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Comparing fears in South African children with and without visual impairments.

Fear, which can be defined as a strong emotional reaction to a real or imagined threat (Gullone, 1996; Li & Morris, 2007), is an integral part of the typical development of children (Gullone, 2000; Lane & Gullone, 1999; Last, 2006). Even though fear is deemed to be part of typical development, some fears may become excessive, cause personal distress, and interfere with day-to-day functioning and activities (King, Muris, & Ollendick, 2005). On the other hand, fear can also take on a positive and adaptive dimension, for example, if the fear of failing a test prompts children to study for their tests or a fear of dogs results in appropriate and cautious behavior around new or strange-looking dogs. In situations like these, fears have a self-preserving and motivational function (Gullone, 2000; Li & Morris, 2007; Robinson & Rotter, 1991). Although fear can have positive effects, it is evident that the worlds of many children are full of dangers, whether these dangers are real or imagined (Mash & Wolfe, 2005).

Children's fears reflect their emerging understanding of the world and their place in it (Elbedour, Shulman, & Kedem, 1997). This is particularly true for children who have visual impairments (that is, those who are blind or have low vision) because their world may be more threatening and complex, partly because of the physical limitations imposed by their disability (King, Josephs, Gullone, Madden, & Ollendick, 1994) but also because of the societal factors that affect them in their day-to-day lives: mobility, literacy, adjustment, making friends, presenting themselves in a socially acceptable manner (Quinn, 1998), and generally just fitting into a sighted world. These factors, which are often taken for granted by those who can see, may pose particular challenges for children with visual impairments (Quinn, 1998). In addition, the tendency for others to reject or overprotect the children (Matson, Manikam, Heinze, & Kapperman, 1986; Weimer & Kratochwill, 1991), misconceptions regarding visual impairments, and stigmatization associated with this disability can also have a negative impact on the children's developmental experiences and processes (such as making friends and socializing). Indeed, studies involving children with disabilities have suggested that these children are at a greater risk of developing psychological difficulties (including fear and anxiety) than are sighted children without disabilities (Gullone, 1996; Harvey & Greenway, 1984; Li & Morris, 2006; Li & Prevat, 2007; Ollendick, Matson, & Helsel, 1985; Rutter, Tizzard, Yule, Graham, & Whitmore, 1976; Weimer & Kratochwill, 1991; Wilhelm, 1989).

Despite this identified risk, as far as we could determine, only seven studies (Dean, 1957; Hardy, 1968; King, Gullone, & Stafford, 1990; Matson et al., 1986; Ollendick et al., 1985; Weimer & Kratochwill, 1991; Wilhelm, 1989) focusing on fear and anxiety within the population of children with visual impairments have been conducted to date, and the last study to explore this topic was conducted more than two decades ago (Weimer & Kratochwill, 1991). Of the seven studies, only two compared the fear profiles of children with and without visual impairments, the first of which was conducted by Ollendick et al. (1985). Ollendick et al. administered Ollendick's (1983) revised Fear Survey Schedule for Children (FSSC-R) to 106 sighted and 70 youths with visual impairments from the United States (aged 10-18). In line with the proposition that children with disabilities would be more prone to the development of psychopathology than would those without disabilities, Ollendick et al. (1985, p. 376) hypothesized "that visually-impaired youths would show greater fear than normally-sighted youths on overall level of fear and on specific factor scores; further, it was hypothesized that responses to specific fear items, particularly those resulting in physical harm, would discriminate between the visually impaired and normally-sighted youths." As expected, the youths who were visually impaired displayed higher levels of fears related to situations in which the potential for physical harm (being hit by a car or truck) was the highest. The sighted youths, on the other hand, evinced fears that related more to psychological harm (such as being teased or failing a test).

The second comparative study was conducted by King et al. (1990) in Australia. Once again, Ollendick's (1983) FSSC-R was administered to 129 visually impaired and 129 gender-and agematched sighted children in the control group (aged 8-16). An unexpected finding was that the two groups did not differ significantly in their overall level of fearfulness. Moreover, the sighted children reported a greater level of fearfulness not only of failure and criticism, but of physical harm. This latter finding was contrary to that found in other studies that found that children with visual impairments were more afraid of physical harm or danger then their sighted peers (Ollendick et al., 1985; Weimer & Kratochwill, 1991).

