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Less than half of those who need mental health counseling receive it globally, underscoring the urgent need for psychology-focused intervention. According to data, 30.9% of Nigerians experience psychological anguish. This study investigated the efficacy and moderators of group cognitive behaviour therapy in psychologically distressed schoolchildren with adventitious blindness in Nigeria. A total of 98 students with adventitious blindness were recruited and participated in this study. The participants were assessed at three points using Perceived Emotional Distress Inventory. A mixed model ANCOVA with repeated measures shows that the CBT treatment had a dependable significant effect in decreasing psychological distress. The results showed that sociodemographic factors do not significantly moderate the efficacy of CBT treatment on the reduction of psychological distress in schoolchildren with adventitious blindness. In conclusion, the effect of a group cognitive behavioural therapy had a consistent significant reduction in psychological distress and none of their sociodemographic characteristics moderated the effects. Therefore, cognitive-behavioural practitioners should collaborate with special schools to diagnose and provide CBT treatment to schoolchildren living with adventitious blindness.
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Introduction
In most schools, children are admitted to acquire knowledge, skills, and formal education. Some schoolchildren live with disabilities, including adventitious blindness. Recognizing the emotional challenges these children face in school, practitioners are recommended to provide counseling to address the needs of schoolchildren with adventitious blindness (Ede et al., 2022; Ramchandani, 2004) with the aim of reducing psychological distress, improving their well-being, and bridging empirical gaps in the literature (Habib & El Din, 2007).
Adventitious blindness is a significant public health concern that can be traumatic and devastating, especially when it occurs late in life. Adventitious blindness occurs when a person loses their sight completely or to a significant degree suddenly or gradually for any reason (Jalali et al., 2014). Turner (2005) defines adventitious blindness as a loss of vision that occurs suddenly or gradually after approximately 5 years of sighted experience. Tuttle (2004) noted that the impact of blindness is greater when it occurs late in life. Individuals with adventitious blindness find it more challenging to adjust compared to those with congenital blindness, as evidenced by various studies (Beaty, 1994; Fitzgerald et al., 1987; Papadopoulos et al., 2013; Tuttle, 2004; Wortman & Silver, 1989). Understanding the rates and experiences of those living with adventitious blindness is crucial for providing psychological interventions to improve their well-being.
Psychological distress among individuals with blindness is a prevalent mental health challenge globally (Abateneh et al., 2013). Studies have shown an increased prevalence rate of psychological distress (15%) among individuals with adventitious blindness from 2005 to 2015 compared to previous years (Global Burden of Disease Collaborative Network, 2016; World Health Organization, 2017). Psychological distress rates are higher among individuals with visual impairment compared to their peers with normal visual development (Abateneh et al., 2013; Pourseyyed et al., 2010). Studies in Nigeria have highlighted a concerning prevalence rate of psychological distress among schoolchildren with blindness (Akanni & Otakpor, 2016), indicating a need for psychological interventions beyond medical and surgical ophthalmic care.
Psychological distress begins when individuals realize they have experienced a complete or gradual loss of vision. Acceptance of this disability is a challenging psychological process, involving shock, disbelief, denial, anger, mourning, withdrawal, and depression (Tuttle, 1987). Individuals with adventitious blindness may experience losses in various areas, such as confidence, mobility, recreation, career, financial security, and self-esteem, leading to psychological distress (Jalali et al., 2014). Adjusting to new behavioral patterns can be difficult for individuals with adventitious blindness, resulting in challenges like reading, writing, learning mobility, increased dependence, and facing hazardous situations (Tuttle, 2004; Khochen-Bagshaw, 2011; McFarlane, 1988; Stevelink & Fear, 2015). Psychological distress associated with loss of sight impacts social functioning, daily living, and quality of life, potentially leading to posttraumatic stress disorder, anxiety disorders, depression, insomnia, low self-esteem, headaches, and substance abuse (Abateneh et al., 2013; Merikangas et al., 2007).
Studies showed that people with such feelings have dysfunctional beliefs about self, future, and the world (Amoke, et al., 2020; Ezegbe, et al., 2019). The feeling that they would be rejected by their friends or that they may not be able to accomplish tasks as they use to could result in negative beliefs and distorted thoughts (Amoke, et al., 2020; Ezegbe, et al., 2019). These have been documented to generate distorted beliefs and thoughts (Davarmanesh & Barrati, 2006). An effective intervention is likely to prevent the development of more severe conditions (Litz, et al., 2002). Psychosocial adjustment to blindness has been adventitious to the nature and quality of psychosocial support and rehabilitation opportunities provided to the individual. Where an intervention is not provided the psychological distress can result in maladjustment and reduced quality of life (Tunde-Ayinmode et al., 2011). Considering the negative effect of psychological distress on the general well-being and quality of life of persons with blindness, previous studies (Amoke, et al., 2020; Ezegbe, et al., 2019) suggested cognitive behavior therapy (Beck, 1964) for the treatment of psychological distress.
