Cognitive behaviour therapy-based early intervention and prevention programme for anxiety in South African children with visual impairments

Abstract

Background: Anxiety is the most common psychological difficulty reported by youth worldwide and may also be a significant problem for children with visual impairments. Cognitive behaviour therapy (CBT) interventions have proven to be successful in treating childhood anxiety; however, mostly these are not suitable for children with visual impairments, as the materials used are not sufficiently accessible to this population.

Objectives: The present study was motivated by the dearth of research on this topic and aimed to examine the effects of a specifically tailored, group-based, universally delivered, CBT intervention for anxiety in children with visual impairments and to examine the influence of three predictor variables (i.e. age, gender and level of visual impairment) on prevention effects.

Method: A randomised wait-list control group design with pre-, post- and follow-up intervention measures was employed. The final sample of 52 children (aged 9–14) with varying degrees of visual impairment received the anxiety intervention. Participants were followed over a course of 10 months during which their anxiety symptoms were assessed quantitatively at four time points (T1–T4).

Results: The results indicated that the anxiety intervention did not significantly decrease symptoms of anxiety within the intervention groups. However, the intervention appeared beneficial for girls, younger children and legally blind participants.

Conclusion: This study demonstrated how CBT interventions can be adapted for use in children with visual impairments. Results obtained provide a foundation upon which future updated anxiety intervention programmes can be built, meeting the need for further research in this area.

Full text

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African Journal of Disability
ISSN: (Online) 2226-7220, (Print) 2223-9170
Page 1 of 8 Original Research
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Authors:
Lisa Visagie1
Helene Loxton1
Leslie Swartz1
Paul Stallard2
Aliaons:
1Department of Psychology,
Faculty of Arts and Social
Sciences, Stellenbosch
University, Stellenbosch,
South Africa
2Department for Health,
Faculty of Humanies and
Social Sciences, University of
Bath, Claverton Down, Bath,
United Kingdom
Corresponding author:
Helene Loxton,
hsl@sun.ac.za
Dates:
Received: 31 Aug. 2020
Accepted: 26 Nov. 2020
Published: 29 Jan. 2021
How to cite this arcle:
Visagie, L., Loxton, H.,
Swartz, L. & Stallard, P.,
2021, ‘Cognive behaviour
therapy-based early
intervenon and prevenon
programme for anxiety in
South African children with
visual impairments’, African
Journal of Disability 10(0),
a796. hps://doi.org/
10.4102/ajod.v10i0.796
Copyright:
© 2021. The Authors.
Licensee: AOSIS. This work
is licensed under the
Creave Commons
Aribuon License.
Introducon
Childhood anxiety is common, with most anxiety being functional and beneficial, providing
motivation and preventing excessive risk-taking. However, for a number of children, anxiety has
a negative effect and interferes so significantly in their daily functioning, or is so developmentally
inappropriate, that the diagnosis of an anxiety disorder may be warranted (Campbell 2003). If
left untreated, anxiety symptoms persist and increase in severity (Prinzie et al. 2014; Weems &
Silverman 2013) placing children at risk for depression, substance abuse, higher suicide ideation,
illicit drug dependence, higher rates of school drop-out and unemployment in late adolescence
and adulthood (Ahlen et al. 2012; Bittner et al. 2007; Donovan & Spence 2000; McLoone,
Hudson & Rapee 2006; Stallard 2010; Stallard et al. 2007).
Children with physical disabilities are more prone than their non-disabled peers to the
development of psychological difficulties (including anxiety) (Gullone 1996; Ollendick,
Matson & Helsel 1985), and a particular high-risk group are children with visual impairments
(Visagie et al. 2013). Despite this increased risk, children with visual impairments have been
neglected in previous fear and anxiety research. The last international study on this research
topic was conducted by Weimer and Kratochwill (1991) in America more than two decades ago.
Given their increased ‘risk’, it is important to develop appropriate interventions to equip
visually impaired children with the necessary skills and strategies to manage anxiety symptoms
when they arise.
Background: Anxiety is the most common psychological difficulty reported by youth
worldwide and may also be a significant problem for children with visual impairments.
Cognitive behaviour therapy (CBT) interventions have proven to be successful in treating
childhood anxiety; however, mostly these are not suitable for children with visual impairments,
as the materials used are not sufficiently accessible to this population.
