Cognitive-behavioral therapy for children with autism spectrum disorders

Understanding the impacts of chronic pain on autistic adolescents and effective pain management: a reflexive thematic analysis adolescent-maternal dyadic study

OBJECTIVE

Sensory elements are core features in chronic pain and autism, yet knowledge of the pain experience in autistic adolescents is limited. Little is known regarding how autistic adolescents experience chronic pain, manage their pain and perceive psychological treatment for their chronic pain.

METHODS

Ten autistic adolescents (6 female, 3 male, and 1 self-identified as agender) with chronic pain and their mothers (n = 10) participated in semistructured interviews concerning their perceptions of living with chronic pain. Participants were recruited from U.K. pain management services. According to preference, interviews were conducted individually (n = 10) or dyadically (n = 10 participants across 5 dyads). Data were analyzed using inductive reflexive thematic analysis.

RESULTS

Two themes were generated. Theme 1, "overstimulated and striving for control" described how adolescents' experience of heightened sensitivity enhanced adolescents' levels of anxiety and subsequent pain, illustrating a reciprocal relationship between anxiety, pain, and sensory elements. Theme 2, "not everyone fits the mold" captured how autistic adolescents positioned themselves as distinct from others due to the unique nature of being autistic and living with pain. This sense of difference negatively impacted adolescents' ability to engage with and benefit from the standard treatment for chronic pain.

CONCLUSIONS

Findings suggest that autistic adolescents living with pain experience pain and face barriers to effective pain treatment. Our results identify the need for educational resources to facilitate clinicians to better understand the experience of autistic adolescents living with pain. In turn, such understanding may improve treatment and outcomes in this population.

Behavioral Interventions for Autism Spectrum Disorder: A Brief Review and Guidelines With a Specific Focus on Applied Behavior Analysis

We conducted a comprehensive review of behavioral and educational interventions for individuals with autism spectrum disorder (ASD). The most prominent type of intervention, Comprehensive Early Intervention, often referred to as Early Intensive Behavioral Intervention (EIBI), has been found to be particularly effective in improving intelligence and adaptive behaviors. The naturalistic developmental behavioral intervention, designed to enhance social and communication abilities, showed effectiveness in improving language, cognitive function, and social initiation. However, more studies are needed to examine its effectiveness. Intensive individualized intervention, which provides a tailored intervention for a specific target behavior, was effective in improving social skills and communication, as well as reducing sleep, eating, and toileting problems. Cognitive behavioral therapy (CBT) is the most effective method for dealing with emotional difficulties, but it has not been widely used because of the shortage of trained experts. Parent-mediated intervention (PMI) involves parents acquiring knowledge and specific skills to improve their child's functioning or reduce challenging behaviors. Speech and language therapy, sensory integration, Treatment and Education of Autistic and related Communications Handicapped Children, developmental approaches, and social stories are frequently used interventions. However, evidence of their effectiveness has yet to be well established. Based on these findings, intervention recommendations for autism include EIBI, Early Start Denver Model, intensive individualized intervention, CBT, and PMI. The choice of intervention should be tailored to the individual's needs and delivered by qualified professionals with expertise in the specific intervention.

A Survey on Autism Care, Diagnosis, and Intervention Based on Mobile Apps Focusing on Usability and Software Design

This article presents a systematic review on autism care, diagnosis, and intervention based on mobile apps running on smartphones and tablets. Here, the term "intervention" means a carefully planned set of activities with the objective of improving autism symptoms. We guide our review on related studies using five research questions. First, who benefits the most from these mobile apps? Second, what are the primary purposes of these mobile apps? Third, what mechanisms have been incorporated in these mobiles apps to improve usability? Fourth, what guidelines have been used in the design and implementation of these mobile apps? Fifth, what theories and frameworks have been used as the foundation for these mobile apps to ensure the intervention effectiveness? As can be seen from these research questions, we focus on the usability and software development of the mobile apps. Informed by the findings of these research questions, we propose a taxonomy for the mobile apps and their users. The mobile apps can be categorized into autism support apps, educational apps, teacher training apps, parental support apps, and data collection apps. The individuals with autism spectrum disorder (ASD) are the primary users of the first two categories of apps. Teachers of children with ASD are the primary users of the teacher training apps. Parents are the primary users of the parental support apps, while individuals with ASD are usually the primary users of the data collection apps and clinicians and autism researchers are the beneficiaries. Gamification, virtual reality, and autism-specific mechanisms have been used to improve the usability of the apps. User-centered design is the most popular approach for mobile app development. Augmentative and alternative communication, video modeling, and various behavior change practices have been used as the theoretical foundation for intervention efficacy.

