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Bibliotherapy for children with anxiety disorders using written materials for parents: A randomized control trial. Journal of Consulting and Clinical Psychology, 74, 436-444



The current trial examined the value of modifying empirically validated treatment for childhood anxiety for application via written materials for parents of anxious children. Two hundred sixty-seven clinically anxious children ages 6-12 years and their parents were randomly allocated to standard group treatment, waitlist, or a bibliotherapy version of treatment for childhood anxiety. In general, parent bibliotherapy demonstrated benefit for children relative to waitlist but was not as efficacious as standard group treatment. Relative to waitlist, use of written materials for parents with no therapist contact resulted in around 15% more children being free of an anxiety disorder diagnosis after 12 and 24 weeks. These results have implications for the dissemination and efficient delivery of empirically validated treatment for childhood anxiety.
Bibliotherapy for Children With Anxiety Disorders Using Written
Materials for Parents: A Randomized Controlled Trial
Ronald M. Rapee, Maree J. Abbott, and Heidi J. Lyneham
Macquarie University
The current trial examined the value of modifying empirically validated treatment for childhood anxiety
for application via written materials for parents of anxious children. Two hundred sixty-seven clinically
anxious children ages 6 –12 years and their parents were randomly allocated to standard group treatment,
waitlist, or a bibliotherapy version of treatment for childhood anxiety. In general, parent bibliotherapy
demonstrated benefit for children relative to waitlist but was not as efficacious as standard group
treatment. Relative to waitlist, use of written materials for parents with no therapist contact resulted in
around 15% more children being free of an anxiety disorder diagnosis after 12 and 24 weeks. These
results have implications for the dissemination and efficient delivery of empirically validated treatment
for childhood anxiety.
Keywords: child anxiety, anxiety disorders, childhood, treatment, self-help
Anxiety disorders in childhood have begun to be recognized as
a serious mental health problem. Epidemiological studies have
repeatedly shown anxiety disorders in childhood to be one of the
most prevalent forms of mental disorder (Anderson, Williams,
McGee, & Silva, 1987; Canino et al., 2004). Combined with this
high prevalence, the moderate to severe life impact of anxiety
(Strauss, Frame, & Forehand, 1987) means that childhood anxiety
provides a serious burden for public health. Furthermore, several
studies have shown that anxiety disorders in childhood provide
risk markers for a range of later adolescent and adult psychopa-
thology (Last, Perrin, Hersen, & Kazdin, 1996; Pine, Cohen,
Gurley, Brook, & Ma, 1998; Weissman et al., 1999).
On the positive side, the past decade has seen an increased focus
on treatment for broad-based childhood anxiety disorders, and
treatment effects have been positive (Allen & Rapee, 2005). These
positive treatment results for childhood anxiety have generally
been achieved through a traditional therapist–client treatment
model typically involving 10–20 face-to-face therapeutic sessions.
Although this model is highly efficacious, it is also resource
intensive. This means that therapeutic costs are high and that many
treatment settings have long waiting lists.
One of the most widely researched alternatives to traditional
therapy is self-help. Individuals can help themselves with the
assistance of video materials, audiotapes, or computerized pro-
grams, but by far the most widely developed and researched
delivery is via printed materials (bibliotherapy). Among adults,
bibliotherapy has been applied to the successful management of
depression, eating disorders, and a variety of anxiety disorders
(Loeb, Wilson, Gilbert, & Labouvie, 2000; McKendree-Smith,
Floyd, & Scogin, 2003; Newman, Erickson, Preworski, & Dzus,
2003). In fact, self-help through bibliotherapy in adults has shown
good outcomes, in many cases as efficacious as standard therapist-
conducted treatment (Mains & Scogin, 2003). One of the obvious
difficulties for self-help lies in the maintenance of motivation to
change throughout a lengthy program. As a result, some biblio-
therapy programs rely on at least minimal involvement from a
therapist, and some evidence has demonstrated that the degree of
improvement in anxiety disorders is related to the amount of
therapist involvement (Marrs, 1995).
One potential characteristic of childhood disorders that may
make them especially amenable to bibliotherapy is the fact that
children live under the care and guidance of an adult, most com-
monly a parent. In this situation, bibliotherapy programs for chil-
dren can make use of a possible motivating factor that exists in the
child’s daily environment by utilizing the parent’s desire for his or
her child to change. The potential advantages of targeting parents
in bibliotherapy for children’s problems are that (a) parents have
personal knowledge of the child across several areas of function-
ing, (b) children usually have established trust and rapport with
their parents, (c) parents have some degree of distance from the
child’s distress, and (d) parents are more broadly present and
available in a child’s life than is a therapist. On the other hand,
conducting therapy for a child through his or her parents can be
filled with dangers: (a) The parents may in fact not be very distant
from the problems and in some cases may be part of the cause
(J. L. Hudson & Rapee, 2004), (b) the parent– child relationship
may be distressed and could undermine trust and rapport, and (c)
parents typically lack the professional education and knowledge of
a therapist. Thus, whether or not parents are capable of helping
Ronald M. Rapee, Maree J. Abbott, and Heidi J. Lyneham, Department of
Psychology, Macquarie University, Sydney, New South Wales, Australia.
Maree J. Abbott is now at the Department of Psychology, University of
Sydney, Sydney, New South Wales, Australia.
We thank Alan Taylor for help with statistical analyses. We also thank
Leigh Carpenter, Joanne McDonald, Sarah Perini, and Lexine Stapinski for
assistance with project management and Jonathan Gaston for clinical
supervision. This research was supported by a grant from the Australian
Rotary Health Research Fund.
Correspondence concerning this article should be addressed to Ronald
M. Rapee, Department of Psychology, Macquarie University, Sydney
NSW 2109, Australia. E-mail:
Journal of Consulting and Clinical Psychology Copyright 2006 by the American Psychological Association
2006, Vol. 74, No. 3, 436 444 0022-006X/06/$12.00 DOI: 10.1037/0022-006X.74.3.436
their children overcome emotional disorders via written materials
is an empirical question.
Despite the promise of bibliotherapy for adult mental disorders
and the potential advantages for childhood problems, there has
been surprisingly little research using this method with children.
Some work has indicated the value of written instructions for
parents for childhood oppositional behavior (Connell, Sanders, &
Markie-Dadds, 1997; Long, Rickert, & Ashcraft, 1993), headache
(Griffiths & Martin, 1996), enuresis (van Londen, van Londen-
Barentsen, van Son, & Mulder, 1995), and social skills in intel-
lectually delayed children (A. M. Hudson et al., 2003). To date, no
studies have examined the value of parent-delivered material for
children’s internalizing problems such as anxiety. This is surpris-
ing given the high prevalence and impact of these disorders
(Canino et al., 2004; Strauss et al., 1987).
The aim of the current study was to examine the impact of using
parents as therapists for their own child in a trial of bibliotherapy
materials for parents of children with anxiety disorders. Being the
first such study, its aim was simply to address the question of
whether bibliotherapy for childhood anxiety was more efficacious
than no treatment and as efficacious as standard therapist-led
treatment. We focused on prepubertal children because of previous
indications that parent involvement in child anxiety treatment is
especially valuable for younger children (Barrett, Dadds, & Rapee,
1996). Furthermore, given the limited theoretical differences be-
tween childhood anxiety disorders, the high levels of comorbidity
between disorders, and the fact that many treatment trials for
childhood anxiety combine several anxiety disorders, this study
included a variety of children’s anxiety disorders using the same,
adaptable program. Finally, we were aware of a serious limitation
to external validity in many self-help trials for adult problems that
include additional motivators such as reminder telephone calls,
regular mail contact, or homework mailings. Therefore, to maxi-
mize the real-world relevance of the trial, we chose to have no
contact between the researchers and self-help participants during
the active treatment phase, thereby providing a very conservative
test of self-help.