Objectives: The present study was motivated by the dearth of research on this topic and
aimed to examine the effects of a specifically tailored, group-based, universally delivered,
CBT intervention for anxiety in children with visual impairments and to examine the influence
of three predictor variables (i.e. age, gender and level of visual impairment) on prevention
effects.
Method: A randomised wait-list control group design with pre-, post- and follow-up
intervention measures was employed. The final sample of 52 children (aged 9–14) with varying
degrees of visual impairment received the anxiety intervention. Participants were followed
over a course of 10 months during which their anxiety symptoms were assessed quantitatively
at four time points (T1–T4).
Results: The results indicated that the anxiety intervention did not significantly decrease
symptoms of anxiety within the intervention groups. However, the intervention appeared
beneficial for girls, younger children and legally blind participants.
Conclusion: This study demonstrated how CBT interventions can be adapted for use in
children with visual impairments. Results obtained provide a foundation upon which future
updated anxiety intervention programmes can be built, meeting the need for further research
in this area.
Keywords: anxiety; prevention; cognitive behaviour therapy; visual impairment; South Africa;
children; schools-based interventions; efficacy.
Cognive behaviour therapy-based early intervenon
and prevenon programme for anxiety in South African
children with visual impairments
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Cognitive behaviour therapy (CBT) is a well-established,
highly researched, evidence-based intervention for the
treatment and prevention of anxiety (Silverman, Pina &
Viswesvaran 2008; Walkup et al. 2008). However, despite
CBT’s encouraging outcomes, less than one quarter of
children who experience anxiety difficulties receive
treatment (Korkodilos 2016; Lawrence et al. 2015; Merikangas
et al. 2010), and of those who do, many will terminate
treatment prematurely (Pina et al. 2003; Wergeland et al.
2015), fail to respond (Rey, Marin & Silverman 2011) or
continue to experience recurrent difficulties despite
treatment (Last et al. 1996). A potential strategy to overcome
these limitations, and manage the high prevalence of anxiety
and its negative consequences, is to place greater focus on
anxiety prevention (Johnston, Kemps & Chen 2018).
Prevention programmes aim to reduce the incidence or onset
of mental health disorders by reducing risk factors and
developing protective factors to prevent the development of
these disorders (World Health Organization 2004).
Prevention programmes are usually conceptualised by their
intended focus, either indicated (targeted to participants
displaying sub-clinical or mild symptoms of disorder),
selective (targeted to participants identified as being at
risk of developing a particular disorder) or universal
(targeted towards whole populations regardless of risk
status) (Liddle & Macmillan 2010; Mrazek & Haggerty 1994;
World Health Organization 2004). Universally delivered
CBT-based anxiety prevention programmes have shown
very positive results; however, they have focused primarily
on children without disabilities (see Johnston et al. 2018
for an overview). The most well-known CBT group-based
anxiety prevention programmes are Kendall’s (1990) Coping
Cat programme and Barrett’s (2005) FRIENDS programme.
Although CBT-based anxiety intervention programmes have
reported promising outcomes, these programmes are not
suitable for children with visual impairments, as much of
their content relies on visual presentation or representations
(i.e. printed worksheets, cartoons, pictures and video-
material). To the researchers’ knowledge, there is currently
no anxiety intervention programme tailored to meet
the specific needs of children with visual impairments.
Considering the given factors and the notion that children
with visual impairments are possibly more prone to the
development of anxiety (Visagie et al. 2013), the researchers
and colleagues (Visagie 2016; Visagie, Loxton & Silverman
2015; Visagie et al. 2017) developed and implemented
a specifically tailored CBT-based anxiety intervention
programme (Positive and Motivating programme – PAM)
for South African visually impaired children.
This article aims to overcome gaps in the childhood anxiety
literature and presents preliminary results obtained from the
implementation of the PAM programme. The objective was
to examine the effects of a specifically tailored, group-based,
universally delivered, CBT intervention for anxiety in
children with visual impairments and to examine the
influence of three predictor variables (i.e. age, gender and
level of visual impairment) on outcomes.
