PurposeTo study associations between strabismus and alcohol use, anxiety and depression among 10-17-year-old children in Guangdong, southern China. DesignCross-sectional, population-based study MethodsAmong 7537 children aged 6 to 17 years from 9 randomly-selected primary and middle schools, ocular alignment was assessed with the Hirschberg light reflex, cover-uncover testing, and alternate cover testing at distance (6 m) and near (40cm). Additionally, 4000 children (53.1%) aged 10+ years received self-administered questionnaires containing screening questions on alcohol use, anxiety and depression. ResultsExaminations were completed on 7,464 of 7,537 subjects (99.0%), including 3,928 (52.6%) boys, with a mean age of 11.1±1.8 years. The prevalence of any strabismus, including exotropia (2.7%), esotropia (0.2%), and intermittent exotropia (3.9%), was 6.8%. Strabismus was more prevalent in urban students (7.3%) and females (7.4%) compared to rural students (6.0%) and males (6.2%) (all P < .05). In multivariate regression models, any strabismus was associated with older age and rural versus urban residence. Among 3903 (97.6%) children answering questionnaires, history of alcohol use (62.3% versus 36.3%) and positive screening responses for depression (26.0% versus 11.6%) and anxiety (10.3% versus 4.9%) were significantly (P < .01 for all) more common among children with strabismus. ConclusionThese Chinese children with strabismus had significantly higher prevalence of alcohol use and possible markers of emotional problems than children without strabismus. Further research should focus on the appropriateness of classifying surgical treatment for strabismus as "cosmetic" (ineligible for reimbursement) under China's rural health insurance.