Psychosocial Impact of Occlusion Therapy in Children with Amblyopia: A Cross-Sectional Study of Child and Parent Perspectives

Abstract

Amblyopia is the most common cause of unilateral visual impairment in childhood. Occlusion therapy remains the gold standard for treatment as its psychosocial and functional consequences may affect both children and their parents, potentially compromising treatment adherence. This cross-sectional study included 36 children (aged 3–9 years) undergoing occlusion therapy for amblyopia and 18 parents who completed a mirrored version of the same questionnaire. Each instrument consisted of 18 items distributed across three domains: Psychosocial (Q1–Q6), Daily and School Activities (Q7–Q12), and Physical and Treatment Acceptance (Q13–Q18). Responses were coded on 0–3 or 0–1 scales, and total scores ranged from 0 to 26, with higher scores reflecting greater psychosocial impact. The mean total score reported by children was 15.3 ± 2.5 (range 10–22), compared to 16 ± 2.7 (range 10–21) for parents. No significant difference was found between the two groups (p = 0.31), indicating a generally consistent perception of treatment impact. Among children, girls (15.5 ± 2.4) scored slightly higher than boys (15 ± 2.5) (p = 0.51). Among parents, mothers (17 ± 2.5) reported significantly greater perceived impact than fathers (14 ± 3.0) (p = 0.03). Age-based comparison revealed no significant differences between age groups (3–4, 5–6, and 7–9 years; F = 0.14; p = 0.87), although younger children (3–6 years) showed slightly higher psychosocial scores than older ones (7–9 years) (p = 0.75). Occlusion therapy exerts a moderate psychosocial impact on amblyopic children, affecting emotional well-being, school performance, and treatment acceptance. While parents generally recognize the burden of therapy, mothers perceive it more strongly than fathers, and younger children appear slightly more emotionally affected. These findings emphasize the importance of including both child self-reports and parental perspectives in clinical assessments and support the need for psychological and educational interventions to improve comfort and adherence during treatment.

1. Introduction

Amblyopia, commonly referred to as “lazy eye,” is a developmental visual disorder characterized by reduced visual acuity in one or both eyes in the absence of any detectable organic pathology, typically resulting from inadequate cortical stimulation during the critical period of visual development [1]. It most often develops in childhood and may arise from anisometropia (refractive asymmetry between the eyes), strabismus, or visual deprivation such as lens opacity [1,2]. Epidemiological studies estimate the global prevalence of amblyopia among children between 1% and 2% [1], while a recent meta-analysis reported a pooled prevalence of 1.36% (95% CI: 1.27–1.46%) [2]. In school-aged populations, amblyopia affects approximately 0.7–0.8% of children, making it a significant pediatric public health concern.

Although optical correction represents a fundamental step in management, occlusion therapy remains the cornerstone of amblyopia treatment. This method involves patching the dominant eye to stimulate visual function in the amblyopic eye and has been shown to be clinically effective. However, despite its visual benefits, occlusion therapy can generate substantial psychosocial consequences. Previous studies have documented that wearing an eye patch often provokes social discomfort, embarrassment, teasing, and limitations in academic or peer interactions [3,4]. These negative experiences can undermine children’s emotional well-being, self-confidence, and adherence to therapy.

Importantly, the psychosocial effects of patching extend beyond the child. Parents frequently experience emotional strain and practical challenges in supervising treatment, and their perceptions and attitudes strongly influence adherence and therapeutic success [4,5]. Nevertheless, several studies have revealed a discrepancy between the child’s reported experiences and parental assessments, with parents often underestimating the child’s emotional distress.

In this context, the present study aimed to evaluate the psychosocial impact of occlusion therapy on amblyopic children using an 18-item standardized questionnaire divided into three dimensions: psychosocial, daily/school activities, and physical and acceptance. A mirrored version of the same instrument was simultaneously administered to parents to assess their perceptions of their child’s experience. This dual child parent approach provides a comprehensive view of the psychological and social implications of occlusion therapy, facilitates the identification of perceptual gaps, and underscores the need for improved educational and psychological support strategies during treatment.