Research Gaps
As indicated in previous studies, individuals with adventitious blindness experience psychological distress, and the rates are very high (Augustin et al., 2007; Sefat et al., 2017), resulting in the need for psychological treatment (Brody et al., 2001). Despite these needs, only a few studies have utilized psychological interventions to reduce psychological distress in visually impaired individuals (Sefat et al., 2017). There is minimal research on the psychological distress of schoolchildren with adventitious blindness.
According to a comprehensive review of randomized or controlled psychological distress or mental well-being studies, predictors and moderators have been studied in only a few studies starting from 2000 to 2013, and the results have offered little consistent understanding regarding moderators (Nilsen et al., 2013). Meanwhile, a past review of CBT treatment studies on depressed and distressed youngsters suggested that the sociodemographic characteristics (e.g., age and family income) of participants have predictive influences (Curry et al., 2006). Despite this limitation, research into potential multiple sociodemographic moderators such as family size and gender is important in psychological distress studies because it can reveal crucial information about the effectiveness of CBT in specific populations. Different reports have been given regarding who experiences psychological distress more between men and women and how the difference impacts interventions. A recent study reported that women were more vulnerable to psychological distress compared to men (Viertiö et al., 2021). Similarly, other past studies found more depressive symptoms (Van Droogenbroeck et al., 2018) and anxiety in women compared to men (Evensen et al., 2016). However, Charney (2004) found that men have higher mental health problems than women but have difficulty believing it. Instead, they prefer acting it out by exhibiting antisocial behaviours such as substance abuse (Charney, 2004; Evensen et al., 2016). The conflicting reports from different past studies were motivations for the current investigation. Our interest in this study is to examine gender differences in mental distress and how the categorization (males and females) moderates the impacts of cognitive behavior therapy. We argue that reporting and documenting through the cognitive appraisal of male and female individuals with adventitious blindness and how gender difference influences their coping skills is important.
Family size is another potential moderator and is seen as the number of family members living in the same house, categorized as small, moderate, and large family sizes. A large household is associated with fewer mental problems in children in Norway (Grinde & Tambs, 2016). Other reports showed that small family size predicts internalizing behavior in schoolchildren in Australia (Bayer et al., 2008) and Mexico (Ozer et al., 2008). From the reviewed studies, there seems to be no studies investigating family size as a potential moderator of intervention in Nigeria. We are the first to seek the treatment outcomes of CBT on psychological distress of children with adventitious blindness. Based on that, this study aimed to investigate the effect of group cognitive behavioral therapy on psychological distress among schoolchildren with adventitious blindness. To ascertain the effect, there would be three assessments, one before the treatment, and others after the treatment. Also, to find out if family size and gender could moderate treatment outcomes in psychological distress among schoolchildren with adventitious blindness. It is hypothesized that there will be a significant reduction in psychological distress among schoolchildren with adventitious blindness when exposed to group cognitive behavioral therapy at Time 2 assessment. We also hypothesized that there will be a consistent significant reduction in psychological distress among schoolchildren with adventitious blindness when exposed to group cognitive behavioral therapy. Additionally, it was hypothesized that family size and gender will moderate and predict treatment outcomes in psychological distress among schoolchildren with adventitious blindness.
General Review of Cognitive Behavior Therapy
Beck believes that cognitive distortions play a role in the development of cognitive behavior therapy. All-or-nothing thinking, overgeneralization, catastrophizing, and personalization, etc. For example, when people think in extremes all of the time, they have an all-or-nothing distortion. For example, polarized thinking occurs when you believe you’re either destined for success or predestined to failure, or that the people in your life are either angelic or demonic. When people overgeneralize, they come to a judgment about one occurrence and then apply that conclusion wrongly across the board. When people catastrophize, everyday problems can swiftly spiral out of control. An expected check, for example, does not appear in the mail. Catastrophizing might lead to the anxiety that it will never arrive, and that as a result, the family will be evicted because they will be unable to pay their rent. Distorted cognition is at the core of cognitive behavior therapy (Beck, 1964). Cognitive distortions are referred to as mistakes in thinking about specific situations that lead to negative behavioral and emotional outcomes such as anxiety and depression (Persons, 1989). Cognitive distortions in Beck’s model result from a reversion to a “primitive information-processing system” activated through the “interaction of personal and environmental factors” (Beck & Weishaar, 1989). The development of distortion occurs when there is a disconnection between an individual’s cognitive representation of a situation and the actual existence of the situation (Ede et al., 2020).
A major component of cognitive behavior therapy is what Beck calls the cognitive triad, which includes negative cognitive judgment of self, the current experience, and the future (Beck, 1976; Beck et al., 1979). Several studies have shown that an individual’s negative thoughts and distorted cognitions about oneself, the future, and the world result in negative emotions and put the individual at risk of developing depression (Ede et al., 2020; Ellis, Moseley, & Wolfe, 1966; Joyce, 2006; Welsh & Tuttle, 1997), low self-worth, helplessness, and hopelessness (Dobson & Dozois, 2001). CBT believes that consciously or unconsciously individuals continuously experience thoughts in different situations and circumstances, which are referred to as automatic thoughts. It is believed that automatic thoughts stem from an individual’s perceptions and interpretations of situations and events based on previous beliefs, assumptions, experiences, and knowledge connected to relevant memories (Beck, 1976). These automatic thoughts were subject to specific types of dysfunctional thoughts or cognitive distortions, which were regarded as “selective abstraction, overgeneralization, dichotomous thinking, and exaggeration of the negative aspects of their experiences (Beck, 1991).
