Self-concept and self-esteem among children and young adults with visual impairment: A systematic review

Abstract The purpose of the study was to summarize current scientific knowledge relating to self-concept and self-esteem among children and young adolescents with visual impairment (VI). A systematic review was conducted of articles published between 1998 and 2016. A total of 26 publications, representing 15 countries, met the inclusion criteria, and 24 of the studies had used a cross-sectional design. Some studies found that the age and degree of vision loss influenced perceived self-esteem. In general, independence in mobility, parenting style, social support, and friendship was reported as important for children with VI to enhance their self-concept and self-esteem. To be able to provide opportunities for a successful development and good self-evaluation, we need more knowledge and further longitudinal observation studies and randomized clinical trials with high quality to increase the possibilities to draw conclusions about cause and effect.

ABOUT THE AUTHOR Liv Berit Augestad (PhD) is a professor at the Department of Neuromedicine and Movement Science, at the Faculty of Medicine and Health Sciences, Norwegian University of Technology and Science (NTNU), Trondheim, Norway. In addition, she has a part-time position at the Department of Visual Impairment, Statped Midt, Heimdal, Norway.
Her main research area at NTNU is physical activity and health. Since 1994, she has also focused on mental and physical health among people with visual impairment. Statped's regional offices are responsible for providing advice and support in special education for students with visual impairment. In Norway, all students with visual impairment are fully integrated in the mainstream schools. She has published handbooks, and peer-reviewed papers in international journals, as well as the results of population-based epidemiological studies and systematic reviews in the field of vision and health.

PUBLIC INTEREST STATEMENT
How do children with visual impairment perceive their self-esteem? Children with vision loss may have reduced mobility, fewer opportunities to learn social skills, greater independency on help, and experience loneliness. Moreover, less participation in leisure-time activities with their significant others may contribute to them having an increased risk of mood disorders. Additionally, children with severe vision loss may find it hard to predict other people's behavior, reactions, and emotions from their facial expressions. A person's self-esteem may depend on their psychological adjustment, quality of life, adaptive behavior, relationships with friends, motivation and success in life, among other factors. Low self-esteem may ensue if there is a discrepancy between a person's expectations and their perception of their adequacy. Children with vision loss may have lower self-esteem due if their challenges in life differ from those of sighted children. However, the self-evaluation, social comparison, and identity of children with different visual statuses may vary. Rosenberg (1979) and Harter (1993) both claim that a person who perceives him-or herself as competent in domains in which he or she aspires to excel will have positive self-esteem. The framework for and definition of self-esteem used by Harter and Rosenberg has much in common with the concept of self-esteem. Self-esteem can be conceptualized as the level of global regard that a person has for him-or herself as an individual (Leary & Baumeister, 2000).

