Emotional and Behavioral Assessment of Youths with Visual Impairments Utilizing the BASC-2.

Authors: Stephanie Vetere Sims, Brian Celso and Ted Lombardo

Date of Publication: July-August 2021
Journal: Journal of Visual Impairment & Blindness (Vol. 115, Issue 4)

Rationale/ Background:

Visual impairments (i.e., blindness or low vision) in children and adolescents are heterogeneous in etiology. The
causes of vision loss include genetic factors, alterations in embryonic development, central nervous system damage,
perinatal complications, trauma, progressive disorders, and infectious diseases of the eye (Roley et al., 2007). In higher-
income countries, cortical visual impairment and optic nerve anomalies (i.e., optic nerve hypoplasia and optic nerve
atrophy) are the most common causes of visual impairment, while retinopathy of prematurity, cataracts, glaucoma, and
non-accidental injury are the most common avoidable causes. The cause of childhood blindness in lower-income countries
has been infectious (i.e., measles) and nutritional (i.e., Vitamin A deficiency) corneal opacities and congenital anomalies;
over time, these etiologies have shifted to those which more closely resemble the pattern seen in higher-income countries
(Solebo et al., 2017).

Allman et al. (2014) suggested that vision impairment can affect a youth's developmental progress across a
number of domains, including communication, language development, mobility, well-being, social interaction, and
participation in age-typical activities. In a school-based, cross-sectional study, the quality of life for otherwise healthy
adolescents with visual impairments was lower when it was compared to that of sighted peers (Wong et al., 2009). On
self-reports, the youths with visual impairments had statistically significant lower total functioning, psychosocial
functioning, and school functioning scores when compared to their sighted peers.

Studies that examined the mental health effects of visual impairments on youths found higher rates of
psychiatric diagnoses and psychological symptoms than sighted peers (Augestad, 2017). In one such study, Koenes
and Karshmer (2000) used the Beck Depression Inventory to compare depression scores between legally blind and sighted
adolescents. The incidence of depression among the adolescents with blindness was significantly higher than the
incidence of depression among the sighted adolescents. Harris and Lord (2016) looked at the risk of psychiatric
disturbance among children with visual impairments and sighted children aged 11 years using the Strengths and
Difficulties Questionnaire. Children with visual impairments obtained significantly higher total scores, indicating more
disturbance, than did the sighted children. On the parent measure, 18-29% of children with visual impairments were
identified as being at high risk for psychiatric disorders, compared to 7-10% of sighted children.

In a Spanish study, adolescents with visual impairments and sighted peers were administered the Adult and
Adolescent Self-Concept Adjective Checklist, the Rosenberg Self-Esteem Scale, the Revised Symptom Checklist, and the
NEO Five-Factor Inventory (Garaigordobil & Bernards, 2009). Adolescents with visual impairments were found to
have significantly higher scores on psychopathological symptoms as well as levels of severity and distress when
compared to sighted peers. Furthermore, adolescents with visual impairments, when compared to their sighted peers,
were shown to have unique neuropsychological profiles with strengths in working memory and verbal memory but
deficits in adaptive functioning, social communication, and behavioral executive functioning (Greenaway et al., 2016).

The Behavior Assessment System for Children, Second Edition (BASC-2), is a widely-used behavioral
assessment tool that consists of clinical scales, adaptive scales, content scales as well as composite scores for adaptive
skills, behavioral symptoms, externalizing symptoms, and internalizing symptoms (Reynolds & Kamphaus, 2004). The
BASC-2 Parent Rating Scale assesses a wide array of behaviors that represent behavioral and emotional strengths and
weaknesses. The form can be completed by a parent in approximately five minutes or less without the need for specialized
training. The BASC-2 scales were normed on a representative sample that closely matches US population characteristics.
In terms of sample sizes and age groups, there were 3600 children ages 6 to 11 years and 5500 adolescents ages 12 to 18
years. The general population sample had a total of 4800 Parent Rating Scales reports.

Objectives:

The objectives of the present study were to first review the BASC-2 profiles for students with visual impairments
who attended a state school for students who are blind. The second objective was to compare the BASC-2 composite
scores for youths with visual impairments with the available standardized BASC-2 data to determine if significant
differences exist between the two populations. The third objective was to compare the scores of students who are
categorized as having low vision to the scores of students who are categorized as being totally blind. The researchers
hypothesized that youths with visual impairments, when compared to the normative sample, would show elevations
in psychological symptoms and deficits in adaptive skills based on type of visual impairment.

Highlights of the Results:

BASC-2 profile of students with visual impairments

On average, the percentage of students who fell within the "at risk" range and those in the "clinically
significant" range was 8.5% and 3.7%, respectively. The number and percentages of children defined as "at risk" or
"clinically significant" for the individual clinical, adaptive, composite and content scales. For the clinical scales, anxiety
(23.5%) and withdrawal (21.9%) had the highest total percentages in both the "at risk" and "clinically significant" groups.
For the adaptive scales, social skills (15.1%) and adaptability (13.0%) had the highest total percentages in both the "at
risk" and "clinically significant" groups that indicated a lesser ability. For the content scales, developmental social
disorder (18.8%) and executive functioning (14.6%) had the highest total percentages with anger control (13.6%) a close
third. Finally, for the composite scales, adaptive skills (14.5%) had the highest total percentage in both the "at risk" and
"clinically significant" groups indicating a lesser ability.