Participants for the study were 267 children meeting Diagnostic and
Statistical Manual of Mental Disorders (4th ed. [DSM–IV]; American
Psychiatric Association, 1994) criteria for an anxiety disorder. Because
demonstration of differences between active treatments requires good
power, the intention was to recruit the maximum sample size possible, with
a minimum of 53 participants per condition, to allow a power of .8 to detect
a maximum effect-size difference of f .25 (Faul & Erdfelder, 1992).
Participants were included if they were in Years 1 through 6 at school (ages
6 –12 years), they met criteria for an anxiety disorder as their principal
(most interfering) disorder, and their parent or parents were able to read a
standard, English-language newspaper. To maximize external validity,
children with comorbid nonanxiety disorders were not excluded unless
these disorders demanded immediate attention (e.g., severe school nonat-
tendance, suicidal risk). Children on medication were included if the
medication had been stable for the previous month.
Diagnoses were assigned by graduate students in clinical psychology or
qualified clinical psychologists following structured interview with the
Anxiety Disorders Interview Schedule for DSM–IV, Parent and Child
Versions (ADIS-CP; Silverman & Albano, 1996). Interviewers received
training to criterion, and research from our clinic overlapping with the
current sample has demonstrated interrater agreement of
1.00 for an
overall diagnosis of anxiety disorder and ranging from .68 to .93 across the
major anxiety disorders (Lyneham, Abbott, & Rapee, 2004). Children met
criteria for the following principal diagnoses: generalized anxiety disorder
(N 103), social phobia (N 64), separation anxiety disorder (N 51),
specific phobia (N 33), obsessive– compulsive disorder (N 13), and
panic disorder (N 3). The main comorbid diagnostic groups included
anxiety disorder (N 219; 82.0%), externalizing disorder (N 72;
27.0%), and mood disorder (N 23; 8.6%).
Structured interview. As described above, all children and their parents
were interviewed by a clinician using the ADIS-CP. The interview was
repeated at posttreatment and 3-month follow-up. Repeated interviews
were conducted by clinicians who were masked to the child’s allocated
treatment condition but who were told the child’s pretreatment diagnoses.
This was done to ensure that clinicians completed a measure of diagnostic
severity on each diagnosis even if the child no longer met criteria. Thus, the
interview provided data on diagnostic status as well as clinician-rated
Child reports. To measure symptoms of anxiety, children completed
the Spence Children’s Anxiety Scale (SCAS; Spence, 1998). This self-
report measure contains 38 anxiety items that all load on a single higher
order scale, with a range from 0 to 114. Internal consistency (.92) and
6-month retest reliability (.60) for the total scale are good (Spence, 1998).
Finally, children completed the Children’s Automatic Thoughts Scale
(CATS; Schniering & Rapee, 2002), a measure of children’s negative
thoughts and beliefs. The measure contains four subscales: social threat
.85), physical threat (
.92), failure and loss (
.92), and
hostility (
.85). The measure also has good retest reliability over 3
months (.68–.77), and the various subscales each discriminate between
relevant forms of child psychopathology (Schniering & Rapee, 2002). For
the current study, total scores were used to provide a measure of general
negative thinking. This measure has a total of 40 items with a range from
0 to 160.
Parent reports. Parents completed the parent version of the SCAS
(SCASp; Nauta, Scholing, Rapee, Abbott, & Spence, 2004). This measure
contains items parallel to those of the child version but relates to questions
about “my child” rather than self. Scores range from 0 to 114, and internal
consistency (.89) is good (Nauta et al., 2004). The measure distinguishes
clinically anxious from nonclinical groups of children (Ms 31.8 and 14.2,
respectively; Nauta et al., 2004). Data from the mother and father SCASp,
when available, were combined to form a single measure of parent-rated
anxiety symptoms. When two parents did not provide data, results are
based on a single parent, most often the mother.
To assess related and comorbid symptoms, parents also completed the
Child Behavior Checklist (CBCL; Achenbach, 1991), which was scored
simply as internalizing (CBCL-int) and externalizing (CBCL-ext) sub-
scales. Internal consistency for the two subscales is reported to be strong
(.89 –.93), as is 1-week retest reliability (.87–.95), and the scales have been
shown to differentiate referred and nonreferred children (Achenbach,
1991). Again, when available, the two parent scores on the CBCL were
combined to form single measures of parent internalizing and parent
externalizing, and t scores are reported.
Treatment Conditions
Group treatment. Group treatment was based on the Cool Kids Pro-
gram, a nine-session cognitive– behavioral program for the management of
broad-based childhood anxiety disorders (Rapee & Wignall, 2002). Previ-
ous research has shown the program to be efficacious and to provide results
comparable with other empirically validated programs for the management
of child anxiety (Rapee, 2000, 2003). Therefore, it provided a valuable
gold standard against which to compare bibliotherapy. Parents and children
attend all nine sessions of the program on a weekly basis over 12 weeks
(the final few sessions are biweekly) and cover recognition of emotion and
anxiety, realistic thinking, child management strategies, exposure to feared
cues, and additional skills such as assertiveness and dealing with teasing.
Each session lasts for approximately 2 hours and is conducted in groups of
around seven families. The program is manualized, and both child and
parents receive written summaries, worksheets, and guides for home prac-
tice during sessions. In the present study, groups were conducted by pairs
of therapists who were mostly graduate students in clinical psychology,
with at least one having had previous experience conducting Cool Kids
Bibliotherapy. Parents of participants allocated to bibliotherapy were
informed that they were to conduct treatment at home with their own child
using self-help materials. Each parent was provided with a copy of the
commercially available consumer book Helping Your Anxious Child: A
Step-by-Step Guide (Rapee, Spence, Cobham, & Wignall, 2000), which
describes anxiety management skills and ways of introducing them to and
implementing them with children. In addition, children were provided with
a workbook that contained the summaries and worksheets referred to in the
parent book and used within the group program. The materials for biblio-
therapy were developed to contain the strategies and information that
characterize most empirically supported treatments for child anxiety.
Hence, the techniques covered in bibliotherapy more or less paralleled
those covered in the standard group program. Nevertheless, we were
working with a commercially available product, and hence, the bibliother-
apy program was not completely parallel to the Cool Kids group program.
Examples of some differences are a section on relaxation in the commercial
book that was not included in the group program and attention to dealing
with teasing and bullying in the group program that was not included in the
commercial book.
Parents were given a cover letter explaining that they were to work
through the materials with their child and would be seen again for assess-
ment in 3 months’ time. The letter informed parents that they were to work
through the program at their own pace but provided them with a suggested
timetable for completing the program within the 3 months. To evaluate
pure bibliotherapy, no further contact with a therapist or the researchers
was to be initiated. If a parent initiated contact during the treatment period,
he or she was encouraged by research staff to continue to implement the
skills and was reminded of the timing of the next assessment. If a parent
reported a severe deterioration in his or her child (e.g., school refusal,
suicidal ideation), research staff referred the case to the unit’s clinical
supervisor to determine the most appropriate course of action.
Waitlist. Participants in waitlist were simply told that they had been
randomly assigned to wait for treatment and that they would be recontacted
for additional assessment in 3 months’ time, after which they would be
offered the next available treatment group.
Recruitment for the study began in November 1999 and ended in August
2002. Final follow-up concluded in early 2003. Participant flow is shown
in Figure 1. Participants contacted the Macquarie University Anxiety
Research Unit (Sydney, New South Wales, Australia) following referral
from school counselors, general practitioners, or mental health profession-
als or by word of mouth and were screened with a brief telephone
conversation to determine whether the stated problem appeared reasonably
appropriate. They were then sent the questionnaire measures to complete at
home and return at the pretreatment structured diagnostic interview. Those
who met criteria for inclusion were allocated to a research condition and
provided the appropriate materials, scheduled into a group, or informed
when their waitlist period would end. Randomization occurred in blocks of
eight to allow allocation to group treatment based on a predetermined
random number schedule known only to the study coordinator (Maree J.
