A substantial body of literature indicating that childhood anxiety presents a serious mental health problem has now been amassed (Barrett & Turner 2001). Firstly, the literature indicates that anxiety is one of the most common forms of psychological distress reported by youth (Barrett & Sonderegger 2005; Dadds et al. 1997). A recent meta analytic prevalence study indicated that an average of 12.3% of school-aged children (ages 6–12) experience significant symptoms of anxiety (e.g., Costello et al. 2011, 2003; Heiervang et al. 2007; McArdle, Prosser & Kolvin 2004; Mullick & Goodman 2005; Petersen et al. 2006). Secondly, although experiencing transient fears and anxieties is deemed to be a normal part of development for most children; for some these experiences may intensify and persist over time, causing interferences in daily functioning (Barrett, Lock & Farrell 2005; Silverman 2011). Thirdly, the experience of childhood anxiety has been associated with a number of somatic difficulties such as fatigue, restlessness, irritability, and sleep disturbances (Beidel, Christ & Long 1991; Pina & Silverman 2004) and psychosocial impairments such as problems with peer relations, low self-esteem, immaturity, impaired academic functioning, and concentration problems (Cooley, Boyd & Gratos 2004; Farrell & Barrett 2007; Messer & Beidel 1994; Motoca, Williams & Silverman 2012). Fourthly, if left untreated, severe symptoms of anxiety can take on a chronic and unremitting course (Barrett & Turner 2004; Cole et al. 1998; Weems & Silverman 2013), and many adults who are diagnosed with an anxiety disorder can trace the onset of symptoms back to their childhood (Rapee & Barlow 1993). Given this suggested relationship between childhood anxiety and adult psychopathology, it is essential for symptoms of anxiety to be addressed as early as possible (Cobham 2003), and promising in this regard is the increased evidence pointing to the amenability of childhood anxiety symptoms to brief psychosocial interventions (Lowry-Webster, Barrett & Dadds 2001; Silverman, Pina & Viswesvaran 2008).

Yet, despite these promising results, research indicates that less than 20% of children who require treatment for anxiety will receive clinical intervention (Day & Roberts 1991; Olfsen et al. 2003), and of those who do, a large number will terminate prematurely (Kazden 1996; Pina et al. 2003), fail to respond (Donovan & Spence 2000; Rey, Marin & Silverman 2011) or, despite treatment, continue to experience recurrent difficulties (Last et al. 1996).

In addition, long waiting lists, high costs, high instances of family drop outs, and no show rates also influence access to treatment (Weist 1999). As a result, health policies across the world increasingly promote prevention as the most important direction in which mental health services should move (Barrett & Turner 2004; Lowry-Webster, Barrett & Lock 2003). Prevention offers a positive adjunct to treatment, as prevention programmes can reach a large number of individuals over a shorter period of time; avoid high levels of personal distress for children and their families; and offer a cost-effective and efficient means of intervention prior to the onset of psychopathology (Farrell & Barrett 2007).

The South African prevalence rates of anxiety symptoms are even higher than the above-mentioned international estimates suggest, with Muris and his colleagues (Muris et al. 2002) reporting prevalence rates of anxiety symptomology between 22% – 25.6% in children aged 7 to 13 years. These findings were confirmed in subsequent South African studies (Burkhardt, Loxton & Muris 2003; Muris et al. 2006). Mostert and Loxton (2008) noted these high prevalence rates and identified the need for a suitable anxiety intervention programme which could be implemented within the South African context. Previous international studies and also the World Health Organization (WHO 2004) had identified Barrett’s (2004) cognitive behavioural therapy (CBT) based FRIENDS Programme to be an efficacious intervention for the reduction of anxiety symptoms in youth (see Briesch, Hagermoser Sanetti & Briesch [2010] for an overview). As a result, Mostert and Loxton (2008) conducted a pilot study to explore the effectiveness and suitability of the FRIENDS Programme for use with South African children. This study reported promising results and its outcomes were in line with the government's white paper on the transformation of the South African health care system, as the study promoted prevention as an important strategy for the enhancement of the mental and physical health of the nation (DOH 1997).

