Effects of cognitive behavioral therapy on daily living skills in children with high-functioning autism and concurrent anxiety disorders

Meta-analysis of Psychotherapy for Autistic Youth

In order to provide more individualized support, it is imperative to further understand the effectiveness of different types of psychotherapy on the clinical areas of need common in autistic youth (Wood et al. in Behav Ther 46:83-95, 2015). Randomized controlled trials of psychotherapy for autistic youth were included if published in English, included random assignment to treatment or control group, required a previous diagnosis of autism, had a mean age of 6-17 years, and provided outcome measure data from both intervention and control groups. A total of 133 measures were coded across 29 studies and included 1464 participants with a mean age of 10.39 years (1.89). A small mean effect size (0.38,95% CI [0.26, 0.47]) was found overall, with the largest effects for cognitive behavioral therapies on autism-related clinical needs (0.81) and overall mental health (0.78). The results show the significant impact of psychotherapy interventions for autistic youth. Additional research should further assess the details of the most effective psychotherapies for each area of clinical need.

Cognitive behavioural therapy to improve social skills in children and adolescents with autism spectrum disorder: A meta-analysis of randomised controlled trials

BACKGROUND

Cognitive behavioural therapy (CBT) is effective in treating various neurological and psychiatric diseases. It improves anxiety symptoms in children with autism spectrum disorder, gaining considerable empirical support. However, social skills results are mixed, leading to debate over its effectiveness, highlighting the need for further development. While the Social Responsiveness Scale (SRS) is a secondary indicator to measure anxiety symptoms, it primarily evaluates social skills, which are essential for rehabilitating children with autism. Therefore, evaluating social disorder improvement in children with autism is imperative. Social impairment is a core autism symptom. Therefore, we conducted a systematic review of randomised controlled trials assessing the effects of CBT on social skills in this population.

METHODS

We reviewed articles published in several databases through October 2022 and relevant reference lists. We used the standardised mean difference (SMD) as the main effect size indicator and focused on SRS metrics from baseline to endpoint. We analysed subgroups, heterogeneity, bias risk, and publication bias.

RESULTS

Our meta-analysis included 214 children from seven randomised controlled trials with nine datasets. Forest plot analysis shows CBT improved social skills in children with autism compared to controls. Subgroup analysis revealed parents' and teachers' SRS scores for children, SRS scores of CBT versus waitlist controls, and those of CBT versus non-waiting-list controls.

LIMITATIONS

Most randomised controlled CBT trials for children with autism have explored anxiety symptom improvement. Further, social skill assessment was a secondary outcome or not assessed. Thus, social skills data are insufficient.

CONCLUSIONS

CBT is effective in improving social impairment in children with autism.

REGISTRATION

This meta-analysis was registered with the International Prospective Register of Systematic Reviews (CRD42022363423).

Developmental surveillance: a prospective observational study on integrating occupational therapy

The purpose of this study was to understand the interprofessional contributions of occupational therapy services within the pediatric primary care team during developmental surveillance for health promotion and prevention. A prospective observational study of 27 well-child visits was conducted. Well-child visits were conducted by a physician, physician assistant, or nursing practitioner. This research compared observed developmental surveillance from an occupational therapy perspective to identify opportunities for supporting daily childhood activity participation. Areas of occupational and developmental participation were generally well covered during developmental surveillance. While there were no observed differences in the scope of the well-child visit conducted by different primary care professionals, habits, routines, roles, rituals, and the environments and contexts that may be impacting participation for children and families were found to be an area of limited discussion during developmental surveillance. There is an opportunity for occupational therapy practitioners to be involved in developmental surveillance with an emphasis on occupational therapy's expertise in habits, routines, roles, and contextual considerations to participation and development.

Assessment of improvement in anxiety severity for children with autism spectrum disorder: The matched correspondence analysis approach

INTRODUCTION

Clinical trials typically involve random assignment to treatment conditions. However, random assignment does not guarantee a lack of systematic variation in the outcomes, and application of covariation methods for multiple dependent measures requires complicated assumptions that are often not met.

METHODS

This study employed matched correspondence analysis (CA) for controlling systematic variation and handling multiple outcomes. One hundred nine children with autism spectrum disorder (ASD) were assessed for anxiety symptom severity across four studies, where participants were randomly assigned to either cognitive behavioral therapy (CBT) or treatment as usual or waitlist (TAU/WT). Matched CA is designed to optimally scale only the differences between baseline and posttreatment, rendering the systematic baseline carryover effects irrelevant.

RESULTS

Differences in treatment efficacy were observed. CBT showed treatment efficacy on anxiety severity and anxiety-related impairment relative to TAU/WT, after the control of baseline carryover effects.

CONCLUSION

This study provides a way to control systematic variation between groups at the outset of treatment trials and is expected to provide a novel pathway to more proper assessment of treatment efficacy for children with ASD and anxiety.

Iterative Development of a Daily Living Skills Intervention for Adolescents with Autism Without an Intellectual Disability

Daily living skill deficits commonly co-occur in individuals with autism spectrum disorder (ASD). These deficits in adolescence are associated with poor outcomes, in both employment and independent living skills as adults. Currently, there are no interventions that directly target daily living skill acquisition in adolescents with ASD without an intellectual disability to facilitate a successful transition to adulthood. In this paper, we discuss the development, refinement, and initial efficacy studies of Surviving and Thriving in the Real World (STRW), a 14-session group treatment for both adolescents with ASD and their parent/caregiver that promotes attainment of critical daily living skills. We summarize initial feasibility studies that have been instrumental in the iterative development of STRW. The structure, core treatment elements, and content of STRW are described in detail. Lastly, we discuss the transition of the in-person STRW intervention to STRW-telehealth, which allows for adolescents with ASD to work on daily living skills in their own home with support from a therapist.

The Pediatric Autism Spectrum Therapy Observation System: Development, Psychometric Properties, and Sensitivity to Treatment

An observational coding system was developed to track clinical change in children with autism spectrum disorder (ASD) during psychotherapy. The Pediatric Autism Spectrum Therapy Observation System (PASTOS) consists of 23 items divided into 5 subscales and is used to rate child behaviors in individual psychotherapy sessions. Manual-based cognitive behavioral therapy session transcripts of 22 children diagnosed with ASD (IQ > 70) and a concurrent anxiety disorder (M = 9.41 years, SD = 1.56 years) enrolled in a randomized, controlled trial were coded. Results suggested that the PