended in the Hall Report.8 The data from the recent studies in America indicate that 2 hours of patching can be as effective as 6 hours for moderately severe amblyopia9 or, alternatively that atropine is also effective and is associated with fewer adverse psychological problems.10 However, further work is needed to explore whether advising patching treatment out of school hours (in children attending school), or using atropine instead of patching, are effective in reducing bullying. It is possible that parents and children would consider that more than halving the risk of being bullied was a good reason for a child to attend a preschool vision screening appointment, rather than waiting for detection and treatment at school, even if the visual outcome was not changed by the earlier screening.
While the causes of bullying are complex and multifactorial, these data suggest that the timing of intervention can lessen the likelihood of a child who is treated with patching being bullied. This is likely to improve the experience for both the child and their family. Bullying and other psychosocial factors should continue to form part of the outcome assessment for experimental amblyopia screening and treatment programmes and also for clinical audits of patient compliance and satisfaction.
We are extremely grateful to all the mothers who took part, to the midwives for their cooperation and help in recruitment, and to the orthoptists who did all the testing. The whole ALSPAC study team comprises interviewers, computer technicians, laboratory technicians, clerical workers, research scientists, volunteers and managers who continue to make the study possible. This study could not have been undertaken without the financial support of the Medical Research Council, the Wellcome Trust, the UK Department of Health, the Department of the Environment, and DfEE, the National Institutes of Health, a variety of medical research charities, and commercial companies. The ALSPAC study is part of the WHO initiated European Longitudinal Study of Pregnancy and Childhood.
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Bullying and eye patching
Sponsors: Support for vision data was specifically provided by the Medical Research Council, the South West Regional Health Authority, and the National Eye Research Centre.
Competing interests: None declared.
Ethical approval: The ALSPAC Study has ethical approval from the three local ethics committees and the ALSPAC Law and Ethics Committee.
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