Research methods and design
A specifically tailored CBT-based anxiety intervention
(PAM programme) for South African children with visual
impairments was evaluated in two special schools (School 1
and School 2). The study was set up as a randomised
wait-list control group design with pre-, post- and follow-up
intervention measures. Participants were randomly assigned
to either an immediate intervention group (IIG) or a delayed
intervention group (DIG) at their school.
Parcipants
All assenting children for whom written parental consent
was granted took part. Inclusion criteria required participants
to be in grades 4 to 7 (aged between 9 and 14 years), be able
to read and write (braille or print) and have no other disability
apart from their visual impairment. All children who met
inclusion criteria received the PAM programme regardless of
their anxiety status (universal prevention).
A final sample of 52 middle-childhood (mean age = 11.46,
standard deviation [SD] = 1.4) girls (n = 24, 46.15%) and boys
(n = 28, 53.85%) participated in the study and were followed
over a period of 10 months.
Schools
Participants attended two special schools (School 1 and
School 2). These are the only two schools that specifically
cater for children who have visual impairments in the
Western Cape Province of South Africa – the province where
the study was undertaken. The two schools are approximately
110 km apart and differ widely in terms of their geographical
location and the availability of resources. The impact of
apartheid and its policies have caused severe economic,
social and spatial disparities amongst various racial groups
in South Africa and this is especially evident at School 1. This
school was historically a school for Black children under the
Bantu or Black Education Act (Act no. 47, 1953) (Union of
South Africa 1953), and still today children who attend this
school are primarily from disadvantaged communities, with
approximately 85% – 90% living below the poverty line, with
their parents unemployed and receiving disability grants,
and the majority of children receiving government child
grants (personal communication, School Psychologist at
School 1). The socio-economic circumstances of children at
School 2 are similar, as approximately 70% of learners are
black or Coloured1 and an estimated 55% of children live in
poverty and receive government child grants (personal
communication, School Psychologist at School 2). The socio-
economic situation of these children is in keeping with
the general situation in South Africa, where over half of
the households in South Africa live below the poverty
line (Budlender 2018). However, despite children having
similar socio-economic backgrounds, School 2 is situated in a
more secure and affluent geographical location. In addition,
1.We use terminology in current South African equity legislaon. We do not believe
that these categories have any genec or scienc basis, but the categories have
social meaning in contemporary South Africa.

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because School 2 was historically a school for white children
(under the Bantu Education Act) (Union of South Africa 1953),
the school has better infrastructure and facilities. Please note
that the racial terms used in this article are controversial in
South Africa and have been referred to for the purpose of
reporting descriptions between racially different South
African communities that exist as a result of the country’s
political past. These terms are not used with the intention to
be discriminatory.
Visual impairment
Participants had varying degrees of visual impairment and
were categorised as legally blind (n = 17) or partially sighted
(n = 34) (data were missing for one participant). Children
categorised as legally blind either had no measurable light
perception or had a very limited degree of light perception
and experienced difficulties functioning in unfamiliar
environments without assistance and could not read printed
material.
Intervenon groups
After assenting to participate, the 52 participants were
randomly assigned to either an IIG or DIG at their respective
school. During data analysis, the IIGs from School 1 and
School 2 were combined to form one IIG, and the DIGs from
School 1 and School 2 were combined to form one DIG. The
combined IIG included 27 participants (15 boys, 12 girls)
with a mean age of 11.44 (SD = 1.47); and the combined DIG
included 25 participants (13 boys, 12 girls) with a mean age of
11.58 (SD = 1.35).
Assessments
Participants (N = 52) were assessed on four separate occasions.
The time line below describes these four assessments for both
the IIG and DIG (T1 = Base-line, Time 1):
Time 1 (T1) • Pre-intervention assessment for the IIG
• Pre-waitlist assessment for the DIG
Time 2 (T2) • Immediate 1 week post-intervention
assessment for the IIG
• Post-waitlist assessment for the DIG
Time 3 (T3) • 3-month follow-up intervention assessment
for the IIG
• Immediate 1-week post-intervention
assessment for the DIG
Time 4 (T4) • 3-month follow-up assessment for the IIG.
On each occasion two standardised measures were completed:
The Revised Child Anxiety and Depression 30-Item Scale
(RCADS-30) (Chorpita, Moffitt & Gray 2005; Sandín et al.