Several types of cognitive distortions have been identified. Beck et al. (1979) identified seven types namely, (1) selective abstraction, (2) overgeneralization, catastrophisation, personalization, temporal causality or predicting without sufficient evidence, self-reference, and dichotomous thinking. Yurica (2002) elaborated more on this and adventitious added a few others to have 11 cognitive distortions which include externalization of self-worth, fortune-telling, magnification, labeling, perfectionism, comparison with others, emotional reasoning, arbitrary inference/jumping to conclusions, minimization, mind-reading, emotional reasoning, and decision-making. Cognitive distortions occur more during high-stress Beck (1976). Essentially Cognitive-behavior therapy (CBT) is founded on three major assumptions (Dobson & Dozois, 2001). The first is that cognitions influence behavior and emotions (Beck & Weishaar, 1989; Dryden & Ellis, 2001). By identifying the distorted thinking in those with visual challenges could help the quality of their life and psychological wellbeing using cognitive and behavioural techniques (Ede et al. 2019; Ede et al., 2022; Egbe et al., 2022; Ugwuanyi et al., 2022).
CBT and Psychological Distress in Individuals with Adventitious Blindness
Cognitive distortions have been identified in adults with blindness and visual impairment (Mullins, 2019; Ueda, 2016). Existing studies have shown that distorted or maladaptive cognitions significantly contribute to the continual occurrence of psychological distress (e.g., Amoke et al., 2020; Ezegbe et al., 2019; Uhl, 2007). Research indicates that certain dysfunctional cognitive structures involving specific cognitive deficiencies and distortions have been associated with emotional and behavioral issues such as psychological distress (Dodge & Schwartz, 1997; Frey & Epkins, 2002; Panourgia & Comoretto, 2017). The presence of cognitive distortions puts individuals at a higher risk of developing emotional and behavioral psychopathology (e.g., Frey & Epkins, 2002). According to Beck (2008), when there are greater dysfunctional structures, there will be more psychological distress and, consequently, more situations that may provoke dysfunctional thoughts. One of the factors that predispose individuals with blindness to dysfunctional thoughts is societal beliefs and perceptions concerning the abilities and inabilities of individuals with blindness (Agah et al., 2020, 2021; Agu et al., 2021). Some of these beliefs are based on maladaptive thinking (Abiogu et al., 2020; Ede et al., 2021a, b) that blind individuals can’t do much on their own, can’t marry and have children, and can’t get good jobs (Śmiechowska-Petrovskij, 2017). Unfortunately, evidence-based studies have shown that these societal beliefs are upheld by persons with blindness (e.g. Welsh & Tuttle, 1997). However, cultural differences exist as what is obtainable in the Nigerian context may differ from other industrialised societies. This suggests the need for future studies. These maladaptive thinking patterns can be particularly damaging for individuals with adventitious blindness and can lead to unhappiness, arbitrary inference, jumping to conclusions, and self-defeating thoughts that could limit their lives (Ueda, 2016). Distorted cognition is highly linked with emotional disorders (Beck, 1967, 1976) and psychological distress (Beck & Freeman, 1990; Beck et al., 2004), anxiety and depressive disorders (Kendall, Kortlander, & Brady, 1992), and adolescent depression and anxiety (Kolko et al., 2000).
Previous studies have highlighted the maladjusted belief statements that visually impaired people often make. These include: (1) an individual’s worth is dependent upon his/her physical adequacy; (2) blind people had to be either gifted or defective in their intellectual functioning; (3) blind people had a special relationship with other people and society in general, and (4) there were magical circumstances about blindness. These negative self-statements have the potential to make individuals unhappy, and self-defeating, and could limit their potential (Needham & Ehmer, 1980; Ueda, 2016). Given the manifestations and associated problems of psychological distress among individuals with blindness, there is a need for interventions to assist them in coping (Abateneh et al., 2013). We argue that if psychological intervention is adopted for populations with adventitious blindness experiencing psychological distress, it may reduce the dysfunctional thinking associated with adventitious blindness. This would also support practitioners in focusing on strength based vs weakness based terms while writing reports. This study aims to investigate the effect of group cognitive behavior therapy on the psychological distress of schoolchildren with adventitious blindness.
Method
Ethical Adherence and Considerations
We adhered to the ethics, and code of conduct guiding the use of human beings in a study. To comply with principles stipulated in American Psychological Association (2013), it is compulsory that every participant must thumbprint an informed consent letter or give us oral approval. Prior to this, the Institutional Review Board from the University of Nigeria gave permission for the study. Upon this, consent was sought from the parents during Parents Teachers Association annual meeting.
Participants, Materials, and Recruitment process
A total of 98 students with adventitious blindness were recruited and participated in this study. The participants were recruited using oral invitation by the research team. As the researchers visited their schools, the school authorities mobilized them to the school theatre where the researchers informed them about the intervention. At this point, their consents were received. Before the participants were admitted to participate, we considered their status bearing in mind admission criteria. These include.
