Helping Your Anxious Child - Bibliotherapy

OVERVIEW

Bibliotherapy is an alternative to traditional therapist-client treatment that focuses on self-help through the use of printed materials.  In the Helping Your Anxious Child program, parents act as therapists, using written materials to help treat their child’s anxiety disorder.  Through the program, parents help familiarize their children with techniques for managing and understanding anxiety. 

An experimental evaluation of the program found that following the treatment there was a significantly greater number of children in the bibliotherapy condition without an anxiety disorder than those in the waitlist group.  However, these numbers were significantly less than those in the standard group treatment (this treatment, the Cool Kids Program, is summarized here).  The same pattern also existed in terms of improvement across time in disorder severity.  For parent reports of child anxiety levels and parent reports of child internalizing and externalizing behavior, children in bibliotherapy did not differ from those in the waitlist condition, but were significantly less improved than those in group treatment.  No differences were found between groups for child reports of anxious symptoms or negative thoughts/beliefs. 

Three month follow-up assessments were conducted for the bibliotherapy and standard group treatment conditions.  The proportion of those in the bibliotherapy treatment who no longer met the criteria for being diagnosed with an anxiety disorder was significantly lower than for those in group treatment.  Similarly, children in bibliotherapy improved significantly less than the standard group treatment condition over time from baseline to follow-up on measures of diagnostic severity, parent ratings of symptoms of anxiety, and parent reports of internalizing and externalizing behavior.  There were no significant differences between conditions on measures of children’s reports of symptoms of anxiety and negative thoughts/beliefs, although scores did significantly change over time.  

DESCRIPTION OF PROGRAM

Target Population: Children with anxiety disorders

The bibliotherapy treatment program consists of having parents of child participants conduct treatment using self-help materials that have been constructed to mimic empirically supported child anxiety treatments.  Each parent is supplied with a copy of a regularly available book called “Helping Your Anxious Child: A Step-by-Step Guide,” which explains strategies for managing anxiety and methods for helping children become familiar with such techniques.  Child participants also receive workbooks containing worksheets and summaries that are found in the parent’s copy of the book. 

Parents receive cover letters that explain the components of the program.  Each parent is to work through the treatment with their child at their own pace, but a suggested timetable is supplied, and assessments are set for three months after the distribution of the treatment materials.  No further contact between participants and the researchers or therapists is initiated.  However, if a parent does make contact, researchers remind parents of the timeline and encourage them to keep working through the program.  If a parent reports serious issues with their child’s condition worsening, participants are referred to a clinical supervisor to determine the most appropriate action to be taken. 

Program materials are available through the Sociometrics website (www.socio.com).  Each treatment package, including all necessary materials, is priced at $315.  

EVALUATION(S) OF PROGRAM

Evaluated population: 260 Year 1 through 6 (the Australian categorization for primary/elementary school – ages 6 through 12) children were selected for the study.  To be included, children had to meet the Diagnostic and Statistical Manual of Mental Disorders, 4^th edition (DSM-IV) criteria for having an anxiety disorder (as diagnosed by trained clinical psychology graduate students or qualified clinical psychologists).  Principal diagnoses of participating children included generalized anxiety disorder, social phobia, separation anxiety disorder, specific phobia, obsessive-compulsive disorder, and panic disorder.

Approach: Participants were randomly assigned to either the bibliotherapy treatment (N=90), standard group treatment (N=90), or a waitlist condition (N=87).  The only significant difference between groups at baseline was that the group treatment condition had a larger proportion of female participants.  For a description of the standard treatment condition (the Cool Kids Program), see the link provided above.  Children assigned to the waitlist condition were told that they had been randomly selected to wait for treatment and would be re-assessed after a 3 month period, at which point the group treatment program would be made available to them.

To measure the effectiveness of the bibliotherapy program, data was collected from diagnostic interviews, and from both child self-report measures and parent reports of their child’s behavior.  These scales covered outcomes such as symptoms of anxiety (child and parent reports), negative thoughts/beliefs (child), and child internalizing and externalizing behavior (parent).  All measures and diagnostic interviews were completed at baseline and immediately following the conclusion of the treatment programs for all three conditions, but only the bibliotherapy and group treatment conditions were assessed at a three-month follow-up.               

Results: A significant difference was found between conditions in the proportion of participants dropping out (not returning data at the end of the intervention). Twenty-nine dropouts were from bibliotherapy, 14 were from group treatment, and 12 were from the waitlist condition.  A comparison on psychopathology measures demonstrated that those who dropped out had significantly higher scores on several psychopathology measures and significantly greater numbers of multiple diagnoses of disorders.

Immediately following the intervention, a significantly greater number of children in the bibliotherapy condition than those in the waitlist were free of an anxiety disorder, but significantly less than those in the standard group treatment.  Similarly, across time children in the bibliotherapy condition improved significantly more than those in the waitlist in the severity of their disorder, but significantly less than those in group treatment.  For parent reports of child anxiety levels, participants in the bibliotherapy condition did not differ from those in the waitlist condition, while participants in group treatment were significantly more improved than those in waitlist.  Bibiliotherapy participants were significantly less improved than those in group treatment.  The same pattern was also shown for parent reports of both child internalizing and externalizing behavior.  No differences were found between groups in terms of child reports of anxious symptoms or negative thoughts/beliefs.

At the three month follow-up, the proportion of those in the bibliotherapy treatment who no longer met the criteria for having an anxiety disorder was significantly lower than for those in group treatment.  There was a significant difference in change across time between both groups from baseline to follow-up (bibliotherapy improved less than group treatment), but not from post-treatment to follow-up for diagnostic severity, parent ratings of symptoms of anxiety, and parent reports of internalizing and externalizing behavior.  For children’s reports of symptoms of anxiety and negative thoughts/beliefs, scores significantly improved over time, but there were no significant differences between conditions.              

SOURCES FOR MORE INFORMATION

Website: http://www.socio.com/ced08.php

References

Rapee, R.M., Abbott, M.J., Lyneham, H.J. (2006). Bibliotherapy for children with anxiety disorders using written materials for parents: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(3), 436-444

KEYWORDS: Children, Adolescents, Elementary, Middle School, Males and Females (Co-ed), Home-Based, Cost Information is Available, Manual is Available, Counseling/Therapy, Parent or Family Component, Anxiety Disorders/Symptoms

Program information last updated 9/15/11

© Child Trends 2003