2. Materials and Methods

2.1. Study Design

This was a cross-sectional, descriptive, and analytical study conducted using a structured questionnaire designed to assess the psychosocial impact of occlusion therapy on amblyopic children and the perceptions of their parents.

2.2. Study Population

The study included 36 children aged 3 to 9 years diagnosed with amblyopia and undergoing occlusion therapy, as well as 18 parents (either father or mother) who agreed to participate and who have only one child being treated for amblyopia in this period of the study. All participants were recruited from the Department of Ophthalmology and Orthoptics at the Provincial Hospital of al youssoufia, Morocco.

The study included children aged 3 to 9 years who had been clinically diagnosed with amblyopia and were undergoing occlusion therapy (patching) for a period of at least six months. Eligible participants presented with one of the following types of amblyopia: strabismic, anisometropic, mixed, or deprivation. In addition, participation required the presence of a parent or legal guardian willing to complete the corresponding parental questionnaire. Written informed consent was obtained from all parents or guardians, and verbal assent was collected from the children whenever applicable.

Children were excluded if they had other ocular pathologies besides amblyopia, such as congenital cataract, glaucoma, or corneal anomalies. Those with neurological or cognitive impairments that could interfere with comprehension of the questionnaire were also excluded. Furthermore, non-compliance with occlusion therapy or refusal to participate by either the child or the parent constituted exclusion criteria.

2.3. Authorization and Access

The study protocol received ethical approval from the local committee. Written informed consent was obtained from all parents, and assent was collected from children when applicable. Participation was voluntary and anonymous, and the study was conducted in accordance with the principles of the Declaration of Helsinki.

2.4. Sampling Method

A non-probability convenience sampling approach was used, including all eligible children who met the inclusion criteria during the study period.

2.5. Data Collection Tool

A structured questionnaire (see Appendix A and Appendix B) was used to assess the psychosocial and functional impact of occlusion therapy. It consisted of 18 items divided into three domains: Psychosocial domain, Daily and School Activities domain, and Physical and Treatment Acceptance domain.

The same questions were administered to both children and parents, with wording adapted to the respondent’s age, level of cooperation, and comprehension. For the children’s version, the questions were explained and administered by the examiner, or by the parents when necessary, using the child’s native language and in a simple, age-appropriate manner to facilitate understanding.

The questionnaire was developed and validated in collaboration with a clinical psychologist. All items were revised, simplified, and linguistically adapted to ensure clarity, cultural relevance, and ease of comprehension for both children and parents, using clear and non-technical language. For children aged 3–4 years, the questions were explained and administered by the investigators, with complementary parental assistance when necessary to ensure adequate comprehension and reliable responses.

Responses were coded using a standardized scale: Never = 0, Sometimes = 1, Often = 2, and Always = 3 for frequency-based items, and Yes/No responses coded as 0/1 for binary items. Items scored from 0 to 3 corresponded specifically to the psychosocial dimension, allowing for a more precise assessment of the emotional and social impact of occlusion therapy on children.

Subscores were calculated for three predefined domains: the Psychosocial domain (items 1–6), the Daily and School Activities domain (items 7–12), and the Physical and Treatment Acceptance domain (items 13–18). The total score ranged from 0 to 26, with higher scores indicating a greater psychosocial impact of treatment.

2.6. Ethical Considerations

Participation in the study was entirely voluntary and anonymous. No personal or identifying information was collected at any stage. Written informed consent was obtained from all parents or legal guardians, and children provided verbal assent whenever possible. The study protocol adhered to the ethical principles of the Declaration of Helsinki.

2.7. Data Analysis

All data were entered and analyzed using IBM SPSS Statistics version 21 (IBM Corp., Armonk, NY, USA). Descriptive statistics were computed, including means, standard deviations, and frequency distributions. Comparative analyses were performed as follows: child versus parent scores were compared using the paired t-test; comparisons by sex were conducted using the independent t-test; and differences among age categories (3–4, 5–6, and 7–9 years) were assessed through one-way ANOVA. The association between age and total score was examined using Spearman’s rank correlation coefficient. A p-value less than 0.05 was considered statistically significant.

