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School-Based Intervention for Test Anxiety

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School-Based Intervention for Test Anxiety

Lay See Yeo, Valerie Grace Goh &

Gregory Arief D. Liem

Child & Youth Care Forum

Journal of Research and Practice in
Children's Services

ISSN 1053-1890

Child Youth Care Forum

DOI 10.1007/s10566-015-9314-1

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DOI 10.1007/s10566-015-9314-1

ORIGINAL PAPER

School-Based Intervention for Test Anxiety

Lay See Yeo1 • Valerie Grace Goh2 •

Gregory Arief D. Liem1

Ó Springer Science+Business Media New York 2015

Abstract
Background With children today being tested at younger ages, test anxiety has an earlier
onset age. There is relatively limited research on test anxiety management programs with
elementary school children. The theoretical basis for this nonrandomized pre-post inter-
vention study is grounded in cognitive and behavioral interventions for test anxiety found
to be efficacious with children.
Objective The purpose is to examine the impact of a school-based test anxiety pre-
vention program on a sample of Singaporean fourth grade students relative to their levels
of academic achievement and to identify active treatment components.
Methods 115 children aged 9–12 were assigned to group-based cognitive-behavioral
treatment (n = 58) or control condition (n = 57). They completed the Children’s Test
Anxiety Scale and Cognitive-Behavioral Skills Checklist at pre-, post-treatment, and
2 months’ follow-up. Anxiety ratings were hypothesized to be lower for the intervention
than the control group at post-treatment. Skills that contributed to treatment outcomes were
identified.
Results A mixed-design analysis of variance revealed significant test anxiety reduction
with medium treatment effect that was maintained for the intervention group across time.
There was no change in the control group. Behavioral skills (e.g., relaxation exercises,
study skills) contributed to treatment outcomes. Cognitive skills such as calming self-talk
did not.
Conclusions The study provided preliminary evidence on the utility of brief, school-
based anxiety interventions in test anxiety prevention for children. It added credence to
adopting behavioral over cognitive strategies in treating test anxious children. Children
with severe test anxiety at baseline benefited particularly from treatment.

& Lay See Yeo

laysee.yeo@nie.edu.sg
1
Psychological Studies Academic Group, National Institute of Education, Nanyang Technological
University, 1 Nanyang Walk, Singapore 637616, Singapore
2
Singapore Prison Service, Singapore, Singapore

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Keywords Cognitive-behavioral therapy (CBT)
Childhood
Elementary school

School-based
Test anxiety

Introduction

Test anxiety, a phenomenon universally experienced the world over, is a serious problem
for many students (Ergene 2003). Indeed, in most parts of the developed world, coping
with frequent tests and examinations is becoming tougher and more anxiety-provoking in
light of educational policy changes that called for high-stakes testing and school ac-
countability (Putwain 2008). As testing begins earlier at younger ages, the preoccupation
about doing well in school is beginning to surface in young children (Yeo and Clarke
2005). The literature suggests that test anxiety has become a growing concern among K-12
students (Hembree 1988) with the onset age as early as 7 (Connor 2003). Ergene (2003)
reported that test anxiety starts to affect the performance of elementary school children
about fourth grade and recommended that test anxiety prevention programs be introduced
in lower grades.
In the most recent systematic review of test anxiety treatment studies from 2000 to
2010, von der Embse, Barterian and Segool (2013) reported the prevalence rate for test
anxiety to be between 10 and 40 % (Gregor 2005). Tracking the studies on test anxiety
measures to assess the prevalence of test anxiety, McDonald (2010) revealed an upward
trend: 10 % in the 1960s, 25 or 30 % in the 1970s to 41 % in the 1990s. Prevalence rates in
Singapore on which this study was based were, however, unavailable. Nevertheless,
judging by the paramount importance attached to educational success in Singapore (Ang
et al. 2009) and cross-cultural research indicating test anxiety levels among Singaporean
elementary male students to be higher than those of their counterparts in the US (Lowe and
Ang 2012), test anxiety can be considered a mental health concern for Singapore school
children.
The primary purpose of the study was to examine the utility of a school-based test
anxiety intervention on fourth grade children in Singapore. Meta-analyses of test anxiety
research by von der Embse et al. (2013) and Ergene (2003) show that the research has
focused largely on older and mostly college-age students. Thus, this paper sought to extend
the test anxiety research to an understudied population of elementary age children. In the
context of tracking (or streaming) practices in Singapore schools that unwittingly impose
additional stress, a secondary goal of the study was to examine treatment outcomes in
relation to the children’s achievement levels in order to identify groups of students who
would benefit most from treatment as well as to pinpoint active treatment components.

Test Anxiety

Test anxiety is a negative affective state that occurs in evaluative situations such as a class
test or an examination (Sarason 1984; Zeidner and Matthews 2005). It is experienced by
test anxious students as tension, worry, and over-stimulation of the central nervous system
(Ergene 2003). The vast amount of research literature on test anxiety has coalesced in it
being treated as a multidimensional construct consisting of cognitive, emotional, behav-
ioral, and physiological components (Sarason 1984). In recent research, the general focus