Abbott). After the initial 12 weeks, all children were once again given the
initial questionnaires and were reassessed using the ADIS-CP by inter-
viewers who were masked to group allocation. No adverse events due to
participation in treatment were noted. Participants in waitlist were then
offered group treatment. Participants in bibliotherapy and group treatments
were asked to continue practicing the skills for a further 3 months, at which
time they were again reassessed. After the 3-month follow-up period,
bibliotherapy participants were offered group treatment if they felt they
needed it.
Parents signed informed-consent forms, and children provided verbal
assent. The methods were approved by the Macquarie University Human
Ethics Committee.
Data Analysis
Data from all three conditions were available only at pre- and posttreat-
ment points because, for ethical reasons, waitlist participants were offered
group treatment after the end of the waiting period. Thus, the three
experimental groups were compared at pre- and posttreatment using
mixed-model analyses. Two types of analyses were conducted. Treatment
completer analyses included only those participants who returned data at
both time points and, in the group condition, completed at least seven
sessions. An equivalent to the seven-session rule for people in bibliother-
apy was not possible, and therefore, all bibliotherapy participants who
returned data were included in treatment completer analyses. Hence, results
for this condition are necessarily somewhat conservative. Intention-to-treat
analyses included all participants who were allocated to a condition (aside
from 7 participants who did not return any data at pretreatment) and used
267 Children with DSM-IV
anxiety disorders
Group Treatment
N = 90
N = 90
N = 87
N = 76
N = 61
N = 75
N = 14
N = 29
N = 2
N = 0
Referred for
N = 74
N = 61
N = 12
Random Allocation
Figure 1. Flow diagram of participants through the study. DSM-IV
Diagnostic and Statistical Manual of Mental Disorders (4th ed.).
the last-point-carried-forward method to deal with missing data. Both
methods of analyzing data address somewhat different questions.
In addition, the two active conditions, bibliotherapy and group treatment,
were compared across the three time points for which they were expected
to return data: pretreatment, posttreatment, and 3-month follow-up. Mixed-
model analyses were used, and again, both completer and intention-to-treat
analyses were conducted.
Pretreatment Comparisons
Of the 267 children, 90 were allocated to group treatment, 90 to
bibliotherapy, and 87 to waitlist. Participants allocated to the three
experimental groups were compared on both demographic vari-
ables and pretreatment measures of psychopathology. On demo-
graphic variables, there were no significant differences between
groups on child’s age, parent marital status, percentage on a low
family income, number of siblings, or use of medication (all ps
.10). Child’s sex differed significantly between groups,
(2, N
267) 11.13, p .01, with the group treatment condition having
a greater proportion of female children. Therefore, all analyses
described below were repeated with sex included as a covariate. In
no case was sex a significant covariate, and hence, it is not
described further. Demographic data are presented in Table 1. On
measures of psychopathology, there was no significant difference
between groups on their principal diagnosis, severity of principal
diagnosis, number of comorbid diagnoses, or scores on the SCAS,
CATS, SCASp, CBCL-int, or CBCL-ext (all ps .10; see
Table 2).
Analyses of Dropout Data
A total of 55 participants (20.6%) failed to return posttreatment
data or attended fewer than seven group treatment sessions.
Among these participants, 12 (13.8%) were from waitlist, 29
(32.2%) were from bibliotherapy, and 14 (15.6%) were from group
treatment. There was a significant difference between conditions in
the proportion of those who did not return posttreatment data,
N 267) 11.30, p .01.
Participants who dropped out at posttreatment were compared
with those who did not drop out on demographic and psychopa-
thology measures. Those who dropped out had a significantly
greater number of comorbid diagnoses (M dropout 2.2, SD
1.3; M nondropout 1.8, SD 1.3), F(1, 265) 4.71, p .05,
and scored significantly higher on several measures of psychopa-
thology: CATS (M dropout 48.9, SD 33.8; M nondropout
34.3, SD 26.7), F(1, 254) 11.18, p .001; CBCL-ext (M
dropout 57.8, SD 9.1; M nondropout 54.4, SD 9.7), F(1,
262) 5.29, p .05; and SCAS (M dropout 39.6, SD 18.6;
M nondropout 31.8, SD 18.2), F(1, 246) 7.64, p .01.
Several other measures did not differ significantly between groups,
including child’s age, child’s sex, child’s medication use, parents’
marital status, number of siblings, SCASp, and CBCL-int.
Among participants in the bibliotherapy and group treatments,
45 (25.0%) failed to return any data at 3-month follow-up. Among
these participants, 29 (32.2%) were from bibliotherapy, and 16
(17.7%) were from group treatment,
(1, N 180) 5.01, p
Pre–Post Comparisons Between Conditions
Changes across time from pre- to posttreatment (completion of
first 12 weeks) were compared between the three conditions using
repeated measures mixed-model analyses. As described above,
both completer and intention-to-treat analyses were conducted.
The proportion of children in each condition who no longer met
criteria for any DSM–IV anxiety disorder is shown in Figures 2 and
3. There were significant differences between groups based on
both the completer sample,
(2, N 212) 51.79, p .001, and
the intention-to-treat sample,
(2, N 267) 47.88, p .001.
Post hoc analyses indicated that for the completer sample, biblio-
therapy resulted in significantly more children free of an anxiety
disorder (25.9%) than for waitlist (6.7%),
(1, N 136) 8.62,
p .005, but less than for children in group treatment (61.1%),
(1, N 137) 15.31, p .001. A similar pattern was apparent
for the intention-to-treat sample: bibliotherapy (17.8%) versus
waitlist (5.7%),
(1, N 177) 6.12, p .05; bibliotherapy
versus group treatment (48.9%),
(1, N 180) 19.6, p .001.
The clinician-rated global severity scale for the principal anxiety
disorder diagnosis also showed a significant Condition Time
interaction based on both completer, F(2, 208.8) 67.14, p
.001, partial
.372, and intention-to-treat samples, F(2, 264)
44.77, p .001, partial
.253. Comparisons of the change
across time for each condition using the intention-to-treat sample
showed that children in bibliotherapy improved more than those on
waitlist, t(264) 2.14, p .05, but not as much as those in group
treatment, t(264) 6.95, p .001. Children in group treatment
improved significantly more than those on waitlist, t(264) 9.03,
p .001. Similar patterns were shown in the completer sample:
bibliotherapy versus waitlist, t(208.1) 3.54, p .001; biblio-
therapy versus group, t(210.3) 7.19, p .001; group versus
waitlist, t(208) 11.41, p .001. Data are presented in Tables 2
and 3.
Parent report of child anxiety (SCASp) demonstrated a signifi-
cant difference between groups based on both intention-to-treat,
F(2, 262.6) 8.20, p .001, partial
.058, and completer
samples, F(2, 179.3) 6.75, p .001, partial
.072. Com
parisons of change across time for each condition showed slightly
different patterns based on analysis sample. For intention-to-treat
analyses, bibliotherapy failed to differ significantly from waitlist,
t(262.2) 0.98, p .32, but was significantly different from
group treatment, t(262.8) 2.93, p .01. Group treatment also
Table 1
Demographic Data Across the Three Conditions (SDs in
(N 87)
(N 90)
(N 90)
Child age (months) 114.1 (19.1) 114.7 (18.1) 113.7 (20.4)
Child sex (% female) 29.9 35.6 53.3
Marital status (% married) 85.1 87.8 86.7
Low family income
(% below $30,000) 16.3 10.3 17.0
Using medication (%) 17.2 16.7 24.4
Number of siblings 1.4 (0.9) 1.4 (0.7) 1.4 (0.9)
Number of comorbid
diagnoses 1.9 (1.2) 1.9 (1.4) 1.9 (1.4)
showed a greater decrease across time than waitlist, t(262.8)
3.89, p .001. In contrast, completer analyses indicated that
bibliotherapy showed a significantly greater decrease over time
than waitlist, t(180.7) 2.02, p .05, but did not differ signifi-
cantly from group treatment, t(179.9) 1.36, p .17. Group
treatment again showed a significantly greater decrease across
time than waitlist, t(177.5) 3.66, p .001.