Noting these seemingly contradictory findings and the relative lack of research on this topic both internationally and within the South African context, we sought to determine whether significant differences exist between the fear profiles of children with visual impairments and their sighted counterparts. The content, number, level (intensity), and pattern of expressed fear were explored. Furthermore, we aimed to analyze how these different fears were manifest when variables related to gender, age, and degree of visual impairment were taken into account.



A total of 129 South African children aged 8-13 (M = 10.36, SD = 1.46) were examined: 67 (32 girls and 35 boys) with various degrees of visual impairment in the primary group and 62 sighted children (35 girls and 27 boys) in the control group. In the visually impaired group, 31 children were aged 8-10, and 36 were aged 11-13. In the control group, 32 children were aged 8-10, and 30 were aged 11-13. The children in the primary group were categorized as severely visually impaired (n = 20) or moderately visually impaired (n = 47). The children with severe visual impairments either had no measurable light perception or had a limited degree of light perception, experienced difficulties functioning in unfamiliar environments without assistance, and could not read printed material. Moderate visual impairment is a category that is difficult to define because a child's degree of vision can fluctuate and differ depending on the environment. Some influencing environmental factors include inappropriate lighting, glare, and fatigue (Keller, 2005; World Health Organization, 2000). The children in the visually impaired groups had a variety of eye conditions (as communicated to the authors by two school nurses), including ocular albinism, cataracts, optic atrophy, retinoblastoma, glaucoma, high myopia, retinopathy of prematurity, and other less frequently occurring conditions. None of the children with visual impairments had any other major physical disability. The children in our study attended three schools in two towns in the Western Cape, South Africa. Those in the primary group attended two special schools that serve children with visual impairments, and those in the control group attended a mainstream school in the same geographic area.


Demographic questionnaire

The participants completed a short demographic questionnaire requesting information on their ages, dates of birth, gender, school and grade levels, living circumstances, and culture. Nurses at the respective special schools provided information pertaining to the eye conditions and level of vision of the children in the primary group.

South African Fear Survey Schedule for Children

The South African Fear Survey Schedule for Children (FSSC-SA) (Burkhardt, Loxton, Kagee, & Ollendick, 2012) is an adapted version of Ollendick's (1983) 80item FSSC-R. This adaptation better suits the South African context because it was thought that the fear profiles of South African children were somewhat unique and differed from those of children in First-World countries (Burkhardt & Loxton, 2008; Burkhardt et al., 2012). In their adaptation of the FSSC-R, Burkhardt et al. (2012) conducted semistructured interviews with a culturally diverse sample of 40 South African children aged 8-13. From these interviews, additional contemporary fears that were not included in Ollendick's (1983) revised scale were added, and some irrelevant or outdated items were deleted. Seventeen new items were added, and 23 of the original items were deleted, yielding a total of 74 items on the FSSC-SA. The FSSC-SA showed internal consistency of [alpha] = 97, which is in line with previous research aimed at adapting the FSSC-R. This internal consistency makes the FSSC-SA an internally consistent instrument to use within the South African context (Burkhardt et al., 2012).


Before the data collection began, the study's protocol was ethically approved by the Committee for Human Research, Research Development and Support Division, Faculty of Health Sciences at Stellenbosch University, South Africa (Institutional Review Board Number: IRB0005239), and permission to approach the three identified schools was granted. Permission from the school principals, as well as consent from the children's parents or guardians and from the children was obtained. The children were then administered the demographic questionnaire and Burkhardt et al.'s (2012) FSSC-SA in their schools and their language of instruction (either English or Afrikaans). Each child in the control group (n = 62) was given a copy of the fear survey and instructed to read each item carefully and to place an X in the box that best described his or her level of fear: none, some, or a lot. With regard to the primary (visually impaired) group, certain procedural modifications were necessary. Some children were administered the FSSC-SA individually and orally, others had access to magnification equipment (Merlin), and some were given enlarged versions of the instruments. All the children who used braille as their medium of instruction answered the surveys on a braille answer sheet. Assessments took approximately 40-45 minutes per group. In all cases of administration, concerted efforts were made to ensure that the children understood the instructions and stimulus items and were fully aware of the alternative responses that were available to them.