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has been on two key elements: a cognitive component and a physiological component
(McDonald 2010). The former is best conceptualized as worry over how assessment
performance will be judged by others (Putwain 2008). Worry in children is associated with
cognitive distortions rather than skills deficits (Parkinson and Creswell 2011). Worry
presents as cognitive interference that diverts attention to self-deprecating thoughts (Or-
bach et al. 2007); hence test anxious children entertain negative beliefs about their problem
solving ability even though they are quite capable of solving problems and generating
solutions. The second component of test anxiety is physiological, i.e., autonomic arousal or
emotionality, which is manifested in bodily symptoms such as increased heart rate, sweaty
palms, and shaking that arise from being in an evaluative situation (McDonald 2010).
Test anxiety is an insidious psychological condition that has debilitating effects on
students’ academic performance, motivation, and problem solving confidence. High test
anxiety has an inverse relationship to grade point average (Chapell et al. 2005), con-
tributing to lower test grades and underachievement (Hembree 1988; Keogh et al. 2004).
Test anxiety also reduces university students’ motivation to learn (Hancock 2001). Test
anxiety was also significantly associated with a tendency to avoid coping with problems
both of a general and academic nature (Blankstein et al. 1992), and low problem solving
confidence in elementary school students (Parkinson and Creswell 2011). Test anxiety has
also been linked to internalizing symptoms such as anxiety disorders, depressive disorders,
and PTSD (Weems et al. 2010, 2014).
Test anxiety levels vary in relation to students’ ability or achievement. An Israeli study
among children from fourth to ninth grade found that gifted children demonstrated lower
levels of test anxiety than their non-gifted counterparts (Zeidner and Schleyer 1999). In a
meta-analysis of 562 studies that compared test anxiety levels for students of various
abilities, Hembree (1988) observed that test anxiety for average students exceeded that of
high ability students; similarly, test anxiety for low ability students exceeded that of
average ability students. In Singapore where students are channeled into ability streams
based on their grades at the end of their elementary school years in order to optimize their
learning potential, and in countries where academic tracking is practiced, test anxiety
levels are likely to differ for students across the different ability or achievement levels. As
previously mentioned, the secondary goal was to determine whether responsiveness to test
anxiety treatment differs according to achievement. This is beneficial as the data can
inform allocation of scarce psychological resources and lead to cost effectiveness.

Evidence-Based Test Anxiety Interventions

An excellent review of evidence-based treatments for generalized anxiety disorder and test
anxiety can be found in von der Embse et al.’s (2013) meta-analytical study. In essence,
combined approaches that utilized behavioral and cognitive interventions appeared to be
the most efficacious although each of these interventions was effective in its own right.
Only two out of ten studies in this review evaluated the effectiveness of test anxiety
intervention programs for children (Faber 2010; Larson et al. 2010). Larson et al. (2010),
employing a behavioral approach, found that third grade students who were taught re-
laxation techniques had reduced test anxiety compared to peers in the control condition.
Faber (2010) utilized algorithmic and self-instructional training for a group of students
who had dyslexia and found that teaching spelling techniques lowered spelling-specific test
anxiety and improved scores on spelling achievement tests.

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School-Based Treatment for Test Anxiety

In an elementary school age population, the school is the most appropriate place for
children to receive support for test anxiety and to practice coping skills (Ginsburg et al.
2012) because test anxiety is specific to school where the fear of evaluation occurs. Test
anxiety interventions fit naturally within the ecology of the school setting (Weems et al.
2014). Weems and colleagues developed a school-based prevention model aimed at pro-
moting emotional resilience through targeting test anxiety that has demonstrated highly
encouraging outcomes (Weems et al. 2010, 2014). The model implemented in New Or-
leans involved an active partnership between targeted schools and the University of New
Orleans Child and Family Anxiety Laboratory in which direct services in test anxiety
prevention (i.e., screening of test anxiety and related problems) and intervention were
offered school-wide to youth as an integral and complementary feature of schools’ existing
routines in supporting students’ mental well-being. The five-session, manualized, group-
administered, behavioral strategy-focused intervention showed a reduction in PTSD
symptoms, and an improvement in grades for test anxious 9th grade ethnic minority youth
relative to their non-anxious peers (Weems et al. 2009). What began as an initial impetus to
help youth in the post-Hurricane Katrina environment developed into an ongoing effort to
partner schools in reaching a large number of youth belonging to a wider age group (e.g.,
grades 4–8) (Weems et al. 2010). In the Weems et al. (2010) study, a significant link
between test anxiety and broader internalizing symptomatology (i.e., anxiety disorder and
depression) was highlighted. Test-anxious youth benefited from understanding the inter-
vention content and rated the help received as acceptable. More recently, Weems et al.
(2014) provided longitudinal data showing excellent maintenance outcomes in the group-
administered test anxiety program involving a large sample ranging in age from 8 to 17
followed up over a period of 29 months. Importantly, initial change in test anxiety pre-
dicted positive developmental trajectories in other internalizing disorders and PTSD. Other
school-based studies with children in the literature focused on anxiety disorders in general.
Galla et al. (2012) and Ginsburg et al. (2012) employed individual, modular CBT programs
that showed positive outcomes. An unpublished study in Singapore on class-based stress
management showed reduced test anxiety for 6th grade children who received brief
training in homework planning, breathing exercises, and systematic desensitization.

Cognitive-Behavioral Therapy (CBT)

CBT is evidence-based treatment for children and youth who have anxiety disorders
(Ollendick and King 1998). It posits that maladaptive cognitions, erroneous thought pro-
cesses, and the lack of coping or problem-solving abilities may cause psychological dis-
orders such as anxiety (Dobson and Dozois 2010). Thus, the cognitive-behavioral approach
equips clients with coping self-statements and practical skills to regulate their feelings and
behaviors. CBT for treating anxiety in children and adolescents integrates the behavioral
approach (e.g., relaxation training and exposure tasks) with a focus on the cognitive
processes associated with the individual’s anxieties (Kendall 2012a). Treatment involves
skills training and practice in four areas: awareness of bodily arousal to physical signs of
anxiety, recognition and evaluation of self-talk, problem-solving skills (e.g., plans for
coping), and self-evaluation and reward (Kendall 2012a). Although CBT has received
empirical validation as an effective treatment for children with anxiety disorders, ‘‘the
effective ingredients of change (i.e., the mechanisms of change) have not been identified in

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recent CBT research’’ (Prins and Ollendick 2003, p. 102). Hence, this study also sought to
identify the CBT skills that were active in treating test anxiety.