(a)
must have been diagnosed and confirmed by the school psychologist or related profession
(b)
possession of school identification card
(c)
must submit an authorization letter to be part of the study signed by the participant’s parent(s)
(d)
must meet the cut-off score of the dependent measure(s)
(e)
participants must be within a range of visual acuities (e.g. 15/15, 20/20)
(f)
each participant must be legally blind.
The following certain exclusion criteria guided the selection process. These included:
(a)
being part of any related psychological/clinical intervention
(b)
having been admitted to receive medical/pharmacological treatment
(c)
individuals with double or multiple impairments were excluded
The participants were mixed individuals in terms of gender (61 males and 37 females), lengths of time, position in the family, parental education, gender, and family size. In this study, family size is seen as the number of people that belong to the same father or mother relationship. Family size is classified as small, medium and large. Small family size in this context shows that the number of children, each participant has within the classification ranges from one to three children, medium ranges from four to seven and large family size means that the number of children, some participants have is between eight and above. The total participants were determined using Gpower statistical software and it was shown to be okay for the study. The estimated effect size, calculated using the Gpower software, was 0.60, with an alpha of 0.05 and a power of 0.78. The sample size for the between-group comparison was 90, as predicted.
Materials and Procedure
The school children were invited to one of the special schools in Enugu state. The invitation was initially sent to their parents, informing them of the time and venue of the treatment. A number of parents accompanied their children and wards to the treatment center. All the participants were assessed using the Perceived Emotional Distress Inventory and General Health Questionnaire, respectively. Immediately after distributing the measures, parents, teachers, and research assistants were assigned to the participants to read and interpret the measurement tools. As they read, the participants listened and chose the options that applied to them. They indicated their choices by saying either “Not at all,” “Sometimes,” “Often,” or “Very Much So.” According to the instructions, the teachers should read the items while the participants verbally indicate their responses. Importantly, the purpose was to ascertain the experiences of the participants regarding psychological and health conditions, as well as to establish a baseline for the conditions. This exercise helped to identify qualified subjects.
Out of the 119 school children with adventitious blindness, 98 children aged 5 to 13 years were identified as having higher levels of psychological distress and emotional dysfunctions. The remaining 21 children were not included because 8 children were not allowed to participate by their parents due to potential travel during the treatment period, 9 willingly declined without reasons, and 4 were excluded because they did not meet the cut-off score during the primary assessment (pre-treatment test). The parents of the identified children and their teachers were invited to the same venue on the 7th day. The parents, teachers, and research assistants assisted during group allocation. At this time, the researchers crafted cut-out cards with different inscriptions on each card. A total of 98 cards were tagged with TG and CG. The meaning of these tags was not made known to the participants to ensure they were hidden, and the sequence was concealed until the intervention was assigned. This was facilitated using a double-blind technique. The assignment of the participants was performed by the research team. A total of 98 participants were randomly and equally assigned to the treatment group and control group, respectively. Due to the therapists’ busy schedule, the participants in the control group were not treated and were considered a waitlisted control group. However, they received treatment after the study.
Regarding the treatment group, the participants in this group received twelve sessions of treatment. Each session lasted for 45 min and occurred once every week. Sessions 1 and 2 were for initialization, familiarization, and understanding of the aim, rules, and regulations that guided the sessions. During session 3, the therapists focused on identifying the degree of the condition (psychological distress) and automatic assumptions associated with the condition. Song, lyrics, and play were used during session 3 to sustain the attention of the participants. Sessions 4 and 5 addressed how they feel when they wish to do something but have nobody to assist them, how they react to themselves, and examples of self-talk they usually say when alone. Sessions 6 to 7 covered personal experiences, processing of distorted thoughts and feelings, and replacing inaccurate thinking with accurate thinking. Sessions 8 to 9 covered using songs to rearticulate and change distorted assumptions, self-esteem training, and practicing cognitive-behavioral skills like relaxation (sleep management and breathing skills), problem-solving techniques, and relapse prevention. Sessions 10 and 11 reviewed previous sessions, personal observations, participants’ peer assessment of psychological well-being/outcome, and the benefits of the group encounter. Session 12 was the termination stage where participants were informed of a follow-up meeting. Before leaving the treatment venue, the measurement tool was distributed to all participants for the second time (posttest). The follow-up meeting was scheduled for 10 weeks later. During the follow-up meeting, therapists briefly reviewed the sessions and conducted exercises. At the end of the meeting, a follow-up test was conducted. Therefore, the participants were assessed at the pretest, post-test, and follow-up test.