Table 1 depicts the 10 most common fears, determined by the number of participants in the primary and control groups who rated a particular fear "a lot." To examine differences and similarities with regard to the content of the fears of the children with visual impairments and their sighted counterparts, we compared the 10 most common fears of the two groups (see Table 1). We found that 8 of the top 10 fears were the same for both groups: "fire-getting burned," "being hit by a car or truck," "not being able to breathe," "getting HIV," "getting a shock from electricity," "getting lost in a strange place," "the possibility of being in an accident," and "falling from high places." However, the relative ranking of these shared fears differed. For instance, although both groups reported a fear of getting HIV, this was the highest rated fear item for the control group, but the fourth highest for the primary group. The unmatched items for the primary group were "bombing attacks--being invaded," which ranked seventh, and "death or dead people," which ranked eighth. For the control group, the two unmatched items were "sharks," which ranked eighth, and "shots being fired in the neighborhood," which ranked ninth. The Spearman's rank-order correlation among the eight fears that were common for both groups was .33, which was not significant, suggesting that meaningful differences were evident between the two groups.


In terms of the number of fears that were endorsed "a lot," a series of 3 (children with severe or moderate visual impairments and sighted children) X 2 (boys and girls) X 2 (8-10 year olds and 11-13 year olds) factorial analyses of variance (ANOVAs) were computed. In line with the findings in the literature, the girls (M = 31.96, SD = 13.81) reported a significantly higher number of fears than the boys: (M = 19.94, SD = 15.17), F(1, 125) = 23.87, p < .001. The number of fears reported by the younger children (aged 8-10) (M = 26.52, SD = 15.85) was slightly higher than the number reported by the older children (aged 11-13) (M = 25.85, SD = 15.54), although this difference was not significant, F(1, 125) = 0.10, p = .757. Finally, the number of fears reported by the children with severe visual impairments (M = 38.90, SD = 16.89) was significantly higher than the number of fears reported by the children with moderate visual impairments (M = 22.77, SD = 15.77) and by the sighted children (M = 24.66, SD = 13.12), F(2, 126) = 9.04, p < .001. There was no significant difference between the children with moderate visual impairments and the sighted children. There were no significant two-way or three-way interactions.


With regard to the level or intensity of the fears, we calculated a total fear score. This score was obtained by summing the scores across the FSSC-SA's 74 items (none = 1, some = 2, and a lot = 3) to yield a total fear score ranging from 74 to 222. The total fear score is of interest because it provides a global index of fearfulness (King et al., 1990). The mean total fear score for the entire sample (across group, age, and gender) was 145.54 (SD = 29.99). We calculated a 2 (group) X 2 (gender) X 2 (age) factorial ANOVA using the total fear scores. The total fear scores (M = 146.62, SD = 31.30) and (M = 144.51, SD = 28.89) as reported by the younger (aged 8-10) and older (aged 11-13) children, respectively, were not found to be significantly different. However, the total fear scores as reported by the girls (M = 156.25, SD = 24.12) and boys (M = 133.97, SD = 31.55) were significantly different, with F(1, 125) = 20.59, p < .001. Finally, the mean total fear scores as reported by the severely visually impaired children (M = 166.70, SD = 29.49) was significantly higher than those for both the children with moderate visual impairments (M = 135.72, SD = 31.61) and for the sighted children (M = 146.15, SD = 25.33), with F(2, 126) = 8.38, p < .001. No significant difference was found between the children with moderate visual impairments and the sighted children. There were no significant two-way or three-way interactions.


The FSSC-SA has a five-factor solution: Factor I (fear of danger and death), Factor II (fear of the unknown), Factor III (worries), Factor IV (fear of animals), and Factor V (situational fears). Pattern of fear refers to the total level of fear on each of these 5 factors, respectively. The scores on each of the five factors were totaled and subjected to a series of 3 (group) X 2 (gender) X 2 (age) factorial ANOVAs. The means and standard deviations for gender, age, and group are reported in Tables 2, 3, and 4 respectively.

There was a significant main effect for gender, with the girls reporting significantly higher levels of fear than the boys on all five factors: Factor 1: F(1, 125) = 19.05, p < .001; Factor II: F(1, 125) = 22.61, p < .001; Factor III: F(1, 125) = 19.49, p < .001; Factor IV: F(1, 125) = 14.91, p < .001, and Factor V: 125) = 29.01, p < .001. However, none of the factors yielded significant differences related to age (see Table 3).