The Singapore Context and Present Study

Brief information on schooling and the role of examinations in Singapore will help to
provide a context for understanding test anxiety in this research study. Students attend
6 years of primary/elementary school before transitioning to a secondary school. The
Singapore educational system is highly competitive and doing well is the expected path-
way toward securing good placement in tertiary education (Ang et al. 2009). Except for the
first 2 years in school when there is no formal testing, students are typically evaluated four
times in any given grade level—two continual assessments (CAs) and two semestral
assessments (SAs)—spread out across the school year. Almost all students participate in
high-stakes testing at the end of grade 6 (Primary School Leaving Examination, PSLE),
grade 10 (GCE ‘‘O’’ level examination or GCE ‘‘N’’ level examination), and grade 12
(GCE ‘‘A’’ level examination). At the end of grade 6, students are transitioned into one of
four academic streams (tracks) depending on how well they perform in PSLE: Gifted,
Express, Normal Academic, Normal Technical. The Gifted and Express streams enroll the
brightest and most academically able students; the Normal Academic stream, the average
students; the Normal Technical stream, the weakest students. These national examinations
dictate to a large extent the educational institutions and academic or vocational courses
students may attend; hence it is not unexpected that Singaporean students experience
considerable stress.
Therefore, a preventive test anxiety intervention program is needful to equip young
students with coping skills to manage anxiety as they progress through the educational
system and prepare them ahead of time for major national examinations. In consideration of
limited expertise in mental health care within the school setting, a classroom-based CBT
approach is expedient in targeting large groups of students. In summary, the three objectives
of this study were to: (a) determine the effects of a school-based cognitive-behavioral
intervention on children who have test anxiety; (b) ascertain if anxiety levels differed for
children at high, average and low levels of achievement and how they responded to inter-
vention; (c) delineate the active components of the intervention. We hypothesized that CBT
would lower the test anxiety of children in the experimental group with maintenance of the
skills learned. We further predicted that children who were average in achievement were
likely to be most affected by test anxiety. Finally, to examine the active ingredients that
impact treatment, we tested the prediction, based on empirical research (King et al. 1995),
that behavioral interventions would be effective in lowering test anxiety.

Methodology

Procedures

Ethics clearance and approval for this study were provided by the Nanyang Technological
University Institutional Review Board and the Singapore Ministry of Education. Written
informed parental consent for participation was obtained from the children’s parents. The
children gave verbal assent.

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The study employed a quasi-experimental design, i.e., a nonrandomized pre- and post-
test intervention design with a control group. Randomized assignment of participants was
not possible as the school allocated the control and experimental grouping based on ex-
pedience. Students in each of the control and experimental groups came from intact classes
under the charge of respective form teachers. Children in the control classes were informed
that they were participating in a survey on stress levels aimed at helping students to feel
better about school. They did not receive intervention due to the school’s time and lo-
gistical constraints. Children in the experimental groups were informed that they were
participating in a stress management workshop that would teach them how to cope with
stress in school. During the month leading up to their examinations, children in the ex-
perimental group were provided the test anxiety intervention once a week for 4 weeks
within curriculum time. All participants completed the Children’s Test Anxiety Scale
(CTAS) (Wren and Benson 2004) and a cognitive-behavioral skills checklist at three time
points: a month before Continual Assessment 2 (CA2), immediately after the completion of
intervention (i.e., a few days before CA2), and 2 months after intervention (i.e., a week
before Semestral Assessment Examination 2 or SA2).

Participants

The participants consisted of 115 fourth grade students, 70 boys and 45 girls, aged between 9
and 12 years (M = 10.15, SD = 0.50). In total, 57 students were in the control group and 58
in the experimental (CBT) group (See Table 1 for demographic details). They were drawn
from four classes in a public elementary school consisting of students with a range of ability
or achievement levels. Students were banded according to their performance in third grade;
thus the top two classes had high achieving students whereas the remaining classes had a
mixture of average or low achieving students. Both the CBT and control groups had a
representation of children of high, average, and low achievement levels although the number

Table 1 Demographics of research sample at pre-intervention phase

Control groups (n = 57) CBT groups (n = 58) Total (n = 115)

Age
Mean 10.18 10.12 10.15
SD 0.52 0.48 0.50
Sex
Male 34 36 70
Female 23 22 45
Ethnicity
Chinese 37 42 79
Malay 5 6 11
Indian 6 3 9
Others 9 7 16
Academic achievement
High (band 1) 23 7 30
Average (band 2) 10 40 50
Low (band 3 and 4) 24 11 35

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of students in each of these groups was not equal. The school’s banding system according to
test scores was as follows: High (85 and above), Average (70–84), Low (below 70).
The attendance for experimental groups was 98.7 % with all participants attending at
least 3 out of the 4 intervention sessions. At the pre-intervention phase, no significant
differences were found in the CTAS anxiety scores between the control (M = 2.31,
SD = 0.69) and experimental groups (M = 2.37, SD = 0.62), t (113) = -0.48, p = .63.
There was also no significant difference in CTAS scores among the three achievement
groups: High (M = 2.10, SD = 0.63), Average (M = 2.45, SD = 0.68), and Low
(M = 2.40, SD = 0.60), F(2, 112) = 2.92, p = .06.

