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Behaviour Problems in Children and Adolescents
with Visual Impairment1
Michael Brambring
University of Bielefeld (Germany)
Behaviour problems: Definitions and approaches
Usually, behaviour problems are assessed with two different approaches. The first is statistical
judgment; that is, a behaviour disorder is diagnosed if the child or adolescent exhibits
extremely frequent or extremely severe maladjusted behaviour in comparison with other
children or adolescents of the same age, gender, or sociocultural group. This comparison
means, for example, that separation anxiety from the mother will usually be judged as normal
in 3-year-olds, because most children of this age exhibit such behaviour, but the same
behaviour will usually be judged as maladjusted in 10-year-olds. Whereas, stereotypies may
be judged as a disturbed behaviour in the sighted, this does not necessarily hold for the blind
population, because most blind children exhibit them.
The second kind of assessment is called clinical judgment, that is, behaviour problems
are problems that affect physical, mental, and psychological well-being to a clinically
significant degree. This assessment of the impact on the child or adolescent's current or
prospective developmental potentials is independent of how many children or adolescents
exhibit comparable difficulties.
Assessment methods
In the statistical approach, assessments are carried out with questionnaires such as the wellknown behaviour checklists published by Achenbach and colleagues (Achenbach, 1985).
Child Behaviour Checklist for Ages 2 - 3 (CBCL/2-3)
Child Behaviour Checklist for Ages 4 - 18 (CBCL/4-18)
Teachers' Report Form for Ages 5 - 18 (TRF/5-18)
Youth Self Report for Ages 11 - 18 (YSR/11-18)
The statistical judgment is based on critical cut-off points, that is, when the number of
behaviour problems exceeds statistical norms. For example, a behaviour problem is given
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A detailed version with the same title will be published in German in cooperation with Heinrich Troester.
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only if less than 5 % of the comparison group exhibit this type of maladjusted behaviour. This
approach raises the methodological problem that almost all questionnaires are standardized
for the sighted population, meaning a risk of invalid items for children with visual
impairment. An example is "avoids eye contact" in CBCL/2-3. There is only one standardized
questionnaire for adolescents with visual impairment, the so-called "Adolescent Emotional
Factors Inventory" (Bauman, 1964).
Clinical judgments, in contrast, are based on two internationally widespread classification
systems:
The Diagnostic and Statistical Manual of Mental Disorders (DSM)
(American Psychiatric Association, 1994)
The International Classification of Diseases (ICD 10). Classification of mental and
behavioural disorders: Clinical descriptions and diagnostic guidelines
(World Health Organization, 1992)
Criteria for clinically relevant disorders are based on the frequency, severity, duration, and
generalizability of the behaviour problems across situations. When applying these
classification systems to the assessment of behaviour problems in children or adolescents with
visual impairment, one has to be aware that such criteria for judging clinically relevant
disorders are almost always based on experiences with sighted children.
Theories of behaviour problems
Many theories offer explanations for the emergence of behaviour disorders from a biological,
psychodynamic, or learning theory perspective (Gelfand, Jenson, & Drew, 1997). One wellknown model for the explanation of behaviour problems is the so-called diathesis-stress or
vulnerability-stress hypothesis. This assumes that behaviour problems emerge if there is an
imbalance between the biological or acquired competencies of the child and the demands of
the physical and social environment. It predicts that behaviour problems emerge in "normal"
children when physical and social demands exceed their competencies to a large extent. In
contrast, one may expect even regular demands to exceed the competencies of children with
impairments. Thus, the model would suggest a higher risk of behaviour problems in this
group.
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Prevalence of behaviour problems
(1) Normal population. The prevalence of behaviour problems in the sighted population may
vary for many reasons such as the type of assessment method or the assessor. The famous
Isle-of-Wight Study (Rutter, Graham, & Yule, 1970), assessing almost 11,000 children and
adolescents, yielded an overall prevalence of behaviour problems in the normal population of
10-15% mild or middle-graded behaviour problems and 7% middle-graded to severe
problems (i. e., psychiatric disturbance). Other empirical studies converge to produce major
conclusions on age and gender differences as well as differences in the kind of behaviour
problems in both sexes:
Age differences:
Findings yield a slight increase in behaviour problems from preschool age to adolescence.