3. Results

The study sample consisted of both children and their parents, grouped by gender and age to explore differences in psychosocial, functional, and acceptance-related experiences associated with occlusion therapy. Among the children (n = 36), boys represented the majority (n = 25) compared to girls (n = 11). Age was distributed across three subgroups: 3–4 years (n = 10), 5–6 years (n = 13), and 7–9 years (n = 13), indicating a relatively balanced representation of preschool and early school-aged children. The parents’ group included 18 participants, divided into 10 fathers and 8 mothers, allowing for a comparative analysis of parental perspectives. Overall, the data reflect a predominantly male and young child population, with corresponding parental pairs, ensuring consistency between the children’s and parents’ subsamples for paired analyses (

Table 1. Comparative dimension scores of children and their parents in the 18-item mirror questionnaire for amblyopia occlusion therapy.

Child ID	Psychosocial (C)	Daily/School (C)	Physical/Treatment (C)	Parent ID	Psychosocial (P)	Daily/School (P)	Physical/Treatment (P)
C1	10	1	4	P1	9	1	4
C2	7	3	3	P2	8	2	4
C3	12	3	2	P3	11	2	5
C4	10	2	3	P4	14	4	2
C5	12	4	1	P5	8	5	2
C6	8	3	1	P6	10	4	5
C7	9	4	1	P7	7	4	2
C8	9	3	4	P8	9	5	3
C9	11	4	3	P9	11	6	4
C10	11	5	3	P10	9	4	3
C11	8	4	2	P11	9	5	3
C12	9	4	2	P12	10	5	3
C13	10	5	2	P13	8	5	3
C14	9	5	2	P14	8	5	2
C15	9	4	2	P15	10	5	4
C16	8	4	2	P16	8	4	2
C17	7	4	2	P17	9	4	2
C18	10	5	2	P18	10	5	2
C19	9	4	3	–	–	–	–
C20	8	4	3	–	–	–	–
C21	8	3	3	–	–	–	–
C22	11	4	3	–	–	–	–
C23	12	4	3	–	–	–	–
C24	10	4	3	–	–	–	–
C25	7	4	2	–	–	–	–
C26	9	4	2	–	–	–	–
C27	10	4	2	–	–	–	–
C28	11	4	3	–	–	–	–
C29	12	4	3	–	–	–	–
C30	10	4	3	–	–	–	–
C31	9	4	2	–	–	–	–
C32	8	4	2	–	–	–	–
C33	10	4	2	–	–	–	–
C34	11	4	3	–	–	–	–
C35	9	4	2	–	–	–	–
C36	10	5	2	–	–	–	–

).

Analysis of the mean scores across the three questionnaire dimensions, Psychosocial (Q1–Q6), daily/school activities (Q7–Q12), and physical and acceptance (Q13–Q18), revealed moderate variations in the differences among subgroups; among the children, girls exhibited slightly higher mean scores than boys across all domains, although this was not statistically significant (p = 0.51); among the parents, mothers reported higher scores than fathers across all dimensions, with a statistically significant difference in the overall score (t = −2.39; p = 0.03 *), indicating that mothers perceived a greater psychosocial impact of the treatment (

Table 2. Comparison of psychosocial impact scores between children and parents across age groups, with statistical test results (p-values).