The Intervention

The preventive intervention program consisted of four 30-min sessions conducted over
4 weeks during the Form Teacher Guidance Period (FTGP). In all Singapore primary
schools, the FTGP was a period set aside once a week to allow purposeful student–teacher
interactions and to equip students with social and emotional competencies. The inter-
vention was delivered as a whole class intervention to each of the two experimental classes
separately. Adopting four sessions was a logistical decision in order to limit disruption to
the school’s own FTGP program. The therapist was the second author, a psychologist and
graduate student in an Applied Psychology program who had completed course work and
practicum in psychological assessment and CBT.
The intervention provided was a four-session, classroom-based, behavioral strategy-
focused intervention with cognitive modification built on the CBT literature based pri-
marily on the work of Kendall (2012b) and Nichols (1999). Consistent with the CBT
intervention research, the intervention utilized key treatment components for anxiety
disorders, which included psycho-education, relaxation training, self-instruction, exposure
to anxiety-provoking contexts, and skills training. ‘‘Homework’’ exercises (e.g., practice
balloon breathing at home) were assigned at the end of each session to facilitate skill
application. Audio CDs with the relaxation script were provided.
In Sect. 1, the children were taught the relationship between thoughts, feelings and ac-
tions, and how to recognize the physiological symptoms of anxiety in an exercise called
‘‘Identifying My Body Feelings Toward Test’’. They learned and practiced balloon breathing
(or deep breathing). In Sect. 2, the children were taught to pay attention to how their body
was feeling and to use calming self-talk (e.g., ‘‘It’s going to be alright. One question at a time.
I can do this.’’) They learned to recall a special memory that helped them to feel calm and
good. They practiced progressive muscle relaxation. In Sect. 3, exposure was provided via
imaginal desensitization. (Children were to imagine it was the morning of a test and they
were on their way to school. They were then prompted to employ relaxation and soothing
self-talk skills during the exposure tasks.) They were also taught study skills to prepare for
examination (e.g., preparing a timetable to complete homework and a revision schedule). In
Sect. 4, checks were made to ensure that children prepared their after-school timetable. The
children reviewed the skills learned and wrote down one thing they learned and one thing
they could use for their examination in the following week.
Intervention skills were made child friendly and easy to grasp. Learning points were de-
livered using activities, picture charts, and handouts. To encourage daily practice, participants
were asked to do self-monitoring by maintaining records during the period of intervention.
Participants who demonstrated through their log that they practiced almost every day were
allowed to choose a reward (e.g., notepads, sweet treats) from the ‘‘reward box’’.

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Measures

Children’s Test Anxiety Scale (CTAS)

The CTAS (Wren and Benson 2004) is a 30-item self-report measure developed in the US
to measure test anxiety in children aged 8–12. The CTAS measures (1) thoughts, 13 items
(e.g., While I am taking tests, I think I am going to get a bad grade); (2) autonomic
reactions, 9 items (e.g., While I am taking tests, I have to go to the bathroom); and (3) off-
task behaviors, 8 items (e.g., While I am taking tests, I look at other people). Response
choices are indicated in a 4-point Likert scale format with 1 (Almost Never) to 4 (Almost
Always), which are summed to compute the overall test anxiety score. According to Wren
and Benson (2004), the CTAS has good internal consistency, with a Cronbach’s alpha
coefficient of 0.92 and subscale reliabilities ranging from 0.78 to 0.89. For this study,
Cronbach’s alpha coefficient is 0.94.

Cognitive-Behavioral Skills Checklist (CBSC)

The Cognitive-Behavioral Skills Checklist is developed by the researchers (See ‘‘Appendix’’). It

details the set of skills in the prevention intervention program that targets test anxiety reduction.
Response choices to the seven skills are in a 4-point Likert scale format with 1 (Never) to 4
(Almost Every Day). This checklist enables tracking of the skills applied when anxiety is ex-
perienced during a test situation. In the current study, Cronbach’s alpha coefficient of the CBSC is
0.84.

Data Analysis

All results obtained were analyzed quantitatively using the PASW Statistics version 18
(PASW 18.0). An alpha value of 0.05 was used for all statistical tests.
To study the effects of treatment, a 2 9 3 mixed-design analysis of variance ANOVA
(groups: experimental and control; time: pre, post, maintenance) was conducted. To ex-
amine baseline test anxiety as a moderator, students in the control and experimental
conditions were grouped into Low and High test anxiety severity if they scored below and
above the median at pre-intervention, respectively. To analyze treatment in relation to
achievement levels, a 3 9 3 mixed-design ANOVA was used (academic achievement:
high, average, low; time: pre, post, maintenance). These analyses were followed by an
investigation of the effect size of the intervention using partial eta square. As the effect size
determines the magnitude of change with the presence of intervention, a value of 0.01, 0.06
and 0.14 for partial eta squared can be interpreted as a small, medium and large effect,
respectively (Tabachnick and Fidell 2007). For research question 4, the practice of cog-
nitive-behavioral skills was used as a covariate in the mixed ANOVA design to determine
whether the skills accounted for response to intervention.

Results

This study investigated whether a brief group CBT would reduce the test anxiety of fourth
grade students of varying achievement levels who were preparing for their final
examination.