The above-mentioned anxiety factors, their high prevalence rates, and identified need for a suitable intervention programme, become even more significant when viewed in terms of the population of children with visual impairments, who are often marginalised, as previous research involving children with physical disabilities suggests that they are at increased risk of developing psychological difficulties when compared to their non-disabled peers (see Gullone [1996] for an overview). Despite this identified risk, this population has been neglected in previous fear and anxiety research. The last international study to touch on this topic was conducted by Weimer and Kratochwill more than two decades ago (1991) in Wisconsin (USA).

Identifying this gap in the literature, the authors (Visagie et al. 2013) conducted an exploratory (baseline) study with South African children with visual impairments. Results indicated that the overall fear profiles of children with visual impairments, and children with normal sight, did not differ significantly (Visagie et al. 2013). This similarity indicates that the two populations (children with and children without visual impairments) have similar needs. As the need for a suitable anxiety intervention programme was highlighted in the general South African population (children without visual impairments) (Burkhardt et al. 2003; Mostert & Loxton 2008; Muris et al. 2006), the same can be said for this specific group. Children with visual impairments also require a suitable and accessible anxiety intervention programme (Loxton, Visagie & Ollendick 2012; Visagie et al. 2013).

On closer evaluation of the study by Visagie et al. (2013), the need for a suitable anxiety intervention programme was noted to be especially prominent for a specific sub-group of children with visual impairments (i.e. children with severe visual impairment). In their 2012 paper Loxton, Visagie and Ollendick (2012) highlighted significant differences in fearfulness between three groups of visually impaired children who had varying levels of sight (i.e. partially sighted, severely visually impaired and totally blind). These levels of vision can be viewed on a sliding scale (i.e. children who are partially sighted have the most vision; children with severe visual impairment have less vision, but they are not totally blind; and the totally blind children have no level of measureable vision). Children with severe visual impairment (i.e. children who have a degree of light perception and movement detection, but who cannot function optimally without assistance and cannot read print material (WHO 2000), were more fearful than the partially sighted and totally blind children. This group reported the highest number (M = 42.09, SD = 17.84) and also level (M = 171.63, SD = 28.60) of fear. This reported number of fears is almost double the number reported by the children with normal sight (M = 24.66, SD = 13.12). The level of fear in children with normal sight was also lower (M = 146.15, SD = 25.33).

Thus, children with severe visual impairment can be identified as a high-risk sub-group within the broader population of children with visual impairments, for the possible development of later anxiety disorders. A possible suggestion for this sub-group's greater instance of fearfulness could relate to the fact that the visual difficulties, of this group of children, are the most differentiated and difficult to understand. The totally blind children can see nothing; therefore, they need assistance in most unfamiliar situations. On the other hand, partially sighted children usually have enough sight to help themselves and move around independently, and the children with severe visual impairment are in the middle, this group's visual difficulties may be the most complex and most disabling.

Although children with severe visual impairments have a degree of measurable vision, they may find it difficult to function independently in an unfamiliar environment. Therefore, the uncertainty when they are faced with new situations and possibilities may contribute directly to their higher fear reactivity (Bensch 2010; Loxton et al. 2012; Sacks et al. 2006; Visagie et al. 2013). Therefore, it is essential for these children to have access to suitable intervention programmes focused on the development of appropriate coping strategies and problem solving skills to enable them to deal competently with anxiety symptoms when they arise.

