Strabismus Linked to Increased Risk of Mental Health Considerations in Children

Visual problems of any kind can be especially distressing for kids, including eye misalignment, affecting around 2% to 7% of kids globally. Due to its commonality, strabismus has been looked at by researchers in terms of impact on children’s mental health. In a recent meta-analysis published in Clinical Ophthalmology, investigators considered nine observational studies to elucidate if any relationship exists between strabismus and attention deficit hyperactivity disorder (ADHD), anxiety or depression.  Correcting strabismus using surgical or orthoptic methods is one of the nine considerations the authors believe may reduce psychosocial challenges and improve quality of life. Photo: AmblyoPlay. Click image to enlarge. The investigation included a total of 683,942 participants, and studies were published between 2008 and 2024. Analysis did reveal a significant positive association of strabismus and mental health disorders, averaging an odds ratio (OR) of 1.92, suggesting kids with strabismus are about twice as likely as those without to experience some mental health consequences. When stratified by time period, earlier reports had larger effect sizes, while more recent studies displayed modest, yet significant associations. Most strongly correlated with mental health disorders was exotropia, with ORs ranging from 1.44 to 2.70; this was followed by esotropia second and unspecified strabismus third.In their paper, the researchers expounded upon the reason this relationship exists. For one, visible ocular misalignment may be coupled with stigmatization, bullying and reduced self-esteem, contributing to anxiety and depression. ADHD, however, may be linked with strabismus via shared neural pathways of the visual and cognitive systems, predisposing kids with strabismus to neurobehavioral disorders. The investigators also note in their paper that “children from underserved or marginalized communities may experience delayed diagnoses or reduced access to mental health support, amplifying the psychological burden of strabismus.”Most importantly, the researchers offer a wealth of clinical considerations for eye doctors to be mindful of when dealing with this population of patients, outlining nine in total. The first is advocating for comprehensive mental health screenings, which they argue should be integrated into routine eyecare for children diagnosed with strabismus, with special focus on ADHD and anxiety—these had the strongest associations.Secondly, they believe there is a need for tailored interventions by strabismus type. For exotropia and its strong link with anxiety and ADHD, targeted psychological interventions like cognitive-behavioral therapy for anxiety and behavior management strategies for ADHD may be beneficial. For esotropia, intervention may focus around bolstering self-esteem and addressing mood-related challenges via counseling or peer support programs. Combining psychological and social interventions in a more generalized approach may work for other strabismus types.Below is the full list of nine considerations this team advocates being mindful of when encountering a child with strabismus:Comprehensive mental health screeningsInterventions tailored by strabismus type Multidisciplinary care teamsParental education and supportSchool or community interventionsEarly surgical or non-surgical interventionsCultural considerations in care Digital or telehealth solutionsPolicy implicationsEach is discussed more fully in their paper, available at the link below.With these in mind, the authors consider that “these findings highlight the importance of integrating mental health considerations into strabismus management, particularly for high-risk subgroups.”Click here for the journal source. Krungkraipetch L, Krungkraipetch N, Threetong T. A meta-analysis of association between strabismus in children/adolescents and risk of mental health disorders. Clin Ophthalmol. 2025:19;2333-42.