2010) is a self-report measure, which assesses anxiety and
depression symptoms across six domains: social phobia,
separation anxiety, obsessive compulsive disorder, panic
disorder, generalised anxiety disorder and major depressive
disorder. Participants are asked to rate the frequency with
which symptoms occur on a 4-point Likert scale ranging
from ‘never’ (scored 0) to ‘always’ (scored 3). A total scale
score is obtained by summing the scales’ 30 items yielding a
total score of between 0 and 90.
The Penn State Worry Questionnaire for Children (PSWQ-C)
(Chorpita et al. 1997) is an 11-item questionnaire, which
assesses the tendency to engage in excessive generalised and
uncontrolled worry. Respondents are asked how often each
item applies to them by indicating answer options on a
4-point Likert scale ranging from ‘never true’ (scored 0) to
‘always true’ (scored 3). A total scale score is obtained by
summing the scales’ 11 items yielding a score between 0 and
33, with higher scores indicating a greater tendency to worry
(Muris, Meesters & Gobel 2001; Stallard et al. 2014).
Intervenon protocol and materials
The PAM programme (Visagie 2016) is a brief CBT-based
early intervention and prevention programme for anxiety,
specifically tailored to meet the needs of visually impaired
children between the ages of 9 and 14 years. Participants
received 10 PAM group sessions over the course of
5 weeks. Sessions were delivered twice weekly and lasted
approximately 45 min. Sessions were delivered in either
English or Afrikaans depending on the children’s language
of schooling (English at school 1 and Afrikaans at school 2).
During the programme, children participate in activities,
which teach coping skills and problem-solving techniques,
thereby helping them to deal more effectively with anxiety.
Activities teach skills to identify feelings; to learn to relax,
to identify unhelpful thoughts and replace them with more
helpful thoughts (cognitive restructuring), how to face and
overcome daily problems and challenges and how to illicit
family and peer support (Barrett, Lowry-Webster & Turner
1999; Stallard et al. 2007; Visagie 2016). The programme
uses a tangible soft toy dog (named PAM) with a collar and
eight symbolic charms to represent key anxiety management
skills. Charms include the following: (1) a heart, a reminder
that feelings come from your heart; (2) a hat, a reminder that
thoughts come from your head; (3) a butterfly, a reminder of
how the body reacts to anxiety (i.e. the butterflies in your
tummy); (4) a noodle, a reminder to use relaxation strategies
to help the body relax (like a cooked noodle); (5) a musical
note, a reminder to do things, which help you to relax and
make you feel good (e.g. listen to music, sing a song, play a
game, etc.); (6) a shoe, a reminder of the steps to take to face
and solve your problems; (7) a star, a reminder to reward
yourself for trying your best; and (8) a hand, a reminder to
reach out for others when you need help. The format of
the programme included large and small group work
sessions, role plays, games, stories, activities and quizzes
(more information pertaining to the programme’s content
can be attained on request).
The 10 sessions of the PAM programme were delivered by
the first author with a research facilitator present. The
first author is a registered counselling psychologist with
ample experience and knowledge relating to developmental

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psychology and CBT. Research facilitators had at least an
honours degree in psychology and had completed a CBT
module as part of their academic work. The first author
trained and familiarised the facilitators as to the content of
the programme. Although they were not required to deliver
any sessions individually, they facilitated smaller groups
within the larger group with the first author present to
provide guidance. Each research facilitator received a copy
of the PAM programme manual. The manual describes the
goals and strategies for each session, the desired outcomes
and the specific activities that are to be completed in each
session. To reinforce and generalise sessions, homework
tasks were assigned to each session and participants were
required to bring completed homework activities to the next
session.
Data collecon procedures
Participants were asked to complete three separate measures,
the first being a biographical questionnaire, which was only
completed at T1, as well as the RCADS-30 and the PSWQ-C
(these measures are described in more detail here). The
first author and two research facilitators (two postgraduate
psychology students) administered the measures in groups
at the two identified special schools. Measures were available
in English or Afrikaans depending on the children’s language
of schooling (English at School 1 and Afrikaans at School 2).