When looking at the levels of fear reported by the three groups on the five factors, we found significant differences for all five factors (see Table 4). Post hoc comparisons showed that the severely visually impaired group scored significantly higher than did the moderately visually impaired group on all five factors (p < .05) and significantly higher than the sighted group on Factors II and III, but not on Factors I, IV, and V (p < .05). There were no significant differences between the moderately visually impaired group and the sighted group on any of the factors. There were no two-way or three way significant interactions.


In terms of the content of fears, it was interesting to note that, on comparing the 10 most common fears of the primary and control groups, we found that 8 fears were the same. However, the relative ranking of these shared fears differed. All the top 10 fears of the primary group loaded on Factor I, fear of danger and death, and all but the 8th-ranked fear of sharks for the control group also loaded on Factor I. Similar findings were obtained in earlier studies, with the exception that the sighted children also evinced more fears related to the possibility of psychological harm or distress (King et al., 1990; Ollendick et al., 1985).

The high endorsement of the item "fire-getting burned" by the children in the primary group could perhaps be attributed to the environmental context in which the majority of these children live and grow up. One of the special schools comprising 57% (n = 38) of the children in the primary group is located in a poor township area of Cape Town, and most of the children live in informal settlements, according to the school's psychologist. The lack of access to electricity forces residents of these areas to rely on paraffin (fire) for cooking, warmth, and illumination. As a result, shack fires are a daily reality for these children, and the children may have experienced such disasters firsthand. It should be noted, however, that our study did not gather data pertaining to exposure to fire. Therefore, these conclusions are drawn with caution.

A further noteworthy finding for the content of fears is related to the high endorsement of the item "getting HIV" in both our samples. This was the most feared item by the sighted children and was ranked fourth by the children with visual impairments. Taking the endorsements for the total sample into account, we found that getting HIV was the most feared item for all the children in the study.

Burkhardt et al. (2012) noted a similar finding, with participants in their study of sighted youths also endorsing getting HIV as their most feared item. This finding was attributed to the role that HIV/ AIDS plays in Africa. As Burkhardt et al. noted, the effects of the HIV/AIDS epidemic are felt both directly and indirectly by South African children--directly, through infection with HIV and death as a result of AIDS, and indirectly as a result of the death and suffering that the epidemic is causing in their families and communities. It was estimated that at the end of 2011, approximately 3.3 million children worldwide were infected with HIV (UNICEF Childinfo, 2011), with the greatest concentration (90%) of infected children under age 15 living in subSaharan Africa (UNAIDS, 2012). Furthermore, in South Africa, life orientation is a compulsory subject in all schools for children from grades R (Kindergarten) to 12 (Prinsloo, 2007), and a theme of this subject is directed toward HIV/AIDS education. The subject's focus area of personal well-being addresses the issue of the prevention and knowledge of sexually transmitted diseases, including HIV and AIDS (South African Department of Education, 2003), making children more aware of the dangers and impacts of the HIV phenomenon.

Gender differences in fearfulness were significant across the number, level, and pattern of fears in both groups, with the girls being consistently more fearful than the boys. This trend has been reported consistently in the literature on normative fear (Angelino, Dollins, & Mech, 1956; Burkhardt et al., 2012; Burnham, 2005; Burnham & Gullone, 1997; Gullone & King, 1992, 1993; Ollendick, 1983; Ollendick, King, & Frary, 1989). This being the case, there is still little clarity about the reasons for these gender differences in fearfulness. The most frequently noted explanations pertain to gender-role expectations and stereotypes and different patterns of socialization experienced by girls and boys. It has been argued that in most cultures, expressions of fearfulness by girls are expected and supported differently from those by boys (King et al., 1990). As a result, reports of fearful responses to certain situations and stimuli are more acceptable for girls than for boys. Thus, girls may be more willing to report their fears than boys (Burkhardt et al., 2012; Gullone, 1996; King et al., 1990). If so, it is clear that this effect was observed for both our sighted and visually impaired samples.