Measure
Perceived Emotional Distress Inventory (Moscoso et al., 2012a, 2012b) is a 15-item scale that measures and identifies the degree of anxiety, anger, depression, and hopelessness in an individual. The PEDI has a 4-point scale of 0 to 3: Not at all (0); Sometimes (1); Often (2); Very much so (3). We calculated the score pattern for each PEDI item using the responder’s ratings and the severity of psychological distress as the comparison between the higher scores and the perceived severity. That is, higher scores represent higher levels of perceived emotional distress which is defined as 0 to 3. Any score that is 2 to 3 was classified as a higher score and 0 to 1 was regarded as a low score. The internal consistency of the PEDI in previous studies for example α = 0.88 (Amoke et al., 2020), α = 0.86 (Ezegbe et al., 2018), and the present study found α = 0.84. To ensure that the items measure the content of PEDI, three experts from Educational Psychology, Counselling Psychology, and Special Education reviewed and validated the questionnaire items. Past study that examined the factor structure of the PEDI reported a three-factor solution with a best simple structure three-factor solution (Moscoso et al., 2012a, 2012b). This shows a valuable and significant meaning to that measurement method, in that it accurately represents the components of the construct (Anxiety, Depression, Hopelessness, and Anger). The present researchers gave credence to a good simple structure As noted by Moscoso and Spielberger (1999), a factor solution was considered to have good simple structure when each item loaded unambiguously on one factor. Pearson correlations between the subscales of the instrument is impressive for such a brief measure (Moscoso et al., 2012a, 2012b).
Intervention
Behavioural intervention programme for psychological distress (see Amoke et al., 2020) is anchored on the principles of Beck. The program is a group-based intervention targeted to reduce the intensity of psychological distress and replace it with an increased state of psychological well-being The intervention programme was conducted and implemented by experienced Cognitive behavioural therapists who have worked with children for years.
Design and Data Analysis
This is a randomized controlled design study. We employed crosstabulation (frequency, percentage, chi-square) and a mixed model ANCOVA with Time as the within-subjects variable, family size and gender as moderators, and lengths of time and parental education as covariates. The IBM Statistical Package for Social Sciences software and JASP 0.16 was used to conduct the data analyses. Partial Eta Square was used to determine the degree of change that is due to the function of intervention. The effect size guidelines (effect sizes of 0.20, 0.50, and 0.80 indicate small, medium, and large effects, respectively) in this study are guided by Cohen (1992). Posthoc analyses were conducted using Sidak (see Šidàk, 1967). After data screening, the data were subjected to an assumption violation test using Mauchly’s test. According to, where the assumption of sphericity is violated, the Greenhouse–Geisser correction (if epsilon value, ε < 0.75), or Huynh–Feldt correction (ε > 0.75) techniques should be used for interpreting the data. Also, the following assumptions were considered to ensure the appropriateness of the interpretation of results.
Test for Equality of Variances (Levene’s) The Levene’s test of equality of variance was conducted using the PEDI scale measurement, the pretest, posttest, and follow-up test of the datasets were significant [F(1, 96) = 7.16, p = 0.09] for pretest; [F(1, 96) = 0.45, p = 0.51] for posttest, and [F(1, 96) = 1.45, p = 0.23].
Test of sphericity The dataset was subjected to a sphericity test. The dataset had a sphericity score of [x2(2) = 41.51, p = 0.001] denoting that the assumption of sphericity was violated and was corrected greenhouse–Geisser since the Msecom value was less than 0.75.
Homogeneity of Regression Slope as measured by CDS Fig. 1 which is the homogeneity slope of PEDI dataset comprised of posttest and follow-up scores. The slope of the regression line pointed in the same direction, denoting no violation of the assumption of homogeneity of regression slopes.
Fig. 1
Homogeneity slope of PEDI dataset comprised of posttest and follow-up scores
×
Results
We examined whether the two groups differ in terms of sociodemographic variables. There is a significant difference in the lengths of time (χ2 = 6.918, p = 0.01), position in family (χ2 = 10.379, p = 0.04), parental education (χ2 = 15.57, p = 0.01) among children with adventitious blindness (participants) in the CBT group and waitlisted control group. The results for the three characteristics (lengths of time, position in the family, and parental education) supported the direction of our predictions that children with adventitious blindness do not differ significantly with regards to lengths of time, position in family, and parental education. However, the demographic shows no significant gender difference (χ2 = 0.043, p = 0.84), family size (χ2 = 1.500, p = 0.47) which is contrary to postulation.
Of all the schoolchildren who participated in the treatment, 31(63.3%) were males and 18(36.7%) were females while in the waitlisted control group, 30(61.2%) were males and 19(38.8%) were females. For lengths of time, there are more than 28(57.1%) schoolchildren in the treatment group who had experienced psychological distress from 1 to years, and 21(42.9%) schoolchildren experienced it from 7 to 12 years. Also, among schoolchildren in the control group, there are more people 40(81.6%) who had experienced psychological distress from 1 to 6 years, and 9(18.4%) schoolchildren who had experienced psychological distress from 7 to 12 years. In terms of position in the family, the treatment group comprised 8(16.3%) schoolchildren who were first child, 6(12.2%) were in the second position, 7(14.3%) were third child, 1(2.0%) in was fourth child position, 27(55.1%) children were in the fifth position in their families; the waitlist control group comprised 8(22.4%) schoolchildren were first child, 7(14.3%) were in the second position, 7(14.3%) were third child, 9(18.4%) in was fourth child position, 15(30.6%) children were in the fifth position in their families. Concerning family size, 14(28.6%), 10(20.4%), and 25(51.0%) schoolchildren from small size, moderate, and large family sizes respectively in the treatment group; the waitlist control group comprised 18(36.7%), 6(12.2%), and 25(51.0%) schoolchildren from small size, moderate, and large family size respectively. The parental education in the treatment group, 15(30.6%), 11(22.4%), 4(8.2%), 10(20.4%), and 9(18.4%) schoolchildren have parents with Senior Secondary School Certificate Examination, Nigeria Certificate in Education, Bachelor degree, Master degree, and Ph.D. respectively. Of all the participants in the waitlisted control group, 5(10.2%), 7(14.3%), 10(20.4%), 5(10.2%), and 22(44.9%) schoolchildren had parents with Senior Secondary School Certificate Examination, Nigeria Certificate in Education, Bachelor degree, Master degree, and Ph.D.