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Effect of the Intervention on Test Anxiety

First, we hypothesized that test anxious children who received CBT would report reduced
test anxiety after intervention. As predicted, the CBT group reported lower anxiety levels
at 2 months after intervention compared to the control group. The mean change in anxiety
scores from pre-intervention to follow-up was significantly greater for the CBT group
(M = 0.26, SD = 0.60) than the control group (M = -0.01, SD = 0.41), t(113) = -2.74,
p = .007, two-tailed. The magnitude of the differences in the mean change in test anxiety
scores (mean difference -0.27, 95 % CI -0.46 to -0.07) was medium (d = 0.52).
Test anxiety (CTAS scores) changed over time in relation to group (CBT or control) as
indicated by significant time by group interaction effect (See Table 2). Unlike the control
group that registered no change in test anxiety scores across all three time points, the CBT
group reported significantly lower test anxiety at follow-up compared to baseline and post-
treatment. No significant change in test anxiety for CBT participants was observed between
baseline and post-treatment (See Fig. 1).
We also used baseline test anxiety scores as a moderator to examine the impact of
treatment on test anxious students in the Low Severity (CTAS scores below the median)
versus High Severity (CTAS scores above the median) groups. Significant differences were
found at post-treatment and at follow-up for only the High Severity group as evidenced by
the large interaction effect [Wilks’ Lambda = 0.72, F(2, 51) = 10.14, p \ .0001, partial
eta squared = 0.29] and large group effect [F(1, 52) = 20.13, p \ .0001, partial eta
squared = 0.28.].

Effect of Intervention on Children Relative to Achievement Levels

Second, we hypothesized that students who were average in achievement were likely to be
most affected by test anxiety. For the control group, a main effect was registered for
achievement groups only (See Table 3). There were large differences in test anxiety scores
for high, average, and low achievers who received no intervention. As predicted, average
achieving students reported increasing test anxiety whereas their high and low achieving
peers were fairly consistent in their anxiety levels. For the CBT group, only time effect was
significant, i.e., test anxiety was reduced over time for all students (See Table 3). The
impact of the intervention was most evident between post-treatment and two-month fol-
low-up as indicated by a substantial main effect for time, Wilks’ Lambda = 0.88, F(1,
55) = 7.37, p = .009, partial eta squared = 0.12.

Cognitive-Behavioral Skills that Contribute to Treatment Outcomes

Finally, we wanted to determine which treatment components were active in reducing test
anxiety. We predicted that interventions that had behavioral elements would be effective in
lowering test anxiety. Between post-treatment and follow-up, the cognitive-behavioral
skills (CBSC) scores reported at follow-up were added as a covariate in the mixed-design
ANOVA to examine the effects of treatment. We had earlier found significant reduction in
test anxiety scores between post-treatment and follow-up. When the CBSC scores were
included as a covariate, we were ‘‘removing’’ the CBT skills that were taught and there-
fore, we expected there would no longer be significant differences in test anxiety scores
between post-treatment and follow-up. After controlling for CBT skills, there was no
significant interaction effect, Wilks’ Lambda = 0.97, F(2, 54) = 0.79, p = .46, partial eta

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Table 2 Group and time differences on the Children’s Test Anxiety Scale (CTAS) scores: a 2 9 3 analysis of variance
Pre-intervention M (SD) Post-intervention M (SD) Maintenance M (SD) Group effect Time effect Group 9 time effect

Control CBT Control CBT Control CBT F(1, 113) g2p F (2, 112) g2p F (2, 112) g2p
(n = 57) (n = 58) (n = 57) (n = 58) (n = 57) (n = 58)

CTAS 2.31 (0.69) 2.37 (0.62) 2.32 (0.76) 2.29 (0.66) 2.32 (0.81) 2.11 (0.71) 0.24 0.002 3.67* 0.06 3.96* 0.07
* p \ .05
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Fig. 1 Children’s Test Anxiety 2.4

Scale Scores of control and
2.35
experimental groups across pre-
intervention, post-intervention 2.3
and maintenance
Mean 2.25

CTAS 2.2

Score 2.15
Control
2.1
Experimental
2.05

2
Pre-Intervenon Post-Intervenon Maintenance

squared = 0.03. As anticipated, there was also no main effect for time, Wilks’ Lamb-
da = 0.99, F(1, 54) = 0.72, p = .40, partial eta squared = 0.01. The difference in test
anxiety scores across the two time periods was no longer significant. The main effect for
achievement groups comparing the three academic achievement groups was also not sig-
nificant, F(2, 54) = 0.94, p = .40, partial eta squared = 0.03. Thus, when we filtered out
cognitive-behavioral skills practice, the change in anxiety between post-treatment and
follow-up was no longer significant.
To determine which cognitive-behavioral skill, if practiced, were active in treatment, we
used participants’ scores on each of the seven skills in the CBSC (See ‘‘Appendix’’) as a
covariate to control for the practice of that specific skill. Again, when we controlled for or
removed the treatment components that were active, we expected to obtain non-significant
treatment outcomes at follow-up. Only one out of seven skills—using calming self-talk—
did not contribute to the positive treatment outcomes. As hypothesized, the cognitive skill
of ‘‘saying positive things to calm myself’’ was not an active treatment component as it
maintained a significant main effect of time, Wilks’ Lambda = 0.85, F (1, 54) = 9.72,
p = .003, partial eta squared = 0.15. However, each of the remaining six skills, when
partialled out, produced a non-significant main time effect on test anxiety scores across the
post-intervention and follow-up: (1) balloon breathing, Wilks’ Lambda = 0.99, F(1,
54) = 0.48, p = .49, partial eta squared = 0.01; (2) following own time-table at home,
Wilks’ Lambda = 0.99, F(1, 54) = 0.55, p = .46, partial eta squared = 0.01; (3) muscle
relaxation, Wilks’ Lambda = 0.98, F (1, 54) = 0.94, p = .34, partial eta squared = 0.02;
(4) thinking of a special memory to feel calm and good, Wilks’ Lambda = 1.00, F(1,
54) = 0.07, p = .79, partial eta squared = 0.001; (5) paying attention to body feelings,
Wilks’ Lambda = 0.97, F(1, 54) = 1.97, p = .17, partial eta squared = 0.04; (vi) prac-
ticing breathing and saying positive things to self simultaneously, Wilks’ Lambda = 0.99,
F(1, 54) = 0.42, p = .52, partial eta squared = 0.01.