In terms of age differences in fearfulness, it has often been said that fears in childhood follow a developmental course, taking on different dimensions and degrees of intensity as children pass through the various developmental stages from infancy to adolescence (Bauer, 1976). Thus, we expected that younger children and older children would show significant differences in their reported fears. This, however, was not the case in our study, since there were no significant age differences related to the number, intensity, or pattern of fears. This finding could likely be attributed to the limited age range of the children in our study. Although two age divisions were distinguished, all the children in the study were younger than those in the samples studied by Ollendick et al. (1985) and King et al. (1990). It is possible that, if the age range was greater (up to 16-18 years as in these earlier studies), the results may have distinguished developmental trends in fearfulness more clearly (Ollendick et al., 1989).

On investigating visual differences in fearfulness, we found that the children with severe visual impairments reported a significantly higher number and level of fears than did the children with moderate visual impairments. The children with severe visual impairments also reported the highest level of fears across all five factors of the FSSC-SA. It is not clear from our study what could have led to these higher levels of fear for the children with severe visual impairments. However, one possible explanation could be related to the fact that this group's visual difficulties may be the most complex and most disabling. Although some of these children had a degree of measurable vision, they may find it difficult to function independently in an unfamiliar environment. Therefore, this uncertainty when faced with new situations and possibilities may directly contribute to their higher fear reactivity. On the other hand, children with moderate visual impairments usually have enough usable vision to help themselves and move around independently. However, this explanation is speculative, and it is imperative for future research to take a more in-depth look at the possible origins of and reasons for the fearfulness of different visual subgroups.

Although differences between the severely and moderately visually impaired children were present, differences between the moderately visually impaired and the sighted children were not evident. The fear profiles of the children with moderate visual impairments (in terms of content, intensity, number, and pattern) did not differ significantly from those of the sighted children. A possible explanation for this similarity could be the greater attention given to the inclusion of children with disabilities mainstream society in recent years. Since 1994, concrete measures have been implemented to address the ways in which people with disabilities were excluded from mainstream society in the past (South African Human Rights Commission, 2002). Governmental legislation is now more focused on disability rights and accessibility and the removal of barriers in society. All people with disabilities and those with special needs (including children with visual impairments) have constitutional rights to equality, inclusion, and the protection of human dignity (Republic of South Africa, 1996). As a result, the worlds to which these two groups of children are exposed are not as different as they may initially seem or as they were 20 or more years ago. Even though the children in the primary group were selected from two special schools, these schools are no longer as "institutionalized" as they were in the past.

Limitations, recommendations, and conclusion

Our study, like all studies, had some limitations, including the relatively small sample. limited age range of the participants, and the fact that the sighted children came from mainstream schools whereas the children with visual impairments came from special residential schools. Furthermore, our study relied on self-reports of fear. To enhance the generalizability of our findings, future studies should use larger samples. Using a broader age range to include children in early childhood and adolescents with visual impairments may also provide a clearer picture of the developmental patterns of childhood fears. Additional sources of data, such as interviews with the children as well as parents' and teachers' reports, would have added to the richness of the data as well.

Despite these limitations, the study had strengths. First, the study was the first of its kind--assessing the fears of children with visual impairments--to be conducted within the South African context. Second, the study added to the under researched and out-of-date body of information related to the fearfulness of children with different levels of visual impairments. This information will aid mental health practitioners in the development of intervention programs and treatment strategies that are targeted to this specific population. Previous research noted that the fears of children with disabilities have been treated successfully using fear-reduction procedures, including modeling, systematic desensitization, in vivo exposure, and positive reinforcement (Jackson & King, 1982; Matson, 1981; Seligman & Ollendick, 2011). These procedures typically involve graduated exposure to the fear-provoking stimuli, as well as cognitive interventions focused on self-instruction strategies and positive self-statements. Thus, since the fears reported by the children in our study were similar to those noted in previous research, it should be noted that children with visual impairments could benefit from programs that focus on coping strategies that can be used in actual fear provoking situations.

We thank the Western Cape Education Department, South Africa, for granting us permission to conduct the study and especially the children and staff members from the selected schools who cooperated with and participated in the study. The financial assistance of the South African National Research Foundation (NRF) for this research is hereby acknowledged. Opinions expressed and conclusions arrived at are those of the authors and are not necessarily to be attributed to NRF.