Group	Subgroup	Psychosocial (Q1–Q6)	Daily/School Activities (Q7–Q12)	Physical and Acceptance (Q13–Q18)	Total (Q1–Q18)	Statistical Test
Children	Boys (n = 25)	7.1 ± 1.8	4.2 ± 1.3	3.7 ± 1.2	15.0 ± 2.5 (10–22)	—
	Girls (n = 11)	7.4 ± 1.9	4.3 ± 1.1	3.8 ± 1.3	15.5 ± 2.4 (11–19)	t = −0.67; p = 0.51
Parents	Fathers (n = 10)	6.5 ± 2.0	4.0 ± 1.5	3.5 ± 1.1	14.0 ± 3.0 (10–20)	—
	Mothers (n = 8)	8.1 ± 1.8	4.6 ± 1.2	4.4 ± 1.0	17.1 ± 2.5 (14–21)	t = −2.39; p = 0.03
Children by Age	3–4 years (n = 10)	7.0 ± 1.5	4.1 ± 1.3	3.9 ± 1.2	15.4 ± 2.1 (12–19)	—
	5–6 years (n = 13)	7.2 ± 1.7	4.3 ± 1.2	4.0 ± 1.1	15.6 ± 2.3 (11–20)	—
	7–9 years (n = 13)	7.5 ± 1.9	4.4 ± 1.4	4.1 ± 1.3	15.9 ± 2.6 (10–22)	ANOVA: F = 0.14; p = 0.87
Children (School Age)	3–6 years (n = 19)	9.7 ± 2.3	2.5 ± 1.1	3.1 ± 1.5	15.3 ± 2.1	—
	7–9 years (n = 17)	8.9 ± 2.6	3.2 ± 1.1	2.9 ± 1.0	15.0 ± 2.9	t = 0.32; p = 0.75
Child–Parent Comparison	Mean scores (n = 18 pairs)	7.2 ± 1.8 vs. 7.4 ± 1.9	4.3 ± 1.2 vs. 4.4 ± 1.3	3.8 ± 1.2 vs. 4.0 ± 1.1	15.3 ± 2.5 vs. 15.9 ± 2.7	Paired t = −1.02; p = 0.31

Student’s t-test, one-way ANOVA.

).

Age-based analysis showed no significant differences among the three age groups (3–4, 5–6, and 7–9 years) across any dimension (F = 0.14; p = 0.87). However, children below school age (3–6 years) had slightly higher psychosocial scores compared to those above school age (7–9 years) (9.7 ± 2.3 vs. 8.9 ± 2.6), although the difference was not statistically significant (t = 0.32; p = 0.75). These findings suggest that younger children may experience slightly greater emotional discomfort during the initial phases of treatment.

Finally, the overall child–parent comparison revealed similar mean scores across all three dimensions and in the total score (15.3 ± 2.5 vs. 15.9 ± 2.7), with no significant difference (paired t = −1.02; p = 0.31). This consistency indicates a generally convergent perception between children’s experiences and their parents’ observations.

4. Discussion

The present study found that occlusion therapy has a moderate psychosocial impact on amblyopic children, affecting emotional well-being, school performance, and physical comfort. The close similarity between child and parent total scores suggests a generally shared perception of treatment burden, although mothers reported higher levels of concern than fathers. These findings are consistent with the results of van der Sterre et al. [6], who observed that parents tended to overestimate their children’s discomfort compared with the children’s own reports. In their cohort of 60 children (mean age ≈ 4.6 years), children rated their discomfort with patching, skin irritation, and daily activities as relatively low, while parents expressed greater empathy and concern regarding treatment challenges (Figure 1).

Similarly, Eslayeh et al. [7] evaluated the psychosocial effects of amblyopia treatment in Palestine using the Amblyopia Treatment Index (ATI) and concluded that patching imposed a low-to-moderate impact on quality of life, with no significant differences by age, gender, or amblyopia severity. This aligns with our findings: the mean total scores in our sample (~15/26) indicate a moderate level of psychosocial burden and overall good tolerance to occlusion therapy, with no statistically significant effect of sex or age.

Together, these studies demonstrate that while occlusion therapy remains psychologically and socially demanding, it does not cause a major deterioration in quality of life. However, a subtle discrepancy between child and parent perspectives persists. As van der Sterre et al. suggested, this divergence may stem from children’s tendency to downplay discomfort to appear brave, while parents, motivated by empathy and protective concern, often amplify the perceived distress.

Methodologically, our study extends the framework of van der Sterre et al. by expanding the questionnaire from 12 to 18 items distributed across three dimensions: Psychosocial, Daily/School Activities, and Physical and Treatment Acceptance. This extension provides a broader and more detailed multidimensional analysis of occlusion therapy’s impact. Unlike the Palestinian study, which relied exclusively on parental reporting, our mirror design captures both the child’s self-reported experience and the parent’s interpretation, offering a more holistic understanding of family dynamics during treatment and greater cultural applicability to the Moroccan context.

Our observations also align with earlier findings by Horwood et al. and Koklanis et al. [4,8], who described common psychosocial effects such as social embarrassment, teasing, and temporary academic difficulties related to patch wearing. However, consistent with Felius et al. and van de Graaf et al. [9,10], the majority of children in our sample demonstrated gradual adaptation and good tolerance, particularly when family support and clear explanations were provided. This explains why most of our participants (67%) fell within the moderate-impact category.