Parent report of internalizing behavior (CBCL-int) showed a
significant Condition Time interaction based on both intention-
to-treat, F(2, 262.1) 9.41, p .001, partial
.066, and
completer samples, F(2, 188.6) 7.75, p .001, partial
.084. Comparisons across time for each condition showed slightly
different patterns based on analysis sample. Intention-to-treat anal-
yses showed that children in bibliotherapy failed to improve sig-
nificantly more than those on waitlist, t(261.4) 0.53, p .60,
and improved significantly less than children in group treatment,
t(262.5) 3.49, p .001. Children in group treatment improved
significantly more than those on waitlist, t(262.5) 3.98, p
.001. In contrast, completer analyses indicated that bibliotherapy
showed a significantly greater decrease over time than waitlist,
t(189.7) 2.08, p .05, but did not differ significantly from
group treatment, t(189.2) 1.55, p .12. Group treatment again
showed a significantly greater decrease across time than waitlist,
t(187.2) 3.93, p .001.
Parent report of externalizing behavior (CBCL-ext) showed a
significant Condition Time interaction based on both intention-
to-treat, F(2, 261.7) 6.03, p .01, partial
.043, and
completer samples, F(2, 183.4) 5.56, p .005, partial
.060. Comparisons across time for each condition showed slightly
different patterns based on analysis sample. Intention-to-treat anal-
yses showed that children in bibliotherapy failed to improve sig-
nificantly more than those on waitlist, t(261.3) 1.26, p .20,
and improved significantly less than children in group treatment,
t(261.9) 2.20, p .05. Children in group treatment improved
significantly more than those on waitlist, t(261.9) 3.43, p
.001. In contrast, completer analyses indicated that children in
bibliotherapy showed a significantly greater decrease over time
than those on waitlist, t(184.1) 2.25, p .05, but did not differ
significantly from children in group treatment, t(183.8) 0.72,
p .47. Group treatment again showed a significantly greater
decrease across time than waitlist, t(182.4) 3.23, p .001.
Children’s reports of anxious symptoms (SCAS) failed to show
a significant Condition Time interaction based on either
intention-to-treat, F(2, 243.3) 0.15, p .86, partial
.01, or
completer samples, F(2, 179.3) 0.82, p .44, partial
As seen in Tables 2 and 3, children reported a marked decrease in
anxiety in all three conditions, including waitlist.
Finally, children’s reports of negative beliefs (CATS) also failed
to show a significant Condition Time interaction based on either
the intention-to-treat sample, F(2, 249.4) 0.15, p .85, partial
.01, or the completer sample, F(2, 187.8) 0.96, p .38,
Maintenance Effects for Active Treatment Conditions
The proportion of participants in each condition who no longer
met criteria for any anxiety disorder differed significantly at
3-month follow-up based on both intention-to-treat (bibliother-
apy 18.9%; group 61.1%),
(1, N 180) 33.43, p .001,
and completer samples (bibliotherapy 17.9%; group 73.6%),
(1, N 128) 39.18, p .001 (see Figures 2 and 3).
Participants in group treatment and bibliotherapy were com-
pared across time from preintervention to 3-month follow-up using
mixed-model analyses. Data are presented in Tables 2 and 3.
Waitlist Bibliothera
Figure 2. Percentage (including standard error) of children in each con-
dition who no longer met criteria for any anxiety disorder at posttreatment
and 3-month follow-up based on completer analyses.
Table 2
Mean Pretreatment, Posttreatment, and Follow-Up Data Across the Three Conditions for All Participants (Intention to Treat) With
Last Data Carried Forward (SDs in Parentheses)
Waitlist Bibliotherapy Group treatment
Pre Post Pre Post Follow-up Pre Post Follow-up
Diagnostic severity 6.5 (0.9) 5.8 (1.6) 6.4 (1.0) 5.2 (1.8) 5.0 (1.8) 6.5 (1.0) 3.4 (2.6) 2.8 (2.5)
SCASp 30.1 (13.4) 27.7 (13.8) 31.1 (14.2) 27.2 (15.4) 25.9 (15.7) 32.0 (13.0) 23.7 (13.6) 22.3 (14.3)
CBCL-int 68.4 (7.7) 65.1 (8.8) 68.4 (8.3) 64.6 (10.3) 63.4 (11.0) 67.7 (8.3) 60.3 (9.7) 58.7 (11.3)
CBCL-ext 55.1 (9.5) 53.9 (10.5) 55.1 (9.7) 52.8 (10.5) 51.7 (10.6) 55.2 (9.8) 50.9 (9.3) 49.6 (10.3)
SCAS 33.2 (18.0) 25.5 (15.9) 34.2 (18.2) 28.1 (20.1) 25.4 (19.4) 32.9 (19.6) 25.6 (16.7) 23.8 (17.2)
CATS 36.9 (28.7) 26.8 (24.2) 35.7 (26.2) 18.9 (18.6) 18.6 (19.1) 39.5 (31.7) 25.0 (20.7) 19.0 (21.2)
Note. Pre pretreatment; Post posttreatment; SCASp Spence Children’s Anxiety Scale, Parent Version; CBCL-int Child Behavior Checklist,
internalizing scale; CBCL-ext Child Behavior Checklist, externalizing scale; SCAS Spence Children’s Anxiety Scale; CATS Children’s Automatic
Thoughts Scale.
Analyses based on both intention-to-treat and completer analyses
produced similar patterns, and hence, only intention-to-treat anal-
yses, being the more conservative, are reported.
Clinician rating of diagnostic severity showed a significant
decrease across time, F(2, 356) 177.00, p .001, partial
.499, and a significant Condition Time interaction, F(2, 356)
36.77, p .001, partial
.171. The two conditions differed
significantly in their change from pretreatment to follow-up,
t(356) 8.03, p .001, but not in their change from posttreatment
to follow-up, t(356) 1.40, p .16.
Parent rating of anxiety (SCASp) showed a similar significant
effect of time, F(2, 354.2) 69.31, p .001, partial
and a Condition Time interaction, F(2, 354.2) 6.97, p .001,
.038. Bibliotherapy and group treatment differed
significantly in their change from pretreatment to follow-up,
t(354.3) 3.27, p .001, but not in their change from posttreat-
ment to follow-up, t(354.1) 0.06, p .95.
Parent report of internalizing symptoms (CBCL-int) showed a
significant decrease across time, F(2, 353.5) 90.68, p .001,
.338, and a Condition Time interaction, F(2,
353.5) 7.72, p .001, partial
.041. The conditions differed
significantly in their change from pretreatment to follow-up,
t(353.6) 3.55, p .001, but not in their change from posttreat-
ment to follow-up, t(353.2) 0.31, p .75.
Parent report of externalizing symptoms (CBCL-ext) also
showed a significant effect of time, F(2, 353.3) 59.68, p .001,
.252, and a significant Condition Time interaction,
F(2, 353.3) 3.54, p .05, partial
.019. The conditions
differed significantly in their change from pretreatment to follow-
up, t(353.3) 2.45, p .05, but not in their change from
posttreatment to follow-up, t(353.1) 0.32, p .74.
Children’s report of anxiety symptoms (SCAS) showed a sig-
nificant effect of time, F(2, 322.7) 42.77, p .001, partial
.216, but failed to show a significant Condition Time interac-
tion, F(2, 322.7) 0.06, p .94, partial
Finally, children’s report of negative beliefs (CATS) showed a
significant effect of time, F(2, 327.2) 26.17, p .001, partial
.138, but failed to show a significant Condition Time
interaction, F(2, 327.2) 0.15, p .86, partial
Overall, the results of the current trial demonstrate that children
whose parents received bibliotherapy with no therapist contact
improved somewhat more than children on waitlist after 12 weeks
and that these results maintained up to 3 months. However, the
specific pattern of results differs slightly depending on the type of
analysis and the reporting source. On the basis of structured
clinical interviews, bibliotherapy was significantly better than no
treatment according to both completer and intention-to-treat anal-
yses. In contrast, parent reports indicate a significant difference
between bibliotherapy and waitlist according to completer, but not
according to intention-to-treat, analyses. Finally, children in all
three groups reported significant and marked change over time, but
differences between groups were not significant. The results also
show that standard cognitive– behavioral group treatment with a
therapist resulted in greater change than bibliotherapy according to
both clinician and parent reports. Therefore, these results do not
suggest a replacement of traditional models of therapy but do
suggest a potential alternate model of treatment delivery under
appropriate circumstances.