Although Mostert and Loxton (2008) obtained favourable outcomes with the FRIENDS Programme with a group of South African children, their study did incur some limitations. It was noted that the FRIENDS acronym (F for feeling worried?, R for Relax and feel good, I for Inner thoughts, E for Explore plans of action, N for Nice work, reward yourself!, D for Do not forget to practise, and lastly S for Stay cool and calm! (Barrett 2004, cited in Mostert 2007), which is aimed to aid children in remembering the coping steps to take when faced with a problem, was difficult for some South African children to remember and problematic to translate into Afrikaans (Mostert & Loxton 2008). Furthermore, Mostert and Loxton (2008) concluded that although the FRIENDS Programme has been used successfully in other countries, South African socio-contextual issues (the high incidence of crime and poverty) should not be ignored – research should in addition be focused on constructing a socially relevant anxiety intervention programme that considers the impact of these factors (Mostert & Loxton 2008). In addition, the FRIENDS Programme is not suitable for use with children with visual impairments, as its content (i.e. cartoons, colouring-in pictures, workbook and visual-based activities) is not very accessible to this specific population.

To summarise, the following six factors motivated the proposed study:

The high prevalence rates of anxiety symptomology in the general population (especially in South Africa)

As a result, the proposed study will aim to develop, implement and evaluate an anxiety prevention or early intervention programme (from here on referred to as an anxiety intervention programme), which is specifically tailored to meet the needs of children with visual impairments within the South African context. As far as the researchers can ascertain, no studies focussed on anxiety prevention and early intervention programmes, for children with visual impairments, have been conducted previously.

Thus, the primary aim of the study is to develop, implement and evaluate a specifically tailored anxiety intervention programme for use with South African children with visual impairments. This aim will unfold in the following three steps:

Specifically, it is expected that firstly, there will be a significant reduction in anxiety scores on the RCADS from Time 1 (T1) to Time 2 (T2) for the immediate intervention group (IIG), and secondly, there will be a significant reduction in anxiety scores on the RCADS from T2 to T3 for the delayed intervention group (DIG).

A specifically tailored CBT-based anxiety intervention for South African children with visual impairments will be evaluated in two special schools that cater for children with visual impairments. This study is set up as a randomised wait-list control group design with pre-, post-and follow-up intervention measures, with 60 participants randomly assigned to an IIG (n = 30) and a DIG (n = 30). Before implementation of the programme 10 participants from each group will be randomly selected to take part in a focus group. The focus group will be aimed at obtaining the participants’ personal inputs and to pilot certain sections of the programme before final implementation. Both of the programme's groups will receive the 10 session anxiety intervention programme. The participants will complete baseline (T1), post intervention (T2 for IIG and T3 for DIG) and 3 month (T3 for IIG and T4 for DIG) or 6 month (T4 only for IIG) follow-up assessments.

The research design can be represented as follows:

R  IIG T1   X  IIG T2     IIG T3  IIG T4

R  DIG T1     DIG T2  X  DIG T3   DIG T4

R = Randomisation

X = intervention

A specifically tailored, group-based, anxiety intervention programme for children with visual impairments will be implemented as a universal intervention. The anxiety intervention programme, which is based on a CBT model, was developed over a period of six months. CBT-based interventions employ both cognitive (e.g. positive self-talk) and behavioural (e.g. relaxation) techniques to modify cognitions, behaviour and affect (Kendall 1993; Nevid, Rathus & Green 2000; Silverman & Kurtines 1996). Thus, CBT-based interventions aim to teach children to identify maladaptive thoughts and to replace these thoughts with more positive ones (Mash & Wolf 2005). In addition, one of the greatest benefits of CBT is its longevity, as CBT is focussed on equipping people with a set of coping skills that can be used both now and in the future. Furthermore, CBT-based interventions are usually shorter-term interventions, making them more cost-effective and appealing (Farrell & Barrett 2007; Ollendick & King 1998; Silverman et al. 2008). For these reasons, CBT was the intervention modality of choice for the study.

