Impact of ocular misalignment on social trait attribution in children: a cross-sectional study

To investigate the influence of ocular misalignment on social trait attribution in children and to evaluate whether isolated variations in ocular alignment affect early social perception.

In this prospective, cross-sectional study, 100 children aged 8-14 years evaluated standardized visual stimuli depicting characters that differed in ocular alignment (orthotropic, esotropic, and exotropic). The illustrations were neutrally designed to control for facial expression, symmetry, gender, and skin tone. Four questionnaire forms were created, each containing three images, and each participant completed only one form. Within each form, one image represented each ocular alignment condition, so that no child viewed more than one alignment version of the same base character. This design was intended to reduce direct comparison bias. Participants assigned predefined social traits - including intelligence, bravery, success, and friendliness - to each character. Responses were recorded in a binary format and statistically compared across alignment conditions.

Characters with ocular misalignment were less frequently assigned favorable attributes. Orthotropic characters were significantly more likely to be rated as intelligent, successful, and brave compared with both esotropic and exotropic characters (p < .05 for all comparisons). For friendliness, orthotropic characters were more frequently perceived as friendly than exotropic characters (p = .002). No significant differences were observed between esotropic and exotropic depictions. Age subgroup analysis (8-11 vs. 12-14 years) revealed similar perception patterns across groups.

Ocular alignment appears to influence social trait attribution in childhood. Even under controlled visual conditions, misalignment was associated with reduced attribution of positive characteristics. These findings highlight the potential role of early perceptual bias in the psychosocial experience of children with strabismus and underscore the broader clinical and societal relevance of ocular alignment beyond visual function.