Psychological therapies for anxiety in autistic individuals with co-occurring intellectual developmental disorder: A systematic review

This systematic review aimed to evaluate the efficacy of psychological therapies for anxiety for people with autism and co-occurring intellectual developmental disorder (AUT + IDD). A systematic search identified 13 studies comprising 49 participants with AUT + IDD, aged between 5 and 41 years. Most studies were single-case experimental designs (n = 7) or case studies or case series (n = 4). Studies implemented cognitive behavioural therapy (n = 4) or exposure therapy techniques (n = 9). All studies reported a reduction in anxiety symptoms, as measured by either quantitative measures or defined as participants meeting end of treatment criterion. However, the conclusions are preliminary due to the methodological limitations of the current literature. The implications of these findings, as well as recommendations for future direction in the field, are discussed.

Targeting hostile attributions in inclusive schools through online cognitive bias modification: A randomised experiment

The tendency to make hostile attributions in ambiguous social situations has been associated with aggression and may be targeted through cognitive bias modification for interpretations (CBM-I). Despite their high prevalence of aggression and internalising problems, children and young people with neurodevelopmental disorders (NDD) or special educational needs (SEN) are markedly absent from CBM-I studies. This pilot study investigates whether online CBM-I can reduce hostile attributions and reactive aggression in inclusive school pupils. In Study 1, 71 pupils (mean age = 12.2, SD = 1.5; 25.4% presented with NDD or SEN) were randomly allocated to complete three sessions of either CBM-I (n = 37) or active control training (n = 34). CBM-I involved interpreting ambiguous scenarios or faces in a non-hostile manner, whereas the control training involved attention and memory exercises without resolving ambiguity. Between-group comparison showed CBM-I to reduce both hostile attributions and reactive aggression. In Study 2, follow-up focus groups with 23 pupils demonstrated the acceptability of training content and delivery. Together, these findings show online CBM-I to be acceptable and effective at reducing both hostile attributions and reactive aggression in an inclusive setting. The possibility of intervention effects on behavioural outcomes and potential confounding variables require further investigation.

Cognitive Behavioral Therapy for Autism Spectrum Disorders: A Systematic Review

CONTEXT

In several studies, authors have reported on cognitive behavioral therapy (CBT) for children and adolescents with autism spectrum disorders (ASDs), but inconsistent treatment effectiveness was revealed from these studies.

OBJECTIVE

To evaluate the effectiveness of CBT on the symptoms of ASD and social-emotional problems in children or adolescents with ASD by using a meta-analytic approach.

DATA SOURCES

Data sources included PubMed, Embase, and the Cochrane Library.

STUDY SELECTION

We selected randomized controlled trials (RCTs) in which authors reported effectiveness of CBT on the symptoms of ASD and social-emotional problems in children or adolescents with ASD from database inception to May 2019.

DATA EXTRACTION

For each study, 2 authors extracted data on the first author's surname, publication year, country, sample size, mean age, CBT target, intervention, outcome measurement, follow-up duration, and investigated outcomes.

RESULTS

Forty-five RCTs and 6 quasi RCTs of 2485 children and adolescents with ASDs were selected for the final meta-analysis. There was no significant difference between CBT and control for symptoms related to ASD based on self-reported outcomes (standard mean difference: -0.09; 95% confidence interval: -0.42 to 0.24; P = .593), whereas CBT significantly improved the symptoms related to ASD based on informant-reported outcomes, clinician-rated outcomes, and task-based outcomes. Moreover, the pooled standard mean differences indicated that CBT has no significant effect on symptoms of social-emotional problems based on self-reported outcomes.