The data indicate the usual disagreement between sources of
reporting (Cole, Truglio, & Peeke, 1997). The clearest differences
Waitlist Bibliotherapy Group treatment
Figure 3. Percentage (including standard error) of children in each con-
dition who no longer met criteria for any anxiety disorder at posttreatment
and 3-month follow-up based on intention-to-treat analyses.
Table 3
Mean Pretreatment, Posttreatment, and Follow-Up Data Across the Three Conditions for Participants Who Completed Each
Assessment (SDs in Parentheses)
Waitlist Bibliotherapy Group treatment
Pre Post Pre Post Follow-up Pre Post Follow-up
Diagnostic severity 6.5 (0.9) 5.8 (1.7) 6.4 (1.1) 4.7 (1.8) 4.8 (1.8) 6.4 (0.9) 2.5 (2.2) 2.0 (2.1)
SCASp 30.6 (13.7) 26.6 (13.1) 29.6 (14.2) 21.0 (12.2) 16.1 (10.8) 30.8 (13.0) 20.2 (11.2) 16.9 (10.8)
CBCL-int 68.6 (7.4) 64.3 (8.8) 68.2 (8.8) 60.6 (10.8) 56.7 (12.1) 67.2 (8.6) 58.3 (9.3) 54.8 (10.9)
CBCL-ext 54.7 (9.1) 52.7 (10.1) 54.3 (10.4) 48.9 (9.9) 46.5 (10.6) 54.3 (9.7) 48.8 (8.2) 45.9 (9.2)
SCAS 32.6 (18.4) 21.9 (14.7) 32.1 (16.6) 19.1 (15.0) 15.5 (11.6) 30.7 (19.5) 21.4 (14.5) 17.6 (14.5)
CATS 34.5 (26.8) 27.1 (24.3) 33.6 (24.6) 18.9 (18.6) 18.6 (19.1) 34.8 (28.5) 25.0 (20.7) 19.0 (21.2)
Note. Pre pretreatment; Post posttreatment; SCASp Spence Children’s Anxiety Scale, Parent Version; CBCL-int Child Behavior Checklist,
internalizing scale; CBCL-ext Child Behavior Checklist, externalizing scale; SCAS Spence Children’s Anxiety Scale; CATS Children’s Automatic
Thoughts Scale.
between conditions are reflected in the ratings made by therapists
and based on interview with parents and child. Although every
attempt was made to keep interviewers masked to treatment con-
dition, in reality this is quite difficult, and it is possible that
interview ratings were influenced by interviewers’ preconceptions
of outcome. Nevertheless, the advantages of interview ratings
include the potential to combine all relevant information, to adhere
to clear diagnostic criteria, to incorporate information about con-
text and interference, and to provide a relative benchmark based on
experience with a variety of cases. Overall, the results based on
interview criteria indicate that relative to the passage of time,
around 15% more children were free of an anxiety disorder simply
through the use of psychotherapeutic materials written for their
In general, the pattern of results from interview was reflected for
the most part in parent questionnaire reports. However, the differ-
ence between bibliotherapy and waitlist failed to reach statistical
significance based on intent-to-treat analyses whereby participants
who failed to return data had their previous data carried forward to
the next point. This is an especially conservative method of miss-
ing data imputation. However, in the absence of widely agreed
methods for handling missing data (Tabachnick & Fidell, 2001),
we decided to utilize this conservative approach. The different
pattern of significance between intent-to-treat and completer anal-
yses suggests that although bibliotherapy appears to be of value for
those who implement it completely, it may not be of significant
value across a general population to which it is applied. In other
words, bibliotherapy for anxious children may be efficacious when
used appropriately, but it may not be effective because of limits in
people’s ability or willingness to implement it. This point is of
relevance to all modes of treatment but may be especially relevant
in the case of self-help strategies such as bibliotherapy where
factors such as understanding, correct implementation, and moti-
vation become particularly salient because of the lack of a thera-
pist. Combining self-help with reduced amounts of therapist input
may be one way in which to maximize the strengths of each
approach (Marrs, 1995; Newman et al., 2003). In addition, future
research into identification of factors that influence the implemen-
tation and success of self-help will be vital to translating efficacy
into effectiveness.
Surprisingly, self-report data from children did not indicate
differences between conditions but showed a marked reduction in
symptoms across all groups, including waitlist. Childhood anxiety
is not generally considered to be a transient condition, and previ-
ous treatment outcome studies have usually indicated relatively
small changes across time (Barrett et al., 1996; Kendall, 1994).
Therefore, the reasons for the greater change across time in child
report relative to other sources of information in this study are
unclear. Some authors have reported the tendency of anxious
children to “fake good” (Kendall, 1993), and it is likely that they
also become bored with repeatedly completing the same measures.
Most self-report measures are not validated at the lower age groups
included in this trial. Consequently, the reports from young chil-
dren such as those used in this study need to be considered with
some care. However, children are the ultimate customer, and
hence, their perceptions of change need to be considered in any
evaluation of outcome. Clearly, the children in this trial reported
marked improvement across the 24 weeks, but whether these
effects were due to intervention or simply to the passage of time
remains uncertain.
On the negative side, bibliotherapy resulted in greater dropout
from participation than did traditional group therapy or waiting for
treatment. This finding highlights an important caveat to the use of
bibliotherapy. Clearly bibliotherapy, or perhaps simply the concept
of bibliotherapy, is not suitable for some people. Patients seeking
psychotherapy often expect guidance and advice from an expert
who assumes some degree of responsibility and control (Furnham
& Wardley, 1990). Thus, individuals with such expectations who
are then confronted with an independent and active model of
therapeutic change may be disheartened. It is possible that an
alternate recruitment strategy, self-selection, or a more active
marketing of the positive side of bibliotherapy could attract a
greater proportion of individuals who are suited to this treatment
model. In the current study, we found that treatment dropouts had
slightly more severe symptomatology than completers. Further
post hoc examination of this issue demonstrated that this greater
severity was not specific to those who dropped out of bibliotherapy
but characterized dropouts across all conditions. Future research
aimed at identifying sufferers who can derive the greatest benefit
from self-help would be of tremendous value for the streamlining
and cost reduction of mental health resources (Baillie & Rapee,
Several additional limitations to the current study should be
considered. First, the structured interviews were not technically
administered in exactly the way prescribed by Silverman and
Albano (1996). Although the interview instructions require inter-
viewers to make separate diagnoses based on parent report and
child report and then to combine these diagnoses, our interviewers
created combined diagnoses based on their separate interviews
with parents and children without the intervening step of produc-
ing actual diagnoses based on each separate interview. It is ex-
tremely unlikely that this would have systematically influenced the
results, but this possibility cannot be excluded. More important to
note is that the lack of separate diagnoses meant that there was no
independent validation for the self-reports from parents and chil-
dren. Given the lack of significant differences shown on child
report, it may be argued that bibliotherapy produced changes only
in parent perceptions rather than in actual anxiety. However, this is
unlikely given that (a) child report in fact indicated a marked
reduction in anxiety, but not significantly more than the surprising
decrease in anxiety reported by waitlist children, and (b) an iden-
tical pattern of results was shown in the group treatment. An
additional limitation is the fact that parents did not complete data
on compliance or preference for bibliotherapy. Such data would be
important to more fully understanding the implications and bene-
fits of self-help and should be included in any future studies.
Perhaps the main limitation to the study is the fact that the sample
for the study came from a traditional, specialist anxiety clinic. This
was necessary to allow a properly controlled scientific design and
a group treatment comparison. However, this recruitment means
that we cannot be certain whether those families who do not seek
traditional forms of therapy would benefit from bibliotherapy.