Discussion

This study provides results, albeit preliminary, that make contributions to the research on
test anxiety in three ways. First, this may be one of the first school-based CBT studies in
Southeast Asia on test anxiety that targets an elementary school age population. The
preliminary findings were encouraging in showing that brief, school-based, group-

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Table 3 Achievement and time differences on the Children’s Test Anxiety Scale (CTAS) scores for control group and CBT group: a 2 9 3 analysis of variance
Measure Pre-intervention Post-intervention Maintenance Achievement Time Achievement
effect M (SD) M (SD) M (SD) effect effect
9 time effect

High Average Low High Average Low High Average Low F g2p F g2p F g2p
(n = 23) (n = 10) (n = 24) (n = 23) (n = 10) (n = 24) (n = 23) (n = 10) (n = 24) (2, 54) (2, 53) (4, 106)

Control group
CTAS 2.02 (0.66) 2.62 (0.79) 2.46 (0.60) 1.99 (0.77) 2.66 (0.78) 2.49 (0.63) 2.00 (0.87) 2.87 (0.86) 2.39 (0.59) 4.5* 0.14 0.48 0.02 1.92 0.07

High Average Low High Average Low High Average Low F(2, 55) g2p F (2, 54) g2p F (4, 108) g2p
(n = 7) (n = 40) (n = 11) (n = 7) (n = 40) (n = 11) (n = 7) (n = 40) (n = 11)

CBT group
Author's personal copy

CTAS 2.34 (0.52) 2.40 (0.66) 2.26 (0.60) 1.99 (0.48) 2.34 (0.70) 2.29 (0.63) 1.87 (0.47) 2.19 (0.77) 1.98 (0.58) 0.62 0.02 5.33** 0.17 0.99 0.04

* p \ .05. ** p \ .01
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administered CBT can lower the test anxiety of young students. That a significant reduction
in test anxiety occurred only at 2-months follow-up prior to the final examination may
suggest that the students needed both the time to internalize the skills they learned and also
the opportunity to practice them. The moderate treatment effect size of 0.7 was close to
that of group-based intervention for anxiety in the literature. The effect size at post-
treatment obtained in Weem and colleagues’ studies that utilized a 5-session group-ad-
ministered test anxiety intervention program were 0.74 to 0.83 (Weems et al. 2009) and
0.84 (Weems et al. 2014). An overall mean effect size of 0.67 was reported in Ergene
(2003)’s meta-analysis of group-based anxiety reduction programs. Although test anxiety
is very common among school children and can be debilitating in its impact on academic
performance, schools do not routinely provide intervention for test anxiety due largely to
limited time and resources and perceivably the more urgent push to cover the curriculum.
Conceivably, very large groups of students (the majority being average achievers) struggle
with test anxiety unaided when faced with major testing situations. However, time-limited,
group format preventive programs that teach targeted skills in managing test anxiety can be
extended school wide. A partnership model, e.g., Weems et al. (2010), that taps into
existing school routines and emotional wellness curriculum offers significant benefits in
setting students on a path of academic success.
Second, the study answered a question about who benefits from test anxiety treatment.
This is an important question in school systems that are short staffed of mental health
professionals and resources therefore need to be wisely allocated. We hypothesized that
children who were average in achievement were likely to be most affected by test anxiety.
Indeed, a salient and important finding is that average achievers in the control group who
had no treatment showed the greatest increase in test anxiety over time, with anxiety levels
peaking during the final examination. Left untreated, the anxious average achieving child
will not only suffer emotional distress but also poor grades. We also found that all students
who received CBT benefited from treatment by showing reduced test anxiety at follow-up.
We also noted that the baseline level of anxiety for the CBT group moderated treatment
outcomes. Treated students who had low test anxiety (Low Severity) at baseline showed no
change after treatment; however, those who fell into the High Severity group at baseline
registered significantly lower test anxiety with large treatment effects. Thus, the results
imply that average achieving students with high test anxiety will particularly benefit from
treatment.
In CBT research, the active ingredients that contribute to outcomes are not well un-
derstood (Prins and Ollendick 2003). The study’s third contribution is answering the
question about what makes treatment work for children. The CBT package comprised a
mixture of cognitive as well as behavioral components. These skills were individually
unpacked to reveal which ones played a role in contributing to the treatment outcomes. It
was discovered that all the skills did, except for ‘‘Saying positive things to myself to feel
calm’’. This supports the notion that cognitive skills may not be effective with elementary
school children. The active ingredients were behavioral, such as relaxation (balloon
breathing), skills training, and pairing of relaxation skills with self-instructional training.
The literature on treating test anxiety also supports the use of relaxation techniques with
school children (Larson et al. 2010; Lee 2003) and the use of study skills (Lee 2003). Thus,
these findings support the outcomes of Ergene’s (2003) meta-analysis that the most ef-
fective treatments for anxiety combine skill-focused approaches with behavioral or cog-
nitive approaches. They add credence to the importance of focusing on behavioral
strategies over cognitive strategies when supporting test anxious children and adolescents
(Hembree 1988; King et al. 1995). The good news is that the skills that work can be taught

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to classroom teachers for inclusion in the school’s social and emotional curriculum
framework.