Data collection took place in classroom settings at both
schools, where participants sat at desks and completed the
measures themselves. Data collection was conducted in a
manner that accommodated all participants’ specific visual
needs (Visagie & Loxton 2014). Questionnaires were read
aloud to participants to ensure that questions were correctly
understood. Participants were informed that all questionnaire
responses were confidential. Participants indicated their
answers using their braille machines or enlarged versions of
the questionnaires (42.00 cm × 59.40 cm). If a participant
required extra attention, one of the researchers assisted him
or her individually to complete their questionnaires. Upon
completion of the questionnaires, all participants were
encouraged to ask any questions that they may have had.
At T2, after all 10 PAM sessions had been delivered to the
IIG, the anxiety status of all participants (N = 52) (IIG and
DIG) was assessed. Data collection procedures occurred
similarly to those at T3; after delivering all 10 PAM sessions
to the DIG the anxiety status of all participants (n = 52)
(IIG and DIG) was reassessed. Data collection once again
occurred, as with T1 and T2. At T4, 3 months after delivering
the PAM programme to the DIG, the anxiety status of all
participants (N = 52) (IIG and DIG) (that in effect was at
3-month follow-up for the DIG and 6-month follow-up for
the IIG) was again assessed.
Data analysis
The Statistical Package for the Social Sciences (SPSS for
Windows version 23.0) (IBM 2015) was used to calculate
descriptive and non-parametric statistics. A series of repeated
measures of analyses of variance (ANOVA’s) were conducted
to compare reports of anxiety within the IIG and DIG across
time (T1–T4) and differences between the IIG and DIG at
each of the four times of testing were explored using one-way
ANOVA. These between-group and within-group effects are
reported here.
Ethical consideraon
Permission to conduct the study was obtained from the
Western Cape Education Department in South Africa
(Reference: 20130507-10635). Ethical approval from
Stellenbosch University Research Ethics Committee: Human
Research (Humaniora) (HS888/2013) was also obtained.
After the two special schools consented to the study, parents
were informed of the project via an information sheet and
consent form, which they were asked to sign and return.
Parental consent was granted for 59 out of a possible 83
children (71%). After enrolment three participants (n = 3)
withdrew from the study and one participant (n = 1) moved
to a different school. The remaining 55 participants were
followed over a period of 10 months. However, at the time of
data analysis, the data of 52 participants could be used. This
was because of the necessary exclusion of participants (n = 3)
from data analysis as a result of one measurement (T1, T2
or T3) being missing.
Results
Scores on the Revised Child Anxiety and
Depression 30-Item Scale and Penn State
Worry Quesonnaire for Children
Overall, results indicate that mean base-line scores on the
RCADS-30 and PSWQ-C for both groups (IIG and DIG)
were slightly higher when compared with post-intervention
(T3) scores. At baseline, participants in the IIG (n = 27)
reported a mean total RCADS-30 score of 27.77 and a mean
total PSWQ-C score of 12.84, whilst participants in the DIG
(n = 25) reported a mean total RCADS-30 score of 34.52 and
a mean total PSWQ-C score of 15.32. These initial mean
scores were lower than expected and fell below the clinical
range on the RCADS-30 of mean scores greater than or
equal to 49. At T3, participants in the IIG (n = 27) reported a
mean total RCADS-30 score of 26.99 and a mean total
PSWQ-C score of 11.29, whilst participants in the DIG
(n = 25) reported a post-intervention (T3) total mean
RCADS-30 score of 29.43 and total mean PSWQ-C score of
12.64. Four participants (n = 4) displayed elevated anxiety
scores at baseline, and at post-intervention (T3) only one
participant (n = 1) reported anxiety symptoms which fell
within the clinical range. This participant was brought to
the attention of the school psychologist for further follow-
up. Tables 1 and 2 present the means and SD for the IIG
(n = 27) and DIG (n = 25) on the RCADS-30 and PSWQ-C
from T1 to T4, respectively.
Overall 2 (groups) × 4 (time points) ANOVAs were performed
on the total scores of the RCADS-30 and PSWQ-C for the IIG
(n = 23) and DIG (n = 22) separately. The multivariate main

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effects for time on both these measures were non-significant
for both the IIG and DIG on either the RCADS-30:
(F[3, 20] = 0.481, p = 0.699 [IIG]: F[3, 19] = 1.202, p = 0.336
[DIG]) or PSWQ-C: (F[3, 20] = 1.538, p = 0.235 [IIG]:
F(3, 19) = 1.408, p = 0.271 [DIG]).