Introduction
Further, self-esteem may play a profound role in all aspects of a child's development (Brooks, 1992;Olsen, Breckler, & Wiggens, 2008). The term self-esteem may reflect a person's overall emotional evaluation of his or her worth and a person's sense of pride and is closely associated with his or her self-consciousness and psychological well-being (Olsen et al., 2008). This is a judgment of the self as well as an attitude toward the self. Therefore, a person's self-esteem may be dependent upon his or her psychological adjustment, the quality of life, adaptive behavior, relationships with friends, motivation, school performance, and success in life (Brooks, 1992;Papadopoulos, Metsiou, & Agaliotis, 2011;Saigal, Lambert, Russ, & Hoult, 2002). Self-esteem is often defined as the evaluative component of self-concept (Pope, Mchale, & Craighead, 1988). Low self-esteem may ensue if there is a discrepancy between a person's expectations and his or her perception of adequacy. Alexander (1996) claims that adjusting to the social impact of vision loss requires the person to adjust positively to life's demands to maintain a positive self-concept. To facilitate the successful inclusion in society of children who are visually impaired, it is important to gain a better understanding of the psychological challenges they face. According to Tuttle and Tuttle (2004, p. 73), "the psychological principles involved in the dynamics of the development of one's self-concept and self-esteem among sighted are equally applicable to persons who are blind." However, children with visual impairment (VI) may have lower self-esteem because the challenges they face in life differ from those faced by sighted children (Alexander, 1996;Hadidi & Al Khateeb, 2013;Konarska, 2007). Roy and MacKay (2002) claim that sighted people might have more difficulties understanding people with low vision than those who are blind. Therefore, self-evaluation, social comparison, and identity may vary between children and young adults who differ in their visual status (Huurre & Aro, 1998;Pinquart & Pfeiffer, 2013). Furthermore, the self-perception of adolescents with low vision could be undermined by any negative attitudes of his or her peers, parents, and teachers.
Additionally, different countries have different school systems, cultures, and social and financial support systems for persons who are visually impaired. Some children with VI live in residential schools for the blind, while others are integrated into mainstream schools. These differences can also affect a child's perception of his or her moral, personal, physical, and social self-esteem (Bracken, 1995).
With increasing age, children naturally tend to seek more involvement with friends than with their parents or siblings, helping them to develop independence and well-being by experiencing different activities (Huurre & Aro, 1998;Olsen et al., 2008). Due to functional restrictions, especially problems with mobility and orientation, children with VI may perceive more stress in their personal and social development compared with sighted children. Their reduced ability to evaluate another person's body language may influence the reaction and feedback they encounter in some situations. Children who are visually impaired may be less socially mature and more egocentric than sighted children, since they often have difficulties observing and imitating their peers which, in turn, may interfere with their ability to develop a positive sense of self-esteem (Tuttle & Tuttle, 2004). Saigal et al. (2002) claim that the self-esteem and social and emotional well-being of children are important domains that one should monitor closely in children considered to have higher risk of problems with adjustment. They also state: "there is now consensus that all aspects of a child's daily activities, motivation, and behavior are impacted by the child's self-esteem" (Saigal et al., 2002, p. 433). In addition, self-perception and feedback from important others are factors that affect whether the level of a person's self-esteem is high or low. Both self-concept and self-esteem play important roles throughout all developmental phases from childhood to adult life. Beaty (1991) suggests that young people with VI have lower self-concept than their peers without VI, in a number of dimensions.
To the best of my knowledge, the peer-reviewed literature does include no review of self-concept or self-esteem among children and young adults with VI. Since peer-reviewed, published papers report mixed results, I considered it important to conduct a systematic review. Accordingly, the aim of this research and review was to summarize current knowledge of self-concept and self-esteem among children and young adults with VI.

Search strategy
First, I used the databases Psychology and Behavioral Sciences Collection, PsycNET, PubMed, Eric, Google Scholar, Web of Science, and MEDLINE to identify published articles on self-esteem and selfconcept among children with VI. I searched the databases using the following search terms: VI, blind, low vision, self-esteem, self-concept, self-worth, and psychosocial development. Second, I conducted a manual search of the reference lists in the retrieved articles.

Criteria for inclusion and exclusion
I included studies of school-age children and young adults with VI in the age range 5-25 years. I chose the upper limit of the age range to be 25 years because many children with VI often need more years to graduate from high school than do sighted children. I restricted articles to those that: were written in English, were based on original data, had been peer-reviewed, and had been published between January 1998 and January 2014 inclusive.
I excluded articles on children and young adults with VI with comorbidity or multiple disabilities. Additionally, I excluded studies that: included only one subject, focused mainly on social support, or were duplicates. Thus, I included a total of 26 studies in the review.

Data extraction
I used a standardized protocol and abstraction form. For each publication, I recorded the first-author's name, publication year, the country in which the study had been conducted, the age and number of people in the study, the number of children with, and the number without VI in the study, the main methods for measuring self-concept and self-esteem, the definition of VI used, the school or college type, and the main results.

Evaluation of the studies
I summarized the results of my research in a table, and used the Quality Assessment Tool for Studies with Diverse Designs (QATSDD) to evaluate the 26 selected studies (Sirriyeh, Lawton, Gardner, & Armitage, 2012). The tool, which was developed to assess the quality of studies on one topic but using different approaches or designs, has been found to have good reliability and validity (Sirriyeh et al., 2012). I used the version with 14 QATSDD items related to quantitative studies. Each item was rated on a four-point scale ranging from "not at all" (0), "very slightly" (1), "moderate" (2), to "completely" (3), with a maximum score of 42. The percentage score was calculated by dividing the actual score by the maximum score (i.e. 42). Papers scoring over 75% were considered "high quality," 50-75% "good," 50-25% "moderate," and those below 25% "poor." The quality ratings are presented in Table 1.

General results
The 26 articles included for evaluation assess either self-concept or self-esteem and the respective authors are listed in Table 1.

