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Q What is the efficacy of parent-directed bibliotherapy for childhood anxiety disorders compared with group cognitive behavioural therapy or waiting list?
METHODS
Design:
Randomised controlled trial.
Allocation:
Concealed.
Blinding:
Single blind (assessors blinded).
Follow up period:
Twelve-week treatment period, plus 12 weeks’ follow up for active treatments.
Setting:
Community and university research setting in Australia; 1999 to 2003.
Patients:
267 children aged 6–12 years old, with a principal diagnosis of DSM-IV anxiety disorder (Anxiety Disorders Schedule for DSM-IV, child and parent versions (ADIS-CP)). Children with comorbidities were not excluded unless they were at risk of suicide or needed urgent intervention.
Intervention:
Group cognitive behavioural therapy (CBT), bibliotherapy, or waiting list. Group CBT: nine two-hour sessions attended by both children and parents over 12 weeks, aimed at the management of childhood anxiety disorders. The programme covered recognition of anxiety, realistic thinking, management strategies and assertiveness, and provided written material for home practise. Bibliotherapy: parents worked through a commercially available book providing information and help techniques with their children over 12 weeks. Children received a workbook that contained summaries and worksheets referred to in the parent book (also used in the group CBT arm). Waiting list: participants were told that they would be reassessed in three months, after which they would be offered the next available treatment group.
Outcomes:
Proportion of children no longer meeting DSM-IV criteria for an anxiety disorder (ADIS-CP).
Patient follow up:
79% at 12 weeks (all groups), and 84% at 24 weeks (active treatment groups only). Last observation carried forward (LOCF) analyses included 97% of participants.
MAIN RESULTS
Bibliotherapy significantly increased the proportion of children who no longer met the criteria for DSM-IV anxiety disorder compared with waiting list after three months, but was significantly less effective than group CBT (17.8% with bibliotherapy v 5.7% with waiting list v 48.9% with group CBT; p<0.05 for bibliotherapy v waiting list; p<0.001 for bibliotherapy v group CBT; LOCF analyses). At six month follow up, bibliotherapy was still significantly less effective than group CBT for this outcome (18.9% with bibliotherapy v 61.1% with group CBT; p<0.01).
CONCLUSIONS
Parent directed bibliotherapy was more effective at reducing childhood anxiety disorders than waiting list, but less effective than group CBT.
NOTES
More participants in the bibliotherapy group did not complete treatment than in the other two groups (32.2% with bibliotherapy v 15.6% with group CBT v 13.8% with waiting list; p<0.01 for overall comparison).
Commentary
Rapee et al found bibliotherapy was superior to waitlist but inferior to active treatment: 5.7% of the children were free of an anxiety disorder after waitlist compared to 17.8% after bibliotherapy and 48.9% after active treatment. Can we now conclude that bibliotherapy is a helpful tool that could be the first treatment in a stepped-care approach, so that only the children that have not improved by bibliotherapy need to receive active treatment? Perhaps not, as we do not know the possible adverse effects completing bibliotherapy may have on subsequent active treatment. Active treatment might be less effective for families who already had (unsuccessful) bibliotherapy, since they are familiar with the rationale, materials, and exercises that have not worked for them, and may have less hope for improvement as a result.
Although bibliotherapy was superior to waitlist on the dependent measure of having an anxiety disorder, bibliotherapy did not outperform waitlist on child and parent questionnaire reports of child anxiety. Also, the effects of the tested parent-directed bibliotherapy for anxious children were modest compared to bibliotherapy for anxious adults.1 One explanation for the relatively modest results is that delivering the bibliotherapy through parents, as was done in this study, might be a less effective approach than directing it at children themselves. This explanation is supported by a recent study showing that active treatment exclusively through mothers was only moderately effective.3 There is currently insufficient evidence that parental involvement is needed in the treatment of child anxiety.2
The next challenge is to test the effects of bibliotherapy for children themselves, through computerised self-help programmes for example, in contrast to therapist-assisted cognitive behaviour therapy (CBT). For now, bibliotherapy through parents cannot be considered an alternative to active CBT.
Footnotes
For correspondence: Ronald M Rapee, Department of Psychology, Macquarie University, Sydney NSW 2109, Australia; ron.rapee{at}mq.edu.au
Source of funding: Australian Rotary Health Research Fund.