The eight key concepts of CBT as described by Barrett and Turner (2001) are central to the anxiety intervention programme's theoretical base, and include:

The programme's core theme relates to the enhancement and development of skills or competencies which can be employed when confronted with difficult situations, whether they relate to fears or worries, daily hassles (e.g. struggling with a difficult homework assignment), or stressful and aversive life events (e.g. moving to a different school or facing family conflict) (Barrett & Turner 2001). In addition to incorporating the eight key concepts of CBT, the anxiety intervention programme lent and built on ideas and concepts adapted from already existing CBT-based approaches and programmes, such as:

The challenge in this adaptation was not only to translate the eight key concepts of CBT into a child-friendly and age-appropriate programme, aimed at combating anxiety symptoms, but also to present the programme in a format that is accessible and appealing to children with visual impairments. As an alternative to reading and colouring in pictures (which is the norm in most of the programmes to date) the adapted programme makes use of clay (and other tactile media), toys, role-plays, games, songs, narratives and other creative techniques as alternative forms of engagement. As the FRIENDS acronym is not suitable for use in the proposed study the title for the adapted intervention programme is the P& M programme (PAM = Positive & Motivating, and in Afrikaans Positief & Motiverend). Activities in the P& M programme are aimed at teaching children with visual impairments practical skills, such as: identifying feelings; relaxation skills; identifying unhelpful and helpful thoughts; and how to deal with daily problems and challenges (Stallard et al. 2007).

As mentioned above, all assenting children from School 1 and School 2 will randomly be assigned to 1 of 2 groups at their respective school (an IIG or a DIG). The IIG groups from School 1 and School 2 will be combined to form one large IIG, whilst the DIG groups from School 1 and School 2 will be combined to form one large DIG.

The evaluation phase will comprise both a quantitative and qualitative component (more information about the qualitative component is given below). For the quantitative evaluation, all assenting children in the IIG and DIG (approximately 60 participants) will be administered a short biographical questionnaire (only at T1) and three self-report questionnaires at pre (T1), post (T2), and follow-up (T3 and T4) intervention. Children in the IIG will receive the intervention programme before the children in the DIG. It is envisaged that the programme will be delivered to the two groups (the IIG and DIG) of children according to the following outline:

It will be possible to measure:

The following six hypotheses are to be tested during the evaluation phase of the proposed study (four hypotheses pertain to between group effects and two hypotheses pertain to within group effects).

Questionnaires will be made available in four different input modes relating to the individual participant's specific needs and degree of visual impairment. In some cases the original print versions of the questionnaires will be provided and read by means of a magnifying aid, questionnaires will also be put in a large print format (A3), and for those participants who cannot read print, the questionnaires will be made available in braille or in an audio format. The modes of response will also be adapted to suit the individual participant's communication needs. Participants who are able to read the standard or large print copies of the questionnaires can indicate their answers in the spaces provided, and for the participants using braille or recorded versions of the questionnaires, specially prepared answer sheets will be made available.

In previous studies (King, Gullone & Stafford 1990; Matson et al. 1986; Ollendick, Matson & Helsel 1985; Wilhelm 1989) where the fears and anxieties of visually impaired children were assessed using self-report measures (e.g. The Revised Fear Survey Schedule for Children, FSSC-R; The South African Fear Survey Schedule for Children, FSSC-SA; and the Revised Children's Manifest Anxiety Scale, RCMAS) similar adaptations were made with great success. Children will complete the questionnaires at their school with the help of the research facilitators. Guidelines put forth by Visagie and Loxton (2014) about the child-friendly assessment and the accomodations needed for children with visual impairments to complete self-report surveys, will be implemented and followed throughout the process of data collection.

The questionnaires will be administered to all participants (IIG and DIG) on four occasions:

This study will employ a randomised wait-list control group design with pre and post-intervention measures to evaluate the effectiveness of a specifically tailored, group-based, CBT anxiety intervention programme for 9–13 year old South African children with visual impairments. It is hypothesised that children in the IIG will experience significantly reduced symptoms of anxiety when compared to children in the DIG.

This study will evaluate the effectiveness of a specifically tailored, group-based, CBT anxiety intervention programme for South African children with visual impairments, and the results rendered by the study will provide insights into the effectiveness of the anxiety intervention, and determine its suitability for future use within the South African context.