Table 1 showed the mean psychological distress of the cognitive behaviour therapy group (M = 51.39, SD = 3.03) and the comparison group (M = 52.48, SD = 2.19) at the pretest as measured by PEDI. The mean scores and standard deviations of the participants in the CBT Group (51.39 ± 3.03) and Waitlist Control Group (52.48 ± 2.19) confirm some degree of equivalence at the pretest. However, at the posttest and follow-up measures, the mean psychological distress of the cognitive behaviour therapy group (M = 31.97, SD = 3.24), (M = 30.38, SD = 3.51) while those of the control group are (M = 47.15, SD = 3.13), (M = 47.57, SD = 3.38) as measured by PEDI. The perceived psychological distress mean scores of participants in cognitive behaviour therapy group against those in the comparison group indicate a decrease in psychological distress (anxiety, anger, depression, and hopelessness). Also, Table 1 shows that schoolchildren’s PEDI scores do not have group x time x gender interaction effect, F(1.45, 136.69) = 0.031, p = 0.93, η2p 0.01.
Table 1
Descriptive and mixed ANOVA statistics results for schoolchildren’s psychological distress as measured with PEDI
Time
Group
Gender
Mean(SD)
N
P
η2p
95%CI
Pretest
CBT Group
Male
51.08(2.83)
31
.044
.042
51.384, 52.469
Female
51.93(3.35)
18
Total
51.39(3.03)
49
Waitlist Control Group
Male
52.92(2.18)
30
Female
51.79(2.06)
19
Total
52.48(2.19)
49
Post-test
CBT Group
Male
31.63(2.88)
31
.00
0.88
38.890, 40.199
Female
32.56(3.78)
18
Total
31.98(3.24)
49
Waitlist Control Group
Male
47.70(3.51)
30
Female
46.29(2.26)
19
Total
47.15(3.13)
49
Follow-Up Test
CBT Group
Male
30.00(3.34)
31
< .001
.864
38.256, 39.676
Female
31.02(3.80)
18
Total
30.39(3.51)
49
Waitlist Control Group
Male
48.10(3.71)
30
Female
46.74(2.68)
19
Total
47.57(3.38)
49
Time * Group * Gender
.93
.00
Time x Group
.00
.69
Time
.00
0.86
Group * Gender
.008
.072
SD = Standard Deviation; CBT-Group = Cognitive Behaviour Therapy Group, N = number of participants; η2p = Partial Eta Square
Given the sphericity assumption violation that was observed based on Mauchly’s test [x2(2) = 43.765, p = 0.00, ε = 0.727], we employed the Greenhouse–Geisser correction to interpret the research data and the results in Table 1 show there was a significant effect of group in improving psychological distress of schoolchildren following their participation in the CBT treatment as measured with the PEDI, F (1, 86) = 692.134, p = 0.000, η2p = 0.88. The results also show a statistically significant effect of time on schoolchildren’s psychological distress as measured with the PEDI, F (1.45, 136.69) = 586.077, p = 0.000, η2p = 0.86. The significant effects show that scores are influenced by group and their interaction effect, F (1.45, 136.69) = 209.068, p = 0.000, η2p = 0.69. The significant effects also show that scores are influenced by the group and gender interaction effect, F (1, 86) = 7.269, p = 0.008, η2p = 0.07.
Sociodemographic moderators of CBT treatment and psychological distress
The results of a mixed model ANCOVA show that the length of time does not significantly moderate the efficacy of CBT treatment on the reduction of psychological distress among schoolchildren with adventitious blindness at post-test, F(1,93) = 1.692, p = .197, η2p 0.018. Also, the family size significantly moderates the efficacy of CBT treatment on the reduction of psychological distress among schoolchildren with adventitious blindness, F(1,93) = 7.149, p = .009, η2p 0.071 (Table 2). In addition, it shows that parental education significantly moderates the efficacy of CBT treatment on the reduction of psychological distress among schoolchildren with adventitious blindness, F(1,93) = 6.627, p = .012, η2p .067. The three significant results mean that lengths of time, position in the family, and parental education are potentially confounding variables. From the intercorrelation matrix in Table 3, lengths of time and parental education are significantly correlated. Family size is also significantly correlated, but it did not differ between the two groups so it is not a confound.