LIMITATIONS

The quality of included studies was low to modest, significant heterogeneity among the included studies for all investigated outcomes was detected, and publication bias was inevitable.

CONCLUSIONS

These findings indicate that CBT may significantly improve the symptoms of ASD and social-emotional problems in children or adolescents with ASD.

Behavioral interventions for sleep disturbances in children with neurological and neurodevelopmental disorders: a systematic review and meta-analysis of randomized controlled trials

STUDY OBJECTIVES

Sleep disturbances are common and associated with negative functional and health consequences in children with neurological and neurodevelopmental disorders (NNDDs) and represent an important potential target for behavioral interventions. This systematic review examined the efficacy of behavioral sleep interventions (BSIs) for children with NNDDs and comorbid sleep disturbances.

METHODS

A systematic search of MEDLINE, EMBASE, PsychINFO, and CENTRAL was conducted in April 2019. Randomized controlled trials (RCTs) of BSI for children with NNDDS were included. Meta-analysis and GRADE quality ratings were performed on sleep and secondary functional outcomes (cognition, academics, and behavior).

RESULTS

Nine RCTs were identified (n = 690; Mage = 8.39 ± 2.64years; 71.11% male). The quality of the evidence was predominantly rated as moderate. Posttreatment improvements in sleep were found on self-reported sleep disturbances (total sleep disturbance [standardized mean difference, i.e. SMD = 0.89], night wakings [SMD = 0.52], bedtime resistance [SMD = 0.53], parasomnias [SMD = 0.34], sleep anxiety [SMD = 0.50]) and self-reported sleep patterns (sleep duration [SMD = 0.30], sleep onset duration [SMD = 0.75]) and (2) objectively measured actigraphic sleep patterns (total sleep time [MD = 18.09 min; SMD = 0.32], sleep onset latency [MD = 11.96 min; SMD = 0.41]). Improvements in sleep (self-reported, not actigraphy) were maintained at follow-up, but few studies conducted follow-up assessments resulting in low-quality evidence. Reduction in total behavioral problems (SMD = 0.48) posttreatment and attention/hyperactivity (SMD = 0.28) at follow-up was found. Changes in cognition and academic skills were not examined in any studies.

CONCLUSIONS

BSIs improve sleep, at least in the short term, in children with NNDDs. Benefits may extend to functional improvements in behavior. More rigorous RCTs involving placebo controls, blinded outcome assessment, longer follow-up durations, and assessment of functional outcomes are required.

Inclusiveness of cognitive bias modification research toward children and young people with neurodevelopmental disorders: A systematic review

Cognitive bias modification (CBM) is increasingly used to target cognitive biases related to internalising or externalising problems, which are common in neurodevelopmental disorders (NDD). This systematic review assesses the available evidence for using CBM in children and young people with NDD, in particular regarding ambiguous interpersonal information, and the extent of their exclusion from this type of intervention research. PsycINFO, PsycARTICLES, MEDLINE, Cochrane Central Register of Controlled Trials and Science Citation Index were consulted using MeSH terms and synonyms of "neurodevelopmental disorders", "mental health problems", "cognitive bias", "modification" and "review". Data extraction focused on the efficacy of CBM for NDD, how CBM was delivered, whether studies adopted exclusion criteria relating to NDD and the rationale for such criteria. The search identified 2270 records, of which twenty-nine studies assessed CBM for interpretations and were included in the qualitative synthesis. Three studies targeted bias in NDD, whereas a third of studies explicitly excluded participants based on NDD-related criteria: most frequently intellectual impairment, reading or learning difficulties and autism spectrum disorder (ASD). Only one study provided a rationale for excluding NDD which related to the reading demands of their intervention. There is tentative evidence for the feasibility of using CBM to reduce interpretation bias in children and young people with mild intellectual disability, ASD or attention-deficit/hyperactivity disorder (ADHD). We recommend that CBM research should consider including participants with NDD, use CBM tasks and adaptations that enable this group's inclusion, or provide a sufficient rationale for their exclusion.