Gender differences:
(1) No significant gender differences are found at preschool age.
(2) Behaviour problems are more frequent in boys than in girls at school age.
(3) In contrast, there are more frequent behaviour problems in girls than in boys during
adolescence.
Kind of behaviour problems:
(1) Boys exhibit a predominance of so-called externalized behaviour problems such as
attention and hyperactivity deficiency, aggression, or oppositional behaviour.
(2) Girls exhibit a predominance of so-called internalized behaviour problems such as
anxiety, depression, social withdrawal, or psychosomatic complaints.
(2) Prevalence in children or adolescents with visual impairment. The prevalence of
behaviour problems in children or adolescents with visual impairment can be ascertained from
two studies with almost representative samples. First, the Vancouver study (Jan, Freeman, &
Scott, 1977), and second, the Israel study (Tirosh, Shnitzer, Davidovitch, & Cohen, 1998).
Both studies were carried out at regional children's hospitals responsible for the treatment of
children with visual impairments. Assessments performed by experienced pediatricians, child
psychiatrists, or psychologists referred to the judgment of psychiatrically disturbed behaviour
problems.
Table 1 reports the sample characteristics of both studies.
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Table 1: Sample Characteristics
Characteristic
Vancouver
Israel
Number of subjects
92
193
Age
1-19 years
13 mo-8 years
Visual impairment
-
Blind
27%
32.5%
-
Partially sighted
71%
67.5%
Additional impairments
-
Mental retardation
20%
18%
-
Cerebral palsy
19%
12.5%
-
Hearing impairment
15%
12.4%
-
Epilepsy
15%
10.8%
The percentages in Table 1 indicate comparable characteristics except for the participants' age
distribution. Participants in the Vancouver study were older than those in the Israel study.
Table 2 reports the prevalence of behaviour problems in children and adolescents with
visual impairment.
Table 2: Prevalence of Behaviour Problems
Assessor
Vancouver (1977)
Israel (1998)
Parents/Teachers
61%
XXX
Psychiatrist/Psychologist
57%
49%
There is a high level of agreement between the different assessors in the Vancouver study
(parents/teachers vs. psychiatrist/psychologist) as well as a high level of agreement between
both studies despite a 20-year interval, different age ranges, and different cultural settings.
Table 3 reports the findings of a follow-up study carried out by Freeman, Goetz, Richard,
and Groenveld (1991).
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Table 3: Follow-up Study at Vancouver 1991 (Freeman et al., 1991)
Prevalence
Main study
Follow-up study
(1977)
(1991)
Overall
57%
49%

Blind
68%
52%

Partially sighted
51%
48%

Visually impaired
47%
32%
without mental retardation
Results indicate a decrease in the prevalence of behaviour problems from childhood
/adolescence to adolescence/adulthood, particularly in the group of those who are blind or
visually impaired without mental retardation. Nonetheless, the prevalence still remains much
higher than that in the normal population.
Autism in children with congenital blindness
A new and controversial debate has arisen over autism in children who are congenitally blind.
Autism is a pervasive disorder that includes disturbance in social interaction and
communicative competencies as well as severe restrictions in activities, interests, and
fantasies. The prevalence in the sighted population is approximately 4-5 per 10,000 (0.0040.005%).
Findings on the prevalence of autism in the blind population vary greatly as a function of
(a) the experiences of the assessor with blind-specific idiosyncrasies, (b) the explanation of
these blind-specific idiosyncrasies, and (c) the chosen method, that is, clinical or statistical
judgment.