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Lisa Visagie, M.A., doctoral student, Department of Psychology, Stellenbosch University, corner of Ryneveld and Victoria Streets, Stellenbosch, 7600, South Africa; e-mail: <>. Helene Loxton, D.Phil., senior lecturer, Stellenbosch University, South Africa; e-mail: <hsl@>. Thomas H. Ollendick, Ph.D., University Distinguished Professor and director, Child Study Center, Virginia Polytechnic Institute and State University, 460 Turner Street, Blacksburg, VA 24060; e-mail: <>. Henry Steel, M.A., lecturer, Stellenbosch University, South Africa; e-mail: <>. Address all correspondence to Dr. Loxton.
Table 1
Rank order of fears for the primary (n = 67) and
control (n = 62) groups (FSSC-SA).

Children with visual impairments (primary group)
Item                                    f      %

1. Fire-getting burned                 47    70.1
2. Being hit by a car or truck         46    68.7
3. Not being able to breathe           45    67.2
4. Getting HIV                         44    65.7
5. Getting a shock from electricity    43    64.2
6. Getting lost in a strange place     42    62.7
7. Bombing attacks-being
   invaded                             42    62.7
8. Death or dead people                42    62.7
9. The possibility of being in an
   accident                            41    61.2
10. Falling from a high place          39    58.2

Sighted children (control group)
Item                                    f      %

1. Getting HIV                         51    82.3
2. Not being able to breathe           50    80.6
3. Being hit by a car or truck         48    77.4
4. Falling from a high place           47    75.8
5. Getting a shock from electricity    45    72.6
6. Fire-getting burned                 41    66.1
7. The possibility of being in an
   accident                            40    64.5
8. Sharks                              40    64.5
9. Shots being fired in the
   neighborhood                        39    62.9
10. Getting lost in a strange place    38    61.0

Table 2
Means, standard deviations, F values, and p values for
the pattern of fear for the total sample (N = 129),
with reference to gender based on FSSC-SA.

Factors        Gender     M      SD       F       P

Factor I       Girls    52.71   7.70    19.05   > .001
                Boys    45.21   11.03
Factor II      Girls    40.13   9.21    22.61   > .001
                Boys    32.31   9.44
Factor III     Girls    26.92   5.07    19.49   > .001
                Boys    22.60   6.09
Factor IV      Girls    18.88   3.93    14.91   > .001
                Boys    15.75   4.97
Factor V       Girls    19.41   3.66    29.01   > .001
                Boys    15.67   4.06

Table 3
Means, standard deviations, F values, and p
values for the pattern of fears for the total
sample (N = 129), with reference to age, based

Factors      group     M      SD      F     P

Factor I     8-10    48.90   11.44   .06   .801
             11-13   49.45   9.39
Factor II    8-10    37.10   10.39   .62   .434
             11-13   35.67   9.98
Factor III   8-10    24.55   5.84    .15   .699
             11-13   25.12   6.18
Factor IV    8-10    17.16   4.51    .23   .632
             11-13   17.58   4.92
Factor V     8-10    17.40   4.37    .32   .574
             11-13   17.83   4.22

Table 4
Means, standard deviations, F values, and p values for the
pattern of fears for the severely impaired (n = 20), moderately
impaired (n = 47) and sighted (n = 62) groups based on FSSC-SA.

Factors             Group            M      SD      F       p

Factor I     Severely impaired     54.00   9.04    5.98    .003
             Moderately impaired   45.37   11.43
             Sighted               50.35   9.41
Factor II    Severely impaired     43.25   9.99    7.56    .001
             Moderately impaired   33.24   9.83
             Sighted               36.52   9.40
Factor III   Severely impaired     30.10   6.96    9.51   > .001
             Moderately impaired   24.07   6.78
             Sighted               23.73   4.66
Factor IV    Severely impaired     19.65   4.63    4.25    .016
             Moderately impaired   16.11   5.04
             Sighted               17.60   4.30
Factor V     Severely impaired     19.60   4.16    3.27    .041
             Moderately impaired   16.73   4.60
             Sighted               17.65   3.88
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Article Details
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Author:Visagie, Lisa; Loxton, Helene; Ollendick, Thomas H.; Steel, Henry
Publication:Journal of Visual Impairment & Blindness
Article Type:Report
Geographic Code:6SOUT
Date:May 1, 2013
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