Comparison to the standardized BASC-2 scores. Significant differences were shown among students with visual
impairments when compared to the standardized BASC-2 normative sample based on age and sex. The overall test of the
MANCOVA was statistically significant (F = 4.56, p = 0.003). The ANCOVA tests for the individual composite scales
revealed significant differences for each of the four scales in the group with visual impairments when compared to the
normative sample while controlling for level of visual impairment. Statistically significant higher differences were
detected for the behavioral symptoms index and internalizing problems for the group with visual impairments,
demonstrating behaviors that were more problematic. Statistically significant lower differences for the adaptive skills and
externalizing problems composites that indicated more deficits in adaptability and yet decreased acting out.

Comparison between visually impaired student groups. On the comparison of scores between the students with
low vision and the students with total blindness. Wilcoxon Rank Sums tests found statistically significant differences
between the two groups. On the clinical scales, the students with low vision had significantly higher scores
(indicating more deficits) for anxiety, attentional problems, conduct problems, and depression than did the
students with total blindness. On the adaptive scales, the students with total blindness had significantly higher scores
(indicating more deficits) for adaptability and functional communication than did the students with low vision . On
the content scales, the students with low vision had significantly elevated scores (indicating more deficits) for anger
control, developmental social disorder, and executive functioning. In addition, the students with low vision had
statistically significant lower scores (indicating more deficiency) in resiliency than did the students with total blindness.
On the composite scales, the students with low vision had significantly higher scores (indicating more deficits) for the
behavioral symptoms index, externalizing and internalizing problems. The youths with total blindness had significantly
elevated scores (indicating more deficits) for adaptive skills than did the students with low vision.

Discussion

The purpose of the present study was to evaluate the psychological profile of students with visual impairments
utilizing a widely-used behavioral assessment tool. The BASC-2 parent-generated rating scores for youths with visual
impairments were compared to the normative data from the BASC-2 to determine if significant differences existed
between the two populations. The parents of youths with visual impairments endorsed items that signified more
deficiencies in behavioral symptoms and internalizing problems than the BASC-2 normative sample. Furthermore,
the students with visual impairments were found to have fewer adaptive skills than did the normative sample, although
they were less likely to express their perceived inadequacies outwardly. Thus, the results indicate that youths with
visual impairments may have particular difficulty coping with their emotions, since they have insufficient adaptive
skills to manage their conduct adequately.

Our findings also indicated that youths with visual impairments were more likely to internalize their
problems; this finding was supported by the significantly higher difference between the group with visual impairments
and the normative group. We showed that a sizable proportion of the youths with visual impairments endorsed symptoms
of increased withdrawal. Withdrawal, as defined by the BASC-2, is "the tendency to evade others to avoid social contact"
(Reynolds & Kamphaus, 2004). Pinquart and Pfeiffer (2012) suggested that for adolescents with visual impairments,
social withdrawal may occur because the adolescents have many challenges to confront with regard to their own ability to
travel independently and to access social opportunities. Similarly, adolescents with visual impairments were shown to
have smaller social networks than did sighted adolescents (Kef et al., 2000).

Similar to the present study, Greenaway et al. (2016) revealed that youths with visual impairments had deficits in
activities of daily living, adaptive functioning, and social communication. Youths with visual impairments showed deficits
in not only functional communication, but they were also deficient in the social use of language, which was found to be
behind that of their sighted peers (Tadic et al., 2009). Moreover, adults with visual impairments showed a significant
relationship between their visual deficits and negative health effects and life expectancy (Christ et al., 2008). Visual
impairment was also associated with both increased illness later in life and higher mortality.

Results suggest that differences do exist in the psychological profile of youths with low vision compared to
youths with total blindness. The youths with blindness exhibited more deficits in adaptive skills when they were
compared to youths with low vision. Children with congenital visual impairments lack the primary sensory system that
typically is used to understand oneself as separate from others, to verify information, and to receive feedback related to
actions. Therefore, the lower adaptive ratings for children with blindness were anticipated because the experience of total
blindness inhibits these children from learning through observation (Allman et al., 2014).

Implications to Rehabilitation Psychology / New Concepts Learned:

Professionals working with youths with visual impairments are faced with a number of daunting challenges. First,
the conditions under the umbrella of visual impairment are heterogeneous, and the variation exists within a statistically
low-incidence disability category. Added to this issue is the high level of comorbidity in this population, which includes
autism, psychiatric problems, and learning problems (e.g., Bradstreet et al., 2017). Therefore, there is a dearth of
psychological research to guide professionals working in educational and clinical settings with these unique students.
Those who work with youths with visual impairments have to apply various and unique methods to understand,
train, teach, rehabilitate, or counsel these youths. Overall, the results implies that there is a clear need for further
studies on the psychological profiles of youths with blindness and low vision to determine if universal screening
for mental health difficulties is warranted.

Reference:

Sims, S. V., Celso, B., & Lombardo, T. (2021). Emotional and Behavioral Assessment of Youths With Visual
Impairments Utilizing the BASC-2. Journal of Visual Impairment & Blindness, 115(4), 310-318.