Evaluating the Effectiveness of a School-Based Cognitive Behavioural Therapy Intervention for Anxiety in Adolescents Diagnosed with Autism Spectrum Disorder

This study evaluated the effectiveness of a school-based Cognitive Behavioural Therapy (CBT) on symptoms of anxiety, social worry and social responsiveness, and indices of attentional control and attentional biases to threat in adolescents diagnosed with Autism Spectrum Disorder. Thirty-five young people (11–14 years; IQ > 70) with ASD and elevated teacher or parent reported anxiety were randomly assigned to 6 sessions of the Exploring Feelings CBT intervention (Attwood in Exploring feelings (anxiety). Future Horizons, Arlington, 2004) (n = 18) or a wait-list control group (n = 17). The intervention (compared to the wait-list control) group showed positive change for parent, teacher and self-reported anxiety symptoms, and more marginal effects of increased teacher-reported social responsiveness. The discussion highlights the potential value and limitations of school-based CBT for young people with ASD.

Social skills plus relaxation training with a child with ASD in the schools

A social skills plus relaxation training (SSRT) program was developed using direct training, relaxation training, and reinforcement principles. The aim was to examine the effectiveness of SSRT on increasing the frequency of three target behaviors for one 8-year-old, student classified with autism spectrum disorder (ASD). A multiple-baseline across behaviors design was used to evaluate the effects of SSRT. During baseline, intervention, and maintenance sessions the student's responses were videotaped and then subsequently viewed and coded after the session. During intervention, the student's correct responses for the targeted social skills increased and were maintained 17 weeks after SSRT ended. This study adds support for the use of this SSRT program in a school setting with children who have ASD.

Anxiety in youth with autism spectrum disorders: implications for treatment

Anxiety disorders are one of the most common psychiatric comorbidities among children and adolescents with autism spectrum disorders (ASD). There has been a recent proliferation of research examining the prevalence, phenomenology, assessment and treatment of anxiety disorders among youth with ASD. While there is currently very limited support for the use of pharmacological agents to treat anxiety among youth with ASD and comorbid anxiety, there has been overwhelming support across numerous modestly sized controlled studies for the efficacy of cognitive behavioral therapy. This review discusses advances in the treatment literature for anxiety in youth with ASD, and discusses the current evidence base for whether standard treatment needs to be adapted for this population.

Advances in evidence-based intervention and assessment practices for youth with an autism spectrum disorder

This special series is designed to highlight recent advances in the evidence-based treatment and assessment of youth with autism spectrum disorder (ASD). The seven articles for this special series include novel applications of cognitive-behavioral therapy to address core aspects of ASD, empirical research that provides understanding of ways to assess and intervene with individuals with ASD, and studies that focus on the implementation of evidence-based interventions for youth with ASD. In this introductory paper, we provide an overview of the current state of the field related to the treatment and assessment of youth with ASD and discuss related themes addressed across the papers in the series. We conclude with a brief description of each of the seven papers in the series.

Facing your fears in adolescence: cognitive-behavioral therapy for high-functioning autism spectrum disorders and anxiety

Adolescents with high-functioning autism spectrum disorders (ASDs) are at high risk for developing psychiatric symptoms, with anxiety disorders among the most commonly cooccurring. Cognitive behavior therapies (CBTs) are considered the best practice for treating anxiety in the general population. Modified CBT approaches for youth with high-functioning ASD and anxiety have resulted in significant reductions in anxiety following intervention. The purpose of the present study was to develop an intervention for treating anxiety in adolescents with ASD based on a CBT program designed for school-aged children. The Facing Your Fears-Adolescent Version (FYF-A) program was developed; feasibility and acceptability data were obtained, along with initial efficacy of the intervention. Twenty-four adolescents, aged 13–18, completed the FYF-A intervention. Results indicated significant reductions in anxiety severity and interference posttreatment, with low rates of anxiety maintained at 3-month follow-up. In addition, nearly 46% of teen participants met criteria for a positive treatment response on primary diagnosis following the intervention. Initial findings from the current study are encouraging and suggest that modified group CBT for adolescents with high-functioning ASD may be effective in reducing anxiety symptoms. Limitations include small sample size and lack of control group. Future directions are discussed.