Study characteristics
All of the evaluated articles report results from observational studies with a cross-sectional design, except for two that report results of interventional studies (Bowen, 2010b;Shapiro, Moffett, Lieberman, & Dummer, 2005). The study conducted by Bowen included a six-month educational intervention for four children with VI, and the study conducted by Shapiro et al. included 43 children with VI who attended a one-week summer camp. The articles were conducted in 15 countries. Most studies included only a small number of subjects, although 7 of the 26 studies included more than 100 participants with VI (Huurre, Komulainen, & Aro, 1999Kef, 2002;Kotb, Gadallah, & Marzouck, 2011;Mishra & Singh, 2012;Pinquart & Pfeiffer, 2013;Were, Indoshi, & Yalo, 2010). The age range of the participants, school type, definition of VI, and outcome measurements differed from study to study.

Gender
With regard to self-esteem and self-concept, Bowen (2010a) and Were et al. (2010) found that girls with VI had better scores than boys with VI, but two other studies did not find gender differences (Datta & Talukdar, 2016;Mishra & Singh, 2012). By contrast, Al-Zyoudi (2007) found that compared with boys with low vision, girls with low vision scored higher on self-concept regarding their physical appearance but lower on self-concept in social relationships. Shapiro et al. (2005) found that girls with VI had lower perceptions of their competence than boys with VI, and although the girls' perception of competence increased after a one-week summer camp, the boys still scored higher on competence than the girls. Three studies from Finland showed that girls with VI had lower self-esteem than girls without VI, while boys with VI seemed to be well adjusted with respect to their self-esteem (Huurre & Aro, 1998, 2000Huurre et al., 1999). Huurre and Aro (2000) claim that the findings are indicative of different coping mechanisms or different ways of expressing health differences between boys and girls. This finding is in line with results reported by Halder and Datta (2011).

Severity and age of onset
Two studies found that the severity of children's VI did not influence their self-concept (Huurre et al., 1999;Pinquart & Pfeiffer, 2013); by contrast, four studies found the opposite results for self-esteem (Bowen, 2010a;Garaigordobil & Bernarás, 2009;Papadopoulos, 2014;Were et al., 2010). Pinquart and Pfeiffer (2013) found that children with congenital VI scored lower on self-identity than children with acquired VI, while Papadopoulos (2014) found the opposite results. The results of the study conducted by Roy and MacKay (2002) showed that young adults with low vision had poorer selfevaluation and identity than those who were blind. Huurre et al. (1999) found that the onset of VI did not influence the self-esteem of children with VI compared to peers with VI.

Social support and friendship
Social support, especially friendship (Huurre et al., 1999(Huurre et al., , 2001Shapiro et al., 2008), seemed to be important for enhancing the self-esteem or self-concept of children with VI. Al-Zyoudi (2007) concluded that, compared with boys with low vision, girls with low vision had lower scores on self-concept in social relations. Bowen (2010b) conducted an educational intervention study of children with VI who had low self-esteem. Her results showed that interventions that included more cooperative teaching ("circle time" and "circle of friends") and more learning in the classroom had a positive effect. The scores on self-esteem increased.