Limitations

This study was undertaken in a naturalistic setting where it was not possible to exercise
strict experimental control. The school’s selection of classes for participation in the study
limited the equal and randomized distribution of students from each achievement group to
the experimental and control conditions, and thus the evidence of treatment effects was
weaker. External validity was also limited as the study was conducted in one public
elementary school only, hence the findings of this study cannot be generalized to other
elementary schools both locally and internationally. Further studies employing randomized
designs with larger sample sizes are warranted to validate the effectiveness of the inter-
vention program for test anxiety.
In terms of intervention delivery, potential biases such as demand characteristics were
not controlled for, which could have contributed to the observed effects across time.
Although the intervention was explained to the children as a stress management program,
they understood that skills taught were to be employed during test situations. However,
they appeared genuinely interested in lowering their test anxiety and were observed to be
practicing deep breathing in between lessons to better prepare for the final examination. In
light of their motivation, it is unlikely that the experimental group participants changed
their behavior or improved on account of the attention they received from the researcher.
Future research can consider offering organizational skills training without the anxiety
management component as a control condition for comparison with standard CBT.
The measures used were based on the children’s self-report; thus the ratings were open
to distortion if the participants wished to create a positive image, especially in terms of
indicating diligence in practicing the cognitive-behavioral skills taught to them. However,
where internalizing symptoms such as anxious emotions are concerned, youth have been
found consistently to provide valid reports (Weems et al. 2005). The CBSC was developed
by the researchers and had not been validated, although its Cronbach’s alpha indicated
respectable reliability. The CTAS was a tool that originated in the US. The findings,
therefore, need to be interpreted with caution.

Conclusion

In conclusion, the results provide preliminary evidence for the utility of time-limited
school-based anxiety interventions in test anxiety prevention with an understudied
population of Asian elementary school children. Results add to the literature by identifying
in relation to achievement levels students who most need and/or who will most benefit
from test anxiety treatment. Results also add an important aspect to test anxiety inter-
vention by unpacking the active treatment components that alleviate test anxiety in chil-
dren. In an era in which academic testing is beginning earlier and becoming more frequent
and costly in terms of its impact on children’s academic futures and mental health, early
intervention for test anxiety will give children a much needed head start in acquiring a set
of coping skills that are transportable. ‘‘Test anxiety taps into general anxious arousal and
is not necessarily just anxiety associated with tests (i.e., ‘test anxiety’ is less circumscribed
than the name implies.)’’ (Weems, et al. 2009, p. 219). Theoretically, therefore, the skills to

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cope with test anxiety may be applicable to a myriad of life challenges that similarly evoke
anxiety responses and may avert the development of anxiety problems more broadly.

Appendix: Cognitive-Behavioral Skills Checklist (CBSC)

Circle the answers that best describe the amount of activities you do when you feel anxious
in a test or exam situation.

Never 1–2 times per 1–4 times per Almost

month week everyday

1. I practice ‘‘balloon’’ breathing.

2. I say positive things to myself to stay calm.
3. I follow my own timetable at home.
4. I practice relaxing my muscles.
5. I think of a special memory to feel calm and
good.
6. I pay attention to how my body is ‘‘feeling’’.
7. I practice breathing and say positive things to
myself at the same time.

References
Ang, R. P., Klassen, R. M., Chong, W. H., Huan, V. S., Wong, I. Y. F., Yeo, L. S., & Krawchuk, L. L.
(2009). Cross-cultural invariance of the academic expectations stress inventory: Adolescent samples
from Canada and Singapore. Journal of Adolescence, 32, 1225–1237. doi:10.1016/j.adolescence.2009.
01.009.
Blankstein, K. R., Flett, G. L., & Watson, M. S. (1992). Coping and academic problem-solving in test
anxiety. Journal of Clinical Psychology, 48, 37–46. doi:10.1002/1097-4679(199201)48:1%3C37:AID-
JCLP2270480105%3E3.0.CO;2-F.
Chapell, M. S., Blanding, Z. B., & Silverstein, M. E. (2005). Test anxiety and academic achievement in
undergraduate and graduate students. Journal of Educational Psychology, 97, 268–278. doi:10.1037/
0022-0663.97.2.268.
Connor, M. J. (2003). Pupil stress and standard assessment tasks (SATs): An update. Emotional and
Behavioural Difficulties, 8, 101–107.
Dobson, K. S., & Dozois, D. J. A. (2010). Historical and philosophical bases of the cognitive-behavioral
therapies. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 3–38). New
York, NY: Guilford Press.
Ergene, T. (2003). Effective interventions on test anxiety reduction. School Psychology International, 24,
313–328.
Faber, G. (2010). Enhancing orthograhic competencies and reducing domain-specific test anxiety: The
systematic use of algorithmic and self-instructional task formats in remedial spelling training. Inter-
national Journal of Special Education, 25, 78–88.
Galla, B. M., Wood, J. J., Chiu, A. W., Langer, D. A., Jacobs, J., Ifekwunigwe, M., & Larkins, C. (2012).
One year follow-up to modular cognitive behavioral therapy for the treatment of pediatric anxiety
disorders in an elementary school setting. Child Psychiatry and Human Development, 43, 219–226.
doi:10.1107/s10578-011-0258-x.
Ginsburg, G. S., Becker, K. D., Drazdowski, T. K., & Tein, J.-Y. (2012). Treating anxiety disorders in inner
city schools: Results from a pilot randomized controlled trial comparing CBT and usual care. Child &
Youth Care Forum, 41, 1–19. doi:10.1007/s10566-011-9156-4.