Our findings showed that school-aged children experienced less psychosocial impact from occlusion therapy compared to preschool-aged children. This suggests a higher level of emotional tolerance and understanding among children who attend school, likely due to better communication with healthcare professionals and supportive attitudes from teachers who help normalize patch wearing during class hours. In contrast, younger children who are not yet in school may perceive occlusion as distressing because of limited comprehension and reduced social exposure. No statistically significant differences in psychosocial impact were observed between preschool-aged and school-aged children. Although school-aged children tended to show slightly lower psychosocial impact scores compared to preschool-aged children, this difference did not reach statistical significance. These observations should therefore be interpreted with caution. Potential age-related variations in emotional tolerance, understanding of treatment, and social context may influence children’s experiences with occlusion therapy; however, such interpretations remain exploratory and require confirmation in larger, adequately powered studies.

Additionally, the social environment and parental attitudes appear to influence the child’s adaptation to treatment. Some clinicians even recommend performing occlusion during school holidays to minimize social discomfort and stigma. Overall, these observations highlight that school attendance and social maturity may facilitate better acceptance and adherence to occlusion therapy.

Socio-demographic and cultural factors may also influence perceived burden. Van der Sterre et al. noted that language barriers and lower parental health literacy were associated with reduced understanding of treatment and less accurate reporting of children’s discomfort. Similarly, our findings highlight the need for structured educational guidance and culturally tailored communication to optimize adherence and reduce psychosocial distress. Socio-demographic and cultural factors may also play a critical role in shaping treatment perception and adherence. Previous qualitative research has shown that cultural competence, parental beliefs, and communication styles significantly influence pediatric care engagement and adherence, particularly in low-resource or rural settings [11]. These findings support the importance of culturally tailored communication and structured parental education to reduce psychosocial distress and optimize adherence to occlusion therapy in the Moroccan context.

In summary, our results confirm within the Moroccan context that occlusion therapy exerts a measurable but moderate psychosocial burden that parents, particularly mothers, tend to perceive more intensely than their children. This convergence with Dutch and Palestinian data strengthens the external validity of our conclusions and supports the value of using complementary child- and parent-based assessments to capture the full emotional and functional experience of amblyopia treatment.

5. Limitations and Strengths

While certain methodological constraints should be acknowledged, the overall robustness and originality of this study remain noteworthy. The sample size (36 children and 18 parents) was modest but adequate for a pilot exploration of psychosocial dimensions in a specific clinical population. Rather than a limitation, this focused sample allowed for in-depth qualitative and quantitative analysis, providing meaningful preliminary insights that can guide larger-scale studies. The cross-sectional nature of the study does not capture longitudinal changes; however, it offers a valuable snapshot of emotional and behavioral responses at a critical stage of amblyopia therapy. Furthermore, although self-reported questionnaires may inherently carry some response bias, this was minimized through clear instructions and the inclusion of both child and parent perspectives, enhancing internal validity and interpretative depth.

This work contributes to the limited body of literature in Morocco and North Africa by exploring the psychosocial impact of occlusion therapy through a dual child–parent framework. The use of a multidimensional questionnaire adapted to the local linguistic and cultural context provides a contextually relevant assessment of children’s emotional well-being, daily experiences, and treatment adaptation.

Importantly, this investigation study represents, to our knowledge, the first study in Morocco and among the few in North Africa to examine the psychosocial impact of occlusion therapy through a dual child–parent framework. The development of an 18-item multidimensional tool adapted to local linguistic and cultural contexts provides a comprehensive and contextually relevant assessment of the child’s daily experiences, emotional well-being, and physical adaptation. This mirror approach not only strengthens the reliability of the findings but also introduces an innovative perspective that bridges clinical practice and family-centered care.

Overall, the study offers original and contextually significant contributions, emphasizing the necessity of integrating psychosocial and cultural dimensions into amblyopia management programs. Its findings pave the way for future multicentric and longitudinal investigations aimed at optimizing both the therapeutic and emotional outcomes of occlusion therapy in children.