Within group and between eects
Results of the multivariate main effects for time were not
significant for both the IIG and DIG on either the RCADS-30
(F[3, 20] = 0.481, p = 0.699 [IIG]: F(3, 19) = 1.202, p = 0.336
[DIG]) or the PSWQ-C (F[3, 20] = 1.538, p = 0.235 [IIG]:
F(3, 19) = 1.408, p = 0.271 [DIG]). There were no significant
between group effects.
Total group eects
When taking the statistical sample as a whole (N = 52) into
account, there was a significant decline in the total worry
score on the PSWQ-C from pre- (T1) to post- (T3) test
(F[1, 51] = 4.436, p = 0.040). Results on the RCADS-30 for the
total sample (N = 52) from T1 to T3 were non-significant
(F[1, 51] = 2.347, p = 0.132). Effects on the six sub-scales of
the RCADS-30 from T1 to T3 were also non-significant
(F[6, 46] = 1.080, p = 0.388).
Eects of predictor variables
When considering the variables of age (younger 9–11-year-
old vs. older 12–14-year-old children), gender (girls vs. boys)
and level of visual impairment (legally blind vs. partially
sighted), the following was noted:
In terms of age, there was a significant interaction between
time and age for younger children (n = 30) on the RCADS-30
(F[1, 29] = 11.771, p = 0.002). Thus, the younger participants’
mean score at T3 (M = 24.85) was significantly lower than at
T1 (M = 32.68). Multivariate repeated measures ANOVA’s
were also performed on the six subscale scores of the
RCADS-30. There was a significant multivariate main effect
for the younger participants (F[6, 24] = 2.976, p = 0.026).
Post hoc comparisons with Bonferroni adjustments
indicated significant reductions on the major depression
(p = 0.001) and obsessive compulsive disorder (p = 0.003)
subscales. Results on the PSWQ-C relating to age were non-
significant.
Anxiety scores on the RCADS-30 and worry scores on the
PSWQ-C for boys (n = 28) and girls (n = 24) were also
compared. Results on the RCADS-30 were non-significant for
both boys and girls). However, results on the PSWQ-C were
significant for girls with (F[1, 23] = 13.411, p = 0.001) with the
mean score at T3 (M = 11.67) being significantly lower than at
T1 (M = 15.77).
Total mean scores on the RCADS-30 and PSWQ-C for the
legally blind (n = 17) and partially sighted (n = 34) groups
were also compared. There was a significant interaction
between time and vision for legally blind participants on
the RCADS-30 (F[1, 16] = 7.845, p = 0.013). Thus, for the
legally blind group the mean score at T3 (M = 24.22) was
significantly lower than at T1 (M = 31.41). Multivariate
repeated measures ANOVA’s were also performed on the
six subscale scores of the RCADS-30 with a significant
effect for the legally blind group (F[6, 11] = 4.55, p = 0.048).
Post hoc comparisons with Bonferroni adjustments
indicated that for the legally blind group the mean score on
major depression at T3 (M = 3.24) was significantly
(p = 0.016) lower than at T1 (M = 4.74), and the mean score
on obsessive compulsive disorder at T3 (M = 3.88) was
significantly (p = 0.014) lower than at T1 (M = 6.79). Results
on the PSWQ-C were non-significant.
TABLE 1a: Means and standard deviaons for the total score on the Revised
Child Anxiety and Depression 30-Item Scale for the immediate intervenon
group (n = 27) and delayed intervenon group (n = 25) from T1 to T4.
Assessment
Time (Time)
IIG (n = 27) DIG (n = 25)
Means SD Means SD
T1 27.77 11.31 34.52 13.76
T2 29.45 13.94 31.75 8.84
T3 26.99 16.64 29.43 11.93
Source: Visagie, L.S., 2016, ‘Development, implementaon and evaluaon of a cognive
behavioural therapy based intervenon programme for the management of anxiety
symptoms in South African children with visual impairments’, PhD dissertaon, Department
of Psychology, Stellenbosch University. hps://scholar.sun.ac.za/handle/10019.1/100110
Note. T4 = follow-up and there were only 45 parcipants – IIG (n = 23) and DIG (n = 22).
IIG, immediate intervenon group; DIG, delayed intervenon group; SD, standard deviaon.