Clearly, it would be useful to specifically target these families in
future research.
Given the suggestion that bibliotherapy for child anxiety ap-
pears to be of value at least for those families who successfully
implement it, some important clinical implications can be high-
lighted. Most obviously, written materials could be used to reduce
the waiting lists of busy therapeutic services. In particular, if it was
made clear to clients that bibliotherapy materials were being
offered as an interim measure while waiting for an available
therapist, the current results suggest that up to 20% would no
longer require the services of a therapist 12 weeks later. Although
not directly addressed in the current study, it is also possible that
using bibliotherapy materials might allow a reduction in the
amount of required therapist time and hence allow a stretching of
limited professional resources. Similarly, other research has sug-
gested that augmenting bibliotherapy for childhood anxiety with
alternate methods of therapist contact (such as telephone and
Internet) can provide treatment to populations whose physical
location makes reaching traditional therapeutic services impossible
(Lyneham & Rapee, 2005).
The current study also raises important issues for public health.
Epidemiological surveys have shown that only a small proportion
of children in need reach appropriate sources of help (Canino et al.,
2004; Farmer, Stangl, Burns, Costello, & Angold, 1999). Per-
ceived stigma and a desire to handle problems themselves have
been shown to characterize anxious adults who do not seek help
(Issakidis & Andrews, 2002), and it is likely that similar attitudes
are held by parents of anxious children. The traditional treatment
model is also limited by a lack of physical and professional
resources available to implement the empirically supported treat-
ments (Kendall & Choudhury, 2003; Miller et al., 2003). Conse-
quently, if it were possible to increase the proportion of sufferers
who seek help, there would not exist sufficient resources in the
mental health sector to provide the necessary assistance.
Bibliotherapy has the potential to address all of these issues. The
promising findings reported here provide the first step toward
exploring these broader public health implications by showing that
bibliotherapy has the potential to reduce childhood anxiety.
Clearly, future studies need to focus on methods to attract those
anxious children whose families are reluctant to seek traditional
treatment and to determine whether bibliotherapy can provide an
effective means of reducing the impact of anxiety for these chil-
dren while minimizing stigma and allowing greater flexibility.
Increased public education campaigns or training for professionals
who work with children can help to increase the recognition of
anxiety and its effects, as well as methods for managing it. By
including bibliotherapeutic strategies among the treatment options,
it may be possible to attract a greater proportion of families who
would usually avoid traditional therapeutic services.
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Received January 31, 2005
Revision received October 20, 2005
Accepted December 7, 2005
... Çok geniş çalışma alanı bulunan Bibliyoterapi ile ilgili çalışma başlıklarına bakıldığında; sinirlilik ve öfke kontrolü ile ilgili (Shechtman ve Achshol, 1996), çocukluk anksiyetesi ile igili (Rapee, Abbott ve Lyneham, 2006), kişilerin yaşadığı fobiler ile ilgili (Santacruz, Mendez ve Sanchez, 2006) genç yetişkinlikte yaşanan depresyon ile ilgili (Floyd, 2003;Floyd ve ark., 2004;Floyd ve ark., 2006), duygusal zeka ile ilgili (Sullivan ve Strang 2003), boşanma sonrasında çocukların travmaları ve acılarının hafifletilmesine yönelik (Kramer ve Smith, 1998), üstün yetenekli kişlerle (Hebert, Long ve Neumeister, 2001), ölüm kavramı ile ilgili (Jarjoura ve Krumholz, 1998), öğrenme güçlüğü çeken bireyler ile ilgili (Hieb, 1997), panik atak hastalığı (Wright, 1997), obsesif kompülsif bozukluk yaşayan bireylerle (Lovell ve ark., 2004), depresyon ve anksiyete problemi olan kişilerle (Ekers ve Lovell, 2002), uyku sorunları yaşayan kişilerle (Yamatsu, Adachi, Kunitsuka ve Yamagami, 2004), cinsel işlev bozuklukları olan kişilerle (Lankveld, Grotjohann, Lokven ve Everaerd, 1999) gibi oldukça geniş bir skalada ele alınmıştır. ...
Kitaplar kadimden bu yana psikolojik rahatlama için kullanılmaktadır. Sturm (2003) kitapların iyileşme için güçlü kaynaklar olduklarını ve kendini keşfetme sürecini kolaylaştırmaya yönelik olarak farklı düzeylerde katkılarının olduklarını belirtmiştir. İnteraktif olma, dikkat çekmeyle öğretme, direnci bypas etme, angaje olma ve hayal gücünü besledikleri için bir konu ile alakalı detaylı öyküler iletişimi verimli olarak etkileyebilmektedirler. Bunlara ek olarak öyküler eğitmekte, değerleri aktarmakta, disipline etmekte, deneyim sağlamakta, problem çözmeyi, değişmeyi ve iyileşmeyi kolaylaştırmaktadırlar (Burns, 2004).
... Bibliotherapy has been applied as an approach to educate children on their multicultural identity (Ford et al., 2000(Ford et al., , 2019, coping with trauma (De Vries et al., 2017), bullying (Flanagan et al., 2013), managing anxiety (Rapee et al., 2006), parental divorce (Aziz et al., 2018) and addressing parental incarceration (Clopton & East, 2008;Hames & Pedreira, 2003;Lopez & Bhat, 2007;Nguyen, 2022;Oslick, 2010Oslick, , 2012Oslick, , 2013Shlafer & Scrignoli, 2015;Warren et al., 2019). Moreover, children's literature has proven effective in helping children grapple with a myriad of challenges, including but not limited to death, bullying, depression, trauma and stress (Hazlett-Stevens & Oren, 2017;Moulton et al., 2011;Mumbauer & Kelchner, 2017;Sunderland & McGlashan, 2012;Wiseman, 2013). ...
Research suggests that bibliotherapy can help children cope with life's challenges through age‐appropriate reading and storytelling. Bibliotherapy has been employed to assist children in dealing with grief, divorce, adoption and other stressors. However, limited studies have investigated how this approach can support young children with incarcerated parents. Utilizing bibliotherapy as a framework, this study conducts a thematic analysis of children's picture books published between 1977 and 2014, featuring children of incarcerated parents as main characters to better understand the challenges they face. The study aims to explore the challenges depicted among child characters in picture books addressing parental incarceration for a young reading audience over almost 50 years. Our findings reveal that child characters grapple with various emotional, psychological and social challenges related to the sudden separation from their loved ones. We discuss the implications of each finding in greater detail.
... In current scenario the researchers are using bibliotherapy to treat panic conditions, anxiety problems, depression, weight loss, academic issues and know about understanding individual differences, 30,31 helping students to learn, grief reaction, separation disorders, child abuse and rehabilitation of individuals. 32 According to 33 bibliotherapy is an effective and efficient tool in devising and to reinforce therapeutic intervention. Bibliotherapy can be utilized in psychoeducation and basic health services. ...
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Islamic Psychology is the emerging branch of traditional psychology. It is totally the contributions of prophetic teachings, acts, directions and work of the eminent Muslim scholars including Al-Kindi, AlFarabi, IbnSina, Imam Ghazali and Ashraf Ali Thanvi etc. The Holy prophet (PBUH) is the founder of Muslim psychology. He teached the divine codes revealed by Allah to him time to time. The aim of this paper is to review and collect viewpoints of Maulana Ashraf Ali Thanvi regarding psychology and psychotherapy from Islamic perspective. To collect data for this paper different data bases were searched for research articles on Thanvi's teachings and books of ashraf Ali Thanvi were also studied to gather information related to psychology and psychotherapy. The gathered information was divided into different heading of theory of personality, theory of mental disorders, theory of personality, group therapy, meditation and treating the Nafs, etc.
... Similarly, with youngsters and students, self-help books have been used along with fictional and imaginary books for various developmental issues. Lyneham and Rapee (2006), Rapee et al. (2006), and Thompson (2010) have used self-help and issue-related books to work on the anxiety issue of youngsters. Depression among youngsters is treated by Ackerson et al. (1998) with the help of a self-directed reading of a feel-good self-help book. ...