The above-mentioned studies by Jan, Freeman, and Scott (1977), and Tirosh, Shnitzer,
Davidovitch, and Cohen (1998)—based on clinical judgment—yielded prevalence rates of 3%
(Jan et al., 1977) and 1% (Tirosh et al., 1998). Although these figures are still higher than
those in the sighted population, they are much lower than the prevalence in newly published
studies based on the statistical approach. Goodman and Minne (1995) assessed 17
congenitally blind 4- to 11-year-olds without any additional impairment with the Autism
Behaviour Checklist (Krug, Arick, & Almond, 1978). Autism was diagnosed when the
number of symptoms exceeded a critical cut-off. The prevalence of autism in this sample was
23.5%. Brown, Hobson, Lee, and Stevenson (1997) obtained a similar prevalence rate in their
study. They investigated 24 congenitally blind children (aged 3-9 years) without any
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neurological damage with the Childhood Autism Rating Scale (Schopler, Reichler, & Renner,
1986). They found a prevalence of 20.8% autism.
Hobson et al. (1997) explained their findings by assuming the same underlying abnormal
process in autistic children regardless of whether they are blind or sighted. Their explanation
based on the "theory of mind," is that there is a lack of intersubjectivity in autistic children, in
other words, an inability to understand and to anticipate the thoughts and emotions of others a lack of shared social understanding. It seems reasonable to expect that children without
vision my have difficulties in acquiring intersubjectivity because of their inability to perceive
the cues of nonverbal communication. But these difficulties do not necessarily mean a higher
risk of autism. Many of the same symptoms in the blind and the sighted child may be
explained by divergent processes. The technical term for this phenomenon is "equifinalism,"
meaning that the same symptoms may be based on different causes.
(1) Different processes. First, the reason for autism in sighted children can be considered
to be a pathological information processing. Blind children, in contrast, may have problems
in information gathering, but few problems in information processing. Second, whereas the
autistic symptoms in sighted children are pervasive problems, they are frequently transient in
those who are blind.
(2) Different functions. In addition to different processes, the same so-called autistic
symptoms may have different functions in the blind or sighted child.
First, according to arousal theory, stereotypies may have a functional value for children
who are blind by reducing stress or uncertainty (Troester, Brambring, & Beelmann, 1994).
However, the same stereotypies may be classified as abnormal in the sighted child.
Second, the higher percentage of echolalia may be explained by a different process of
language acquisition in children who are blind. Pérez-Pereira and Conti-Ramsden (1999)
report empirical data indicating a holistic, gestalt-like language acquisition, based on
echolalic, formulaic speech in the first years of life.
Third, the lack of social interaction between blind children and their sighted peers in
kindergarten - another symptom for autism in standardized scales - may be explained by two
factors: (1) Most kindergarten activities are unsuitable for children who are blind because of
the high demands they place on orientation and mobility as well as manual skills (Brambring,
1998). (2) Sighted children of this age have difficulties in anticipating the needs of a peer who
is blind (Preisler, 1993). Both of these reasons may explain the social interaction problems in
the blind.
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Fourth, the last example refers to the frequently observable retardation of symbolic play
in children who are blind - another symptom of autism in standardized questionnaires. Once
again, this delay may be explained by two different factors: (1) Traditional symbolic toys like
dolls or toy automobiles hold hardly any attraction for children who are blind because they
offer only a visual representation of the real objects (Troester & Brambring, 1994). (2) Many
investigators are unaware of the alternative forms of symbolic play in children who are blind
such as verbal role play (Ferguson & Buultjens, 1995). As a result, they may not pick up on
the blind-specific forms of symbolic play.
Conclusion
The conclusion that different perspectives need to be taken when explaining autistic
symptoms in the blind or sighted population implies a serious warning: Counting only
symptoms without taking account of possible differences in underlying processes and
functions may lead to false interpretations and intervention strategies for autism in both the
sighted and the blind child.
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Tröster, H., Brambring, M., & Beelmann, A. (1994). Prevalence and situational causes of
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Michael Brambring, Ph.D.
Department of Psychology
University of Bielefeld
PO 10 01 31
D-33501 Bielefeld, Germany
Phone: ++49-5 21-106-4345/-43 33
Fax : ++49-521-106-8062
e-mail: m.brambring@uni-bielefeld.de