123
 Author's personal copy
Child Youth Care Forum

Gregor, A. (2005). Examination anxiety: Live with it, control it, or mae it work for you? School Psychology
International, 26, 617–635. doi:10.1177/0143034305060802.
Hancock, D. R. (2001). Effects of test anxiety and evaluative threats on students’ achievement and moti-
vation. The Journal of Educational Research, 94, 284–290. doi:10.1080/00220670109598764.
Hembree, R. (1988). Correlates, causes, effects and treatment of test anxiety. Review of Educational Re-
search, 58, 47–77. doi:10.3102/00346543058001047.
Kendall, P. C. (2012a). Anxiety disorders in youth. In P. C. Kendall (Ed.), Child and adolescent therapy:
Cognitive-behavioral procedures (4th ed., pp. 143–189). New York, NY: Guilford.
Kendall, P. C. (2012b). Child and adolescent therapy: Cognitive-behavioral procedures (4th ed.). NY:
Guilford.
Keogh, E., Bond, F. W., French, C. C., Richards, A., & Davis, R. E. (2004). Test-anxiety, susceptibility to
destruction and examination performance. Journal of Anxiety, Stress and Coping, 17, 241–252. doi:10.
1080/10615300410001703472.
King, N. J., Mietz, A., Tinney, L., & Ollendick, T. H. (1995). Psychopathology and cognition in adolescents
experiencing severe test anxiety. Journal of Clinical Child Psychology, 24, 49–54. doi:10.1207/
s15374424jccp2401_6.
Larson, H., Ramahi, M., Conn, S., Este, L., & Ghibellini, A. (2010). Reducing test anxiety among third
grade students through the implementation of relaxation techniques. Journal of School Counseling, 8,
1–19.
Lee, C. K. M. (2003). Test anxiety and academic performance: The effect of a class-based stress man-
agement programme. NIE Digital Repository. National Institute of Education. Singapore. Retrieved
from NIE Digital Repository http://hdl.handle.net/10497/774.
Lowe, P. A., & Ang, R. P. (2012). Cross-cultural examination of test anxiety among US and Singapore
students on the Test Anxiety Scale for Elementary Students (TAS-E). Educational Psychology, 32.
doi:10.1080/01443410.2011.625625.
McDonald, A. S. (2010). The prevalence and effects of test anxiety in school children. Educational Psy-
chology, 21, 89–101. doi:10.1080/01443410020019867.
Nichols, P. (1999). Clear thinking: Talking back to whispering shadows. Iowa: River Lights Publishers.
Ollendick, T. H., & King, N. J. (1998). Empirically supported treatments for children with phobic and
anxiety disorders: Current status. Journal of Clinical Child Psychology, 27, 156–167.
Orbach, G., Lindsay, S., & Grey, S. (2007). A randomised placebo-controlled trial of a self-help internet-
based intervention for test anxiety. Behaviour Research and Therapy, 45, 483–496. doi:10.1016/j.brat.
2006.04.002.
Parkinson, M., & Creswell, C. (2011). Worry and problem-solving skills and beliefs in primary school
children. British Journal of Clinical Psychology, 50, 106–112. doi:10.1348/014466510X523887.
Prins, P. J. M., & Ollendick, T. H. (2003). Cognitive change and enhanced coping: Missing mediational
links in cognitive behavior therapy with anxiety-disordered children. Clinical Child and Family
Psychology Review, 6, 87–105. doi:10.1023/A:1023730526716.
Putwain, D. W. (2008). Deconstructing test anxiety. Educational and Behavioural Difficulties, 13, 141–155.
doi:10.1080/13632750802027713.
Sarason, I. G. (1984). Stress, anxiety and cognitive interference: Reactions to tests. Journal of Pesonality
and Social Psychology, 46, 929–938.
Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (2nd ed.). Boston: Pearson.
von der Embse, N., Barterian, J., & Segool, N. (2013). Test anxiety interventions for children and ado-
lescents: A systematic review of treatment studies from 2000–2010. Psychology in the Schools, 50,
57–71. doi:10.1002/pits.21660.
Weems, C. F., Scott, B. G., Graham, R. A., Banks, D. M., Russell, J. D., Taylor, L. K., & Marino, R. C.
(2014). Fitting anxious emotion-focused intervention into the ecology of schools: Results from a test
anxiety program evaluation. Prevention Science,. doi:10.1007/s11121-014-0491-1.
Weems, C. F., Scott, B. G., Taylor, L. K., Cannon, M. F., Romano, D. M., Perry, A. M., & Triplett, V.
(2010). Test anxiety prevention and intervention programs in schools: program development and
rationale. School Mental Health, 2, 62–71. doi:10.1007/s12310-010-9032-7.
Weems, C. F., Taylor, L. K., Costa, N. M., Marks, A. B., Romano, D. M., Verrett, S. L., & Brown, D. M.
(2009). Effect of a school-based test anxiety intervention in ethnic minority youth exposed to Hurri-
cane Katrina. Journal of Applied Developmental Psychology, 30, 218–226. doi:10.1016/j.appdev.2008.
11.005.
Weems, C. F., Zakem, A., Costa, N. M., Cannon, M. F., & Watts, S. E. (2005). Physiological response and
childhood anxiety: Association with symptoms of anxiety disorders and cognitive bias. Journal of
Clinical Child and Adolescent Psychology, 34, 712–723. doi:10.1207/s15374424jccp3404_13.

123
 Author's personal copy
Child Youth Care Forum

Wren, D. G., & Benson, J. (2004). Measuring test anxiety in children: Scale development and internal
construct validation. Anxiety, Stress and Coping, 17, 227–240. doi:10.1080/10615800412331292606.
Yeo, L. S., & Clarke, C. (2005). Starting school: A Singapore story told by children. Australian Journal of
Early Childhood, 30, 1–8.
Zeidner, M., & Matthews, G. (2005). Evaluation anxiety. In A. J. Elliot & C. S. Dweck (Eds.), Handbook of
competence and motivation (pp. 141–163). London: Guilford Press.
Zeidner, M., & Schleyer, E. (1999). Test anxiety in intellectually gifted students. Anxiety, Stress and
Coping, 12, 163–189. doi:10.1080/10615809908248328.

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