Students come to schools and college to not only learn academic subjects but also gain personal effectiveness skills for life. During the developmental and transition phase of growing up, young students can face a lot of issues and problems related to the self and their surroundings. The participants of this research were post-graduate management students who suffered from a lack of self-management skills. A reading course/intervention based on Shrodes (1950 Shrodes, C. (1950). Bibliotherapy: A theoretical and clinical-experimental study [Doctoral dissertation]. University of California at Berkeley. Dissertation Abstracts Online. [Google Scholar]) model of bibliotherapy was developed. Using developmental and didactic bibliotherapy based on CBT a short reading course was conducted with 138 students. Reflective writing and discussion activities were conducted along with group reading. The impact of the reading course/intervention was analyzed using descriptive research methods (paired sample t-test) and qualitative reading of the reflective writing. The intervention has been successful in bringing positive habit formation and attitude change in the students.
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Research with a background of anxiety experienced by Santri Pondok Pesantren Darussalam including the absence of Maulid Holidays, and the number of activities. With that, students experience anxiety with the criteria: feeling anxious, moody, lazy to study, not focused, worried, bored and some even intend to leave campus without permission. Seeing the background and the existence of qanuns, the researcher suggests applying Bibliotherapy techniques. Bibliotherapy is also known as the book reading technique. According to Herlina stated, bibliotherapy has benefits including: (1) Helping patients gain understanding, (2) Providing relaxation and diversion techniques, (3) Helping sufferers to focus more. The type of research used is descriptive qualitative. Data collection methods: observation, interviews and documentation. Bibliotherapy technique stage: good report card, book identification, book introduction, follow-up strategy, and evaluation. This research shows the benefits that readers get: Helping sufferers gain understanding, relaxation and diversion techniques, Helping to be more focused, forming a positive self-concept, understanding behavior, easing emotions, increasing compassion, and developing empathy and self-awareness.
The aim of this randomized controlled trial was to evaluate an adapted cognitive behavioural therapy (CBT) programme for treating anxiety in adolescents with acquired brain injury (ABI). Participants with ABI (12-19 years, N = 36) recruited from two sites were randomly allocated into either the intervention receiving 11 sessions of CBT (n = 19) or a wait-list control group (n = 17). The primary outcome was participants' anxiety and secondary outcomes were participants' depression, self-perception, and participation in daily activities, and parental stress, measured at (i) pre-intervention, (ii) immediately post-intervention, (iii) 2 months post-intervention and (iv) 6 months post-intervention. Repeated measures ANOVAs revealed significant treatment effects with the intervention group demonstrating greater improvements in self-reported anxiety, as well as self- and parent-reported depression from pre- to immediately post-treatment, compared to wait-list controls. Little evidence of treatment effects was found for the remaining outcomes (parent-reported anxiety, self-perception, daily participation, and parental stress). Significant improvement in self-reported anxiety found immediately post-treatment was maintained at two- and six-month follow-up. Findings provide support for adapted CBT as an effective means of reducing anxious and depressive symptomatology in adolescents with ABI compared to waitlist controls, and offer support for the use of these techniques to manage anxiety in this population..
Importance Depression, suicidal ideation, and self-harm behaviors in youth are associated with functional impairment and suicide. Objective To review the evidence on screening for depression or suicide risk in children and adolescents to inform the US Preventive Services Task Force (USPSTF). Data Sources PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022. Study Selection English-language, randomized clinical trials (RCTs) of screening for depression or suicide risk; diagnostic test accuracy studies; RCTs of psychotherapy and first-line pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms. Data Extraction and Synthesis Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures Test accuracy, symptoms, response, remission, loss of diagnosis, mortality, functioning, suicide-related events, and adverse events. Results Twenty-one studies (N = 5433) were included for depression and 19 studies (N = 6290) for suicide risk. For depression, no studies reported on the direct effects of screening on health outcomes, and 7 studies (n = 3281) reported sensitivity of screening instruments ranging from 0.59 to 0.94 and specificity from 0.38 to 0.96. Depression treatment with psychotherapy was associated with improved symptoms (Beck Depression Inventory pooled standardized mean difference, −0.58 [95% CI, −0.83 to −0.34]; n = 471; 4 studies; and Hamilton Depression Scale pooled mean difference, −2.25 [95% CI, −4.09 to −0.41]; n = 262; 3 studies) clinical response (3 studies with statistically significant results using varying thresholds), and loss of diagnosis (relative risk, 1.73 [95% CI, 1.00 to 3.00; n = 395; 4 studies). Pharmacotherapy was associated with improvement on symptoms (Children’s Depression Rating Scale–Revised mean difference, −3.76 [95% CI, −5.95 to −1.57; n = 793; 3 studies), remission (relative risk, 1.20 [95% CI, 1.00 to 1.45]; n = 793; 3 studies) and functioning (Children’s Global Assessment Scale pooled mean difference, 2.60 (95% CI, 0.78 to 4.42; n = 793; 3 studies). Other outcomes were not statistically significantly different. Differences in suicide-related outcomes and adverse events for pharmacotherapy when compared with placebo were not statistically significant. For suicide risk, no studies reported on the direct benefits of screening on health outcomes, and 2 RCTs (n = 2675) reported no harms of screening. One study (n = 581) reported on sensitivity of screening, ranging from 0.87 to 0.91; specificity was 0.60. Sixteen RCTs (n = 3034) reported on suicide risk interventions. Interventions were associated with lower scores for the Beck Hopelessness Scale (pooled mean difference, −2.35 [95% CI, −4.06 to −0.65]; n = 644; 4 RCTs). Findings for other suicide-related outcomes were mixed or not statistically significantly different. Conclusion and Relevance Indirect evidence suggested that some screening instruments were reasonably accurate for detecting depression. Psychotherapy and pharmacotherapy were associated with some benefits and no statistically significant harms for depression, but the evidence was limited for suicide risk screening instruments and interventions.
Importance: Anxiety in children and adolescents is associated with impaired functioning, educational underachievement, and future mental health conditions. Objective: To review the evidence on screening for anxiety in children and adolescents to inform the US Preventive Services Task Force. Data sources: PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022. Study selection: English-language, randomized clinical trials (RCTs) of screening; diagnostic test accuracy studies; RCTs of cognitive behavioral therapy (CBT) or US Food and Drug Administration-approved pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms. Data extraction and synthesis: Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main outcomes and measures: Test accuracy, symptoms, response, remission, loss of diagnosis, all-cause mortality, functioning, suicide-related symptoms or events, adverse events. Results: Thirty-nine studies (N = 6065) were included. No study reported on the direct benefits or harms of screening on health outcomes. Ten studies (n = 3260) reported the sensitivity of screening instruments, ranging from 0.34 to 1.00, with specificity ranging from 0.47 to 0.99. Twenty-nine RCTs (n = 2805) reported on treatment: 22 on CBT, 6 on pharmacotherapy, and 1 on CBT, sertraline, and CBT plus sertraline. CBT was associated with gains on several pooled measures of symptom improvement (magnitude of change varied by outcome measure), response (pooled relative risk [RR], 1.89 [95% CI, 1.17 to 3.05]; n = 606; 6 studies), remission (RR, 2.68 [95% CI, 1.48 to 4.88]; n = 321; 4 studies), and loss of diagnosis (RR range, 3.02-3.09) when compared with usual care or wait-list controls. The evidence on functioning for CBT was mixed. Pharmacotherapy, when compared with placebo, was associated with gains on 2 pooled measures of symptom improvement-mean difference (Pediatric Anxiety Rating Scale mean difference, -4.0 [95% CI, -5.5 to -2.5]; n = 726; 5 studies; and Clinical Global Impression-Severity scale mean difference, -0.84 [95% CI, -1.13 to -0.55]; n = 550; 4 studies) and response (RR, 2.11 [95% CI, 1.58 to 2.98]; n = 370; 5 studies)-but was mixed on measures of functioning. Eleven RCTs (n = 1293) reported harms of anxiety treatments. Suicide-related harms were rare, and the differences were not statistically significantly different. Conclusions and relevance: Indirect evidence suggested that some screening instruments were reasonably accurate. CBT and pharmacotherapy were associated with benefits; no statistically significant association with harms was reported.