Table 2
Post Hoc Comparisons-TIME
Mean Difference
95% CI for Mean Difference
95% CI for Cohen’s d
Lower
Upper
SE
T
Cohen’s d
Lower
Upper
pholm
TIME 1
TIME 2
12.38
11.35
13.42
0.43
28.95
4.01
3.23
4.78
< .001***
TIME 3
12.96
11.93
13.99
0.43
30.3
4.19
3.38
5
< .001***
TIME 2
TIME 3
0.58
− 0.46
1.61
0.43
1.35
0.19
− 0.15
0.52
0.18
*** p < .001
P-value and confidence intervals adjusted for comparing a family of 3 estimates (confidence intervals corrected using the bonferroni method)
Results are averaged over the levels of: Group, Gender
Table 3
Correlation analysis of demographic characteristics and psychological distress
1
2
3
4
5
Lengths of Time
Pearson Correlation
1
.206*
0.185
− .241*
− .279**
Sig. (2-tailed)
0.041
0.068
0.017
0.005
N
98
98
98
98
98
Position In Family
Pearson Correlation
.206*
1
0.18
0.132
− 0.04
Sig. (2-tailed)
0.041
0.077
0.196
0.696
N
98
98
98
98
98
Family Size
Pearson Correlation
0.185
0.18
1
− 0.085
− .220*
Sig. (2-tailed)
0.068
0.077
0.406
0.029
N
98
98
98
98
98
Parental Education
Pearson Correlation
− .241*
0.132
− 0.085
1
.254*
Sig. (2-tailed)
0.017
0.196
0.406
0.011
N
98
98
98
98
98
Psychological distress
Pearson Correlation
− .279**
− 0.04
− .220*
.254*
1
Sig. (2-tailed)
0.005
0.696
0.029
0.011
N
98
98
98
98
98
*. Correlation is significant at the 0.05 level (2-tailed)
**. Correlation is significant at the 0.01 level (2-tailed)
The results in Table 2 show the schoolchildren in the CBT intervention group had a greater mean PEDI score at the post-test than those in the control group as confirmed by holm’s post hoc analysis by Time (Mean difference = 12.38, standard error = 0.43, p = 0.000, 95%CI: 11.35, 13.42). A Holm’s post hoc analysis conducted on group x time showed that schoolchildren in the CBT intervention had significantly improved PEDI scores from the pretest (Mean difference = − 0.85, standard error = 0.64, p = 0.37, 95%CI: − 2.76, 1.06) to posttest (Mean difference = − 14.89, standard error = 0.64, p = < 0.001, 95%CI: − 16.80, − 12.99) and follow-up test (Mean difference = − 16.91, standard error = 0.64, p = < 0.001, 95%CI: 18.81, 15.00) than those in the control group.
The correlation analysis of the length of time, family size, parental education, and psychological distress. The results show that a significant negative relationship exists between the length of time ( = − .279, p ˃ .005), family size (r = − .220, p˃.029), parental education (r = − .254, p ˃ .011), and psychological distress. On the other hand, position in the family (r = − .040, p ˃ .696) does not significant relationship with psychological distress.
Discussion and Limitation
This study aimed to investigate the efficacy of group cognitive-behavioral therapy on psychological distress among schoolchildren with adventitious blindness. The pre-treatment results show a slight difference between the CBT treatment and waitlist control groups. After receiving treatment, a second assessment (post-test) shows that the CBT treatment had a significantly large effect in decreasing psychological distress. Subsequently, the participants were assessed at a third point (follow-up test) and the results remained consistent. Interestingly, the results showed a large effect size at the post-test (η2p = 0.88) and follow-up test (η2p = 0.86), determining the degree of change. This was also evident in the mean and standard deviation units at the pretest (mean = 51.39; SD = 3.03), post-test (Mean = 31.98; SD = 3.24), and follow-up test (Mean = 30.39; SD = 3.51). The results also show that there is no interaction effect of groups and gender, indicating a significant influence on schoolchildren’s PEDI scores. There was a decrease in the treatment group but not in the control group. Various samples and populations have shown to benefit from CBT, including those who are blind and suffer from depression, in mitigating psychological distress and other health problems (Beck, 1993; Whisman 1993). In a study by Utoyo (2015), CBT was used in the treatment of depressed older adults with partial sight, with positive results. A study by Soleimani et al. (2017) used CBT in the treatment of depressed age-readventitiousd blindness patients. It is still unclear whether CBT reduces the psychological distress of young adults with adventitious blindness, especially in Nigeria, and studies focused on depression among the elderly. Cognitive-behavior therapy modifies and replaces faulty thinking that leads to psychological stress and distress (Teater, 2010). In the absence of addressing dysfunctional and distorted cognitive beliefs, depression can result. Cognitive processes can be altered and changed (Dobson & Dozois, 2001). It is necessary for the individual to modify and challenge the cognitive process to achieve the desired outcome. Beck et al. (1979) provide empirical evidence that changing the cognitive process through psychotherapy can enable the patient to learn how thoughts affect both their mental and physical states.