TABLE 2a: Means and standard deviaons for the total score on the Penn State
Worry Quesonnaire for Children for the immediate intervenon group (n = 27)
and delayed intervenon group (n = 25) from T1 to T4.
Assessment
Time (Time)
IIG (n = 27) DIG (n = 25)
Means SD Means SD
T1 12.84 5.95 15.32 5.91
T2 11.31 5.97 14.33 6.31
T3 11.29 6.44 12.64 4.79
Source: Visagie, L.S., 2016, ‘Development, implementaon and evaluaon of a cognive
behavioural therapy based intervenon programme for the management of anxiety
symptoms in South African children with visual impairments’, PhD dissertaon, Department
of Psychology, Stellenbosch University. hps://scholar.sun.ac.za/handle/10019.1/100110
Note. T4 = follow-up and there were only 45 parcipants – IIG (n = 23) and DIG (n = 22).
IIG, immediate intervenon group; DIG, delayed intervenon group; SD, standard deviaon.
TABLE 1b: Means and standard deviaons for the total score on the Revised
Child Anxiety and Depression 30-Item Scale for the immediate intervenon
group (n = 27) and delayed intervenon group (n = 25) from T1 to T4.
Assessment
Time (Time)
IIG (n = 23) DIG (n = 22)
Means SD Means SD
T4 27.91 15.16 29.41 12.75
Source: Visagie, L.S., 2016, ‘Development, implementaon and evaluaon of a cognive
behavioural therapy based intervenon programme for the management of anxiety
symptoms in South African children with visual impairments’, PhD dissertaon, Department
of Psychology, Stellenbosch University. hps://scholar.sun.ac.za/handle/10019.1/100110
Note. T4 = follow-up and there were only 45 parcipants – IIG (n = 23) and DIG (n = 22).
IIG, immediate intervenon group; DIG, delayed intervenon group; SD, standard deviaon.
TABLE 2b: Means and standard deviaons for the total score on the Penn State
Worry Quesonnaire for Children for the immediate intervenon group (n = 27)
and delayed intervenon group (n = 25) from T1 to T4.
Assessment
Time (Time)
IIG (n = 23) DIG (n = 22)
Means SD Means SD
T4 11.04 7.02 12.41 7.25
Source: Visagie, L.S., 2016, ‘Development, implementaon and evaluaon of a cognive
behavioural therapy based intervenon programme for the management of anxiety
symptoms in South African children with visual impairments’, PhD dissertaon, Department
of Psychology, Stellenbosch University. hps://scholar.sun.ac.za/handle/10019.1/100110
Note. T4 = follow-up and there were only 45 parcipants – IIG (n = 23) and DIG (n = 22).
IIG, immediate intervenon group; DIG, delayed intervenon group; SD, standard deviaon.

Page 6 of 8 Original Research
hp://www.ajod.org Open Access
Discussion
The purpose of this study was to explore the effect of a
specifically tailored CBT-based programme (PAM programme)
on participant-reported symptoms of anxiety.
The PAM programme did not lead to post intervention
reductions in self-reported anxiety and worry scores on the
RCADS-30 and PSWQ-C. These non-significant results may
relate to the fact that base-line anxiety symptoms were
unexpectedly low. The overall mean score within each group
virtually remained unchanged from T1 to T4.
A second aim of the present study was to examine the effects
of the predictor variables of age, gender and level of visual
impairment. Younger (9–11-year-olds) and legally blind
participants reported significant reductions in anxiety scores
on the RCADS-30 from pre- (T1) to post- (T3) test. Girls also
reported a significant reduction in worry scores on the
PSWQ-C. Thus, although there were no overall effects, it
appears that the PAM programme may be beneficial for
girls, younger participants (aged 9–11) and legally blind
children. Results relating to the legally blind group are
particularly noteworthy, as children with severe visual
impairments have been identified as a high-risk group
(Loxton, Visagie & Ollendick 2012; Visagie et al. 2013, 2015).
It is also encouraging to note the effects relating to a decrease
in symptoms of major depression for younger (age 9–11-year-
olds) and legally blind children. These results are important
as it has been noted that some larger scale depression
prevention studies have recently found non-significant
universal effects (Herman et al. 2009; Rowling & Kasunic
2006; Stewart 2008; Taylor et al. 2014).