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Bibliotherapy represents the planned use of literary texts and devices to encourage awareness and processing of emotional, cognitive, and interpersonal problems in individuals with different types of psychosocial distress. As a part of expressive arts-therapies, it includes precisely formulated goals, basic stages, and methodology that are described in this paper. In addition, an overview of recent scientific research on this topic is provided in order to gain insights on the most commonly used approaches, methodologies, and outcomes obtained, as well as the effectiveness of bibliotherapy. Based on our evaluation, we concluded that the use of bibliotherapy is an appropriate complementary approach in educational settings, for children with special needs, as well as for maintaining mental health. Considering the limitations of bibliotherapy, we emphasise the need for further research with the aim of improving practical models and assessment tools. Bibliotherapy can be a promising part of a multimodal educational and rehabilitation approach that recognises the power of language arts, which simultaneously supports both realistic and transcendental aspects of human existence.
Background Parent-only interventions for childhood anxiety may be an important alternative to resource and time intensive child-focused cognitive behavioural therapy (CBT). This systematic review and meta-analysis aimed to investigate the efficacy of parent-only interventions in reducing symptoms of anxiety disorders in school-aged children. Methods A systematic search of five databases (inception to March 2021) identified 29 eligible studies. A range of study designs were captured, including randomised controlled trials (RCTs) and case series. A narrative synthesis was conducted. Random effects meta-analyses were performed on parent- and child-reported outcomes and pre-test post-test effect sizes were calculated for uncontrolled studies. Results Findings indicated a significant treatment effect for parent-only interventions compared to waitlist controls. No significant differences were found when comparing parent-only interventions with other active interventions; anxiety symptoms reduced in both conditions. No significant treatment effects were found for child-rated outcomes. Calculated effect sizes for uncontrolled studies were typically large, although sample sizes were small. No clear evidence was found for a superior type, duration or format of intervention. Limitations The methodological quality of many studies in this review (19/29) was rated ‘weak’. Only English language papers were included. Conclusions To date, this is the first systematic review and meta-analysis of the efficacy of parent-only interventions for reducing symptoms of child anxiety disorders. Our results suggest that parent-only interventions may be effective in reducing child anxiety. These findings are important for clinical practice because they suggest that efficient, low intensity interventions delivered to parents may lead to positive outcomes for children.
This article begins with a brief description of the guiding theory behind cognitive-behavioral interventions with youth, such as a therapeutic posture, an important cognitive distinction, and a specific treatment goal. Next, on the basis of a review of the literature, the nature of cognitive functioning, the treatments, and the outcome of treatment studies are described and examined for (1) aggression, (2) anxiety, (3) depression, and (4) attention-deficit hyperactivity. Conclusions and emerging developments are provided.
The last two decades have been witness to advances in cognitive-behavioral therapy for children and adolescents, and certain treatments have been labeled ‘empirically supported.’ However, not all cases show irrefutable gains and much treatment development and research remains. Following a brief precis of the past and present, we identify and examine several important directions for future research in child and adolescent therapy. Specifically, we consider (a) the nature and magnitude of improvement, including the need to assess the clinical significance of improvement, (b) general issues in assessment, such as parent-child agreement, method variance, and measurement equivalence, (c) the optimal role of parents in child and adolescent treatment, (d) potential moderators and mediators of positive outcomes, (e) the place of medications, and the potential role of parental expectations and/or preferences surrounding treatment selection, (f) therapist factors that may contribute to outcome, and (g) the effects of treatment on the sequelae of the target disorder. Last, the need to consider developmental issues and the transportability of CBT across settings are discussed.
This study evaluated the effectiveness of a cognitive–behavioral treatment program delivered in either clinic-based group format or home-based minimal-therapist-contact format for the treatment of 42 children (aged 10–12 yrs) with chronic headache (migraine, tension, or combined). Ss were assigned randomly to 3 conditions: clinic-based treatment (8 sessions); home-based treatment (3 sessions supplemented by working at home from treatment manuals); and waiting-list control. Measures of headache activity and medication use were derived from "headache diaries," and assessments of psychological symptoms including anxiety, self-efficacy, depression, and coping responses were also administered. Both treatment conditions were associated with significant reductions in headaches, but no changes occurred for the control condition. The 2 treatment formats were equally efficacious; however, the home-based format was over twice as cost effective as the clinic-based format. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This article describes how a child psychologist in a rural community provides the necessary comprehensive consultation and clinical services using a video telephone and the services of Kentucky Telecare. The authors present a clinical consultation model of health care for underserved populations where professional consultation with a team of professionals may benefit service providers in rural communities. The article examines an innovative model of telehealth care delivery through a university-based telehealth system to an underserved regional school system. A number of applications within a broad spectrum of services using telehealth technology are offered. Finally, shifts in administrative paradigms, clinical models, and information technology prevention services through telehealth are addressed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
(from the chapter) Despite the recent increase in the theoretical and empirical literature devoted to generalized anxiety disorder (GAD), surprisingly few publications have examined the potential etiological pathways to the disorder. Instead, the focus has been on the nature and treatment of GAD (Dugas, 2000). For a fuller understanding of the disorder, a complete picture that includes etiology is required. An awareness of the pathways to the disorder will, in turn, have important implications for the prevention and treatment of GAD. The research examining these potential pathways is explored. This chapter covers (1) genetic factors; (2) temperamental factors; and (3) environmental influences (including environmental support of avoidance, the effects of the social environment, and external environmental events). The current chapter reviews the available evidence regarding the development of GAD and presents a model that can be used as a guide for future etiological research. Of course, this model must be considered preliminary, as etiological research in the anxiety disorders remains in its infancy. Further limiting this quest is the small number of studies that have specifically examined the development of GAD. (PsycINFO Database Record (c) 2007 APA, all rights reserved).
Two hundred people completed two questionnaires that concerned their beliefs about what psychotherapy clients experience and their attitudes toward psychotherapy. Both questionnaires were shown to have an interpretable factor structure, and these beliefs and attitudal factors were shown to be clearly related. There were no sex, a few age, but a number of educational and "psychological experience" correlates of the belief and attitudinal factors. A canonical correlation produced one factor that seemed readily interpretable, with psychological experience the most powerful correlate of both beliefs and attitudes. The results were discussed in terms of the work on lay beliefs and expectations about therapy and counseling.
We investigated the prevalence of DSM-III disorders in 792 children aged 11 years from the general population and found an overall prevalence of disorder of 17.6% with a sex ratio (boys-girls) of 1.7:1. The most prevalent disorders were attention deficit, oppositional, and separation anxiety disorders, and the least prevalent were depression and social phobia. Conduct disorder, overanxious disorder, and simple phobia had intermediate prevalences. Pervasive disorders, reported by more than one source, had an overall prevalence of 7.3%. Examination of background behavioral data disclosed that children identified at 11 years as having multiple disorders had a history of behavior problems since 5 years of age on parent and teacher reports. Fifty-five percent of the disorders occurred in combination with one or more other disorders, and 45% as a single disorder.
Results 2 1/2 years after an enuresis nocturna training are presented, including rate of success, percentage and duration of relapse for 113 children (mean age 11.6 year at the start of the training). The bibliotherapeutic treatment by parents did not require any intervention by a professional. Behaviour of parents in the event of a relapse differed between training conditions. Children in the Arousal condition recovered faster from a relapse, 90% of their parents used the Arousal training again at relapse or did not intervene at all and none of them consulted a professional. Clearly they had confidence in the method of Arousal training: combining the alarm device with reinforcement for correct behaviour at the time the alarm goes off. Parents in control conditions did not use the alarm device as often as the parents in the Arousal condition, but tried other means with less success, including consulting professionals.