The results also investigated the moderating effect of sociodemographic factors on CBT intervention on the condition. The results showed that family size, gender, length of time, position in the family, and parental education do not significantly moderate the efficacy of CBT treatment on the reduction of psychological distress among schoolchildren with adventitious blindness. Although these moderators did not have a significant impact on therapy in the current study, it is important to interpret the findings with caution because they are known to generally affect treatment. In order to discover sources of individual differences in treatment response and guide differential group selection, the search for moderators is critical (Stikkelbroek et al., 2020). Despite the importance, the main effects due to sociodemographic factors play no prediction effects. This is consistent with a past study that found no moderator effect and no distinct group that benefited more from CBT could be identified regarding gender and parental educational level (Stikkelbroek et al., 2020). One may wonder about the possible reason for the consistent outcomes. This finding could be due to the small sample size (Curry, 2009). Aside from sample size, there is another statistical reason (e.g., t-test, ANOVA, MANOVA) to consider (Stikkelbroek et al., 2020). However, the present study reported no moderation effect using a different population, statistical tool, sample size, and study location. Research on a heterogeneous population with significant individual differences is more likely to discover moderators with a sensitive measure for individual differences, according to Kraemer (Nilsen et al., 2013). However, the participants of this study were rather homogeneous in terms of demographics and condition/diagnoses, reducing the chances of detecting a moderator.
In terms of group and time interaction effect, past studies have stated that people exposed to psychological intervention recorded improvement (Ogakuw et al., 2022). This suggests that the effectiveness of CBT lasts over time. Other past studies reported a significant influence of cognitive-behavioral approaches on the well-being of people regardless of the time of measurement (Ede et al., 2021a, b, c, d; Ifeanyieze et al., 2021; Iremeka et al., 2021; Obiweluozo et al., 2021). It is possible that the consistent significant interaction effects of group and time may result from the robust method adopted in those researches. Children would benefit from the outcome of this study through seminars and workshops. It is our hope that teachers of schoolchildren would inspire and teach their pupils and wards the benefit of positive thinking. Schoolchildren, especially those that participated in this study, have understood the impact of CBT on their well-being.
The findings have bridged the gaps in the literature as mentioned in the introduction and literature review sections. As noted earlier, the present study has contributed to building additional knowledge about the psychological distress of children with adventitious blindness by documenting the benefits of CBT intervention. Interestingly, the present study has changed the narrative and lack of reports (see Amoke et al., 2020; Brody et al., 2001; Sefat et al., 2017) on intervention for psychological distress among the children population in developing nations such as Nigeria. Besides, reports (David-Ferdon & Kaslow, 2008; Stikkelbroek et al., 2020; Weisz et al., 2006) on the need for the moderating roles of schoolchildren’s sociodemographic information, CBT intervention, and psychological distress have been filled by the present study. This study is the first to investigate the effect of group cognitive-behavioral therapy on psychological distress among schoolchildren with adventitious blindness.
This study, like other quantitative studies, has some limitations. We did not measure other possible mental health challenges associated with psychological distress, nor did we include schoolchildren with different special needs. By focusing specifically on those with adventitious blindness, the generalizability of our findings is limited. Therefore, we caution future researchers to interpret the results of this study carefully. Additionally, the waiting control group did not receive any treatment during the study period. Due to gender differences in the sampling process, with an unequal number of males and females, it is challenging to consider gender as a moderator. On the positive side, this study is a true experiment with a rare population, and confounding variables were controlled. It builds on previous research by testing in a different country and investigating new moderators. We urge future researchers to avoid the same flaws when replicating this study.
Conclusion
In conclusion, this study found that schoolchildren with adventitious blindness who participated in a group cognitive-behavioral intervention experienced a significant reduction in psychological distress, regardless of their sociodemographic characteristics. Cognitive-behavioral practitioners should work with special schools to diagnose and provide CBT treatment to schoolchildren with adventitious blindness.
Practice Implications: Less than half of individuals with special needs receive mental health treatments, highlighting a critical need. Tailored counseling programs can help students with mental health issues stay in school. Our findings underscore the importance of providing mental health therapies to schoolchildren with adventitious blindness. School-based cognitive-behavioral practitioners can make a difference by addressing the psychological well-being and adjustment needs of these students. Collaboration between CBT practitioners and teachers in special schools is crucial, as teachers may lack training in handling psychological distress cases. Specialized training for practitioners in school counseling, psychology, and social work is essential to deliver best practices in school-based mental health support services. Integrating mental health services into school systems can reduce disparities in mental health treatment access among minority groups. Practitioners in countries like Nigeria should acquire training to provide cognitive-behavioral services to schoolchildren with adventitious blindness, ensuring equitable access to services regardless of financial constraints.
Early childhood research has demonstrated the benefit of receiving counselling support and rehabilitation services early in life (Aneke, et al., 2023; Ede & Okeke, 2023; Ede et al., 2021a, b, c, d), especially for those with degenerative visual conditions (Abiogu et al., 2020; Ede, et al., 2021b). However, in the US, educational laws support services if it impacts their education and if they meet a specific criterion. For example, if the student has a diagnosis of retinitis pigmentosa but their vision does not impact their learning right now, they may not receive services until adventitiousr in life after establishing a set of beliefs about self, world, and future. Furthermore, state rehabilitation services may not provide services to the individual until they meet a specific criterion. Individuals have the option to seek out support from private agencies, but many do not.
Declarations
Conflict of interest
The authors declare the absence of conflict of interest.
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