The absence of an overall effect could be masked by two
factors. Firstly, the sample size is small resulting in reduced
statistical power to detect small differences. Secondly, initial
levels of anxiety were unexpectedly low and, with the
exception of four participants, all were in the ‘normal’ range
at base-line. Thus, the groups could not be expected to differ
substantially after implementation of the PAM programme.
This is a limitation of universal approaches and raises the
question of whether it is worth the time and money to offer
a programme to a whole group of children if the majority are
not anxious (Rose, Miller & Martinez 2009). According to a
public health universal approach, even small effects can be
meaningful, as decreasing the distribution of symptoms in
the population by even a small amount may often correspond
to a reduction in the occurrence of overall cases of disorder
(Andrews, Szabo & Burns 2002; Mychailyszyn et al. 2012).
Another limitation relates to the lack of multiple-informants
for data collection. Previous studies have noted non-significant
results post-intervention on participant self-reports, however,
when considering other anxiety measures (e.g. diagnostic
interviews and parent or teacher reports) significant
intervention effects were noted (Bernstein et al. 2005, 2008;
Ginsburg 2009; Nauta et al. 2003; Urao et al. 2016; Wood et al.
2009). This may have also been the case in this study, but
because additional teacher reports to assess intervention
outcomes were not returned, these sources of data could not be
included.
A further limitation relates to the absence of a control group
to assess for possible changes being the result of the natural
passing of time (i.e. maturation). This would have been ideal,
but as a result of the target population already being so
limited in size, the inclusion of a control group was not
feasible. This would have decreased numbers of participants
in the IIG and DIG even further.
Lastly, it may also be that significant effects may present
with ensuing time as children become more adept at using
their newly learnt anxiety management skills (Mostert &
Loxton 2008).
Conclusion
Our results indicate that the PAM programme did not bring
about a significant decrease in symptoms of anxiety within
a group of visually impaired children. However, our results
suggest that the PAM programme may be more beneficial
for girls, younger participants (aged 9–11) and legally blind
children.
The present study is the first of its kind to evaluate the effects
of a specifically tailored CBT-based anxiety intervention
programme for children with visual impairments. This
population has been grossly neglected in previous child
anxiety research, and despite limited results our study
provides an insight into how traditional CBT interventions
can be adapted for use with this group. Participants
perceived the PAM programme to be enjoyable and helpful,
as was evident from their enthusiasm and impromptu
responses throughout programme sessions. Results obtained
from this study provide a good foundation upon which
future up-dated anxiety intervention programmes can be
built. Thus, continued research in the area of anxiety
intervention and prevention for this population should be
promoted.
Acknowledgements
The authors would like to thank Prof. Wendy Silverman
(Yale University) for her invaluable comments and insights
during the process of completing this research; Mr. Henry
Steel for his assistance with the statistical analysis; Jacqueline
Gamble for her technical support and editing of the text; and
most importantly, the school principals, school psychologists
and the participants at the two schools for their willingness
to help and participate, as without them this study would not
have been possible.
This study is based on a PhD dissertation by the first author,
Lisa Visagie, titled: ‘Development, implementation and
evaluation of a Cognitive Behavioural Therapy based
intervention programme for the management of anxiety
symptoms in South African children with visual impairments’,

Page 7 of 8 Original Research
hp://www.ajod.org Open Access
submitted at Stellenbosch University in 2016. Portions of
the text of the article are taken from the dissertation, available
for free download at: https://scholar.sun.ac.za/handle/
10019.1/100110
Compeng interests
The authors declare that they have no financial or personal
relationships that may have inappropriately influenced them
in writing this article.
Authors’ contribuons
L.V., H.L., L.S. and P.S. conceived of the presented idea,
developed the theory and performed the computations and
verified the analytical methods. H.L. and L.S. supervised the
findings of this work. All authors discussed the results and
contributed to the final manuscript.
Funding informaon
The financial assistance of the National Research Foundation
(NRF), South Africa, as well as the Fulbright scholarship
programme, towards this research is hereby acknowledged.
Data availability statement
The authors confirm that the data supporting the findings
of this study are available within the article and its
supplementary materials. For full information please see
Visagie (2016).
Disclaimer
Opinions expressed and conclusions arrived at are those of
the authors and are not necessarily to be attributed to the
NRF or the Fulbright scholarship programme.
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