Discussion
Due to different research purposes, study designs, samples, cultures, and the use of different measurements to evaluate self-concept and self-esteem, the results of the studies were inconsistent. However, friendship, independence in mobility, social support, and parenting style all seemed to be important for enhancing the self-concept and self-esteem of children with VI. Girls with VI appeared to have less selfesteem and a lower sense of self-concept compared with boys with VI. Children with VI may have fewer opportunities to make friends than sighted children and they may face more social isolation. As a possible consequence, they may develop emotional and communication problems (Kef, 2002). Overprotection could leave them feeling less attractive and competent, and consequently they could experience additional frustration and emotional or behavioral problems (Huurre & Aro, 1998, 2000. Good social support, especially support from friends, may help to improve self-concept and selfesteem among children with VI (Lopez-Justicia et al., 2001;Pinquart & Pfeiffer, 2013). Opportunities for children with VI to join leisure activities and other social activities with friends are especially important (Huurre & Aro, 2000). Griffin-Shirley and Nes (2005) claim that the development of self-esteem among children and youths with VI requires an environment that provides freedom to explore and protection from danger. Self-confidence in one's abilities is important, and therefore adults or friends need to help children with VI to find suitable leisure-time activities.
The reported importance of the degree of vision loss differed between the studies. However, most of the studies didn't separately analyze children with mild VI. Lack of information for children with mild VI may therefore have biased some conclusions. Nevertheless, the degree of vision loss and the prognoses of the disease may interfere with evaluations of self-esteem. The inclusion of children with VI in mainstream schools did not seem to have a negative influence on their self-esteem (Gronmo & Augestad, 2000). In some countries, parents may send their child to a school for the blind, but in other countries, the only option may be a mainstream school. The results of the study conducted by Kef (2002) showed that adolescents with VI reported higher self-esteem than sighted adolescents. One reason for those results may be that, of the sample of 316 children with VI, 198 had moderate VI and attended residential schools for children with VI in the Netherlands. Children and youths in residential schools may develop more friendships with each other, and there may be similarities in the way they perceive social acceptance and evaluations of appearances. Perceived lack of these domains may reduce healthy feelings of self-worth. Some researchers suggested that parents and teachers played important roles in the development of identity, moral judgment, social interaction, and physical self-behavior among children with VI (Bowen, 2010b;Cardinali & D'Allura, 2001;Pinquart & Pfeiffer, 2013). The link between perceived acceptance and self-esteem may be important. Additionally, domain-specific competence, such as academic, social, athletic, physical, and behavioral competence, may differ in relation to age, gender, and diagnoses.

Limitations
The aims, study design, participants, and measurement methods differed between the evaluated 26 studies. The studies also differed with respect to the ages of their participants and in the measurements of self-esteem and self-concept, which thus complicated comparisons. The presence of additional disabilities and the economic and cultural status of the participants in each study were not taken into account. However, despite the extensive literature on studies with sighted participants, research on self-concept and self-esteem may be flawed due to ambiguous definitions of the construct and lack of adequate instruments with which to measure it (Saigal et al., 2002).
A further limitation was that different definitions of VI were used in the studies. The majority of the publications (22) do not mention the diagnoses, progression of the disease, or the onset-age of vision loss, yet increasing severity of visual losses may lead to lower scores on self-concept and lower self-esteem (Bowen, 2010a).
In most studies, the age range of the participants was wide, which may have affected the results. Children's emotional or behavioral performances differ according to different age and development stages (Papadopoulos, 2014;Pinquart & Pfeiffer, 2013). Therefore, the different results for self-esteem and self-concept for children with VI may have been partly due to normal psychological development with increasing age for the studied children.
In addition, the majority of the studies evaluated were small, and limited to a specific geographical area; only 7 studies included more than 100 children with VI. All of the studies had a cross-sectional design, except for three interventional studies (Bowen, 2010b;Shapiro et al., 2005Shapiro et al., , 2008. Therefore, the results could not be synthesized in a meta-analysis because of the small number and heterogeneity of the included studies. I suspect that bias due to selection or confounding may have occurred in at least some of the studies (e.g. Al-Zyoudi, 2007;Bowen, 2010b;Datta & Talukdar, 2016;Roy & MacKay, 2002;Shapiro et al., 2005Shapiro et al., , 2008. I strongly suspect there was bias in the studies that lacked randomization, especially those that included only a small convenience sample of children with VI. Unfortunately, many studies used this approach to obtain a more homogeneous sample. Thus, the study subjects may not have represented the target population. Conclusions of some studies might not have been accurate in the cases where selection bias was not taken into account.

Conclusions
The lack of longitudinal observational studies and randomized clinical trials limits the ability to draw conclusions about cause and effect. Some studies found that age and degree of vision loss influenced perceptions of self-esteem in children and young adults with VI. Social support, friendship, independence in mobility, and parenting and teaching style seemed to be important for helping children with VI to enhance their self-concept and self-esteem. In order to provide opportunities for successful development and healthy self-evaluation for children and young adults with VI, we need more knowledge and additional longitudinal and randomized studies of high quality.

Implications for practitioners
The findings may have implications for the education of children with VI as well as the provision of services for them. To achieve a good self-esteem and self-concept, it is important for children with VI to have more experiences of cooperation, independence in mobility, and more opportunities to attend activities with their peers. Furthermore, there is a need for a better understanding of the emotional and social needs of children with VI, in order to improve their self-esteem and to enhance their psychological self-evaluation and well-being. In a successful development process, all children can develop and become well adjusted, emotionally balanced individuals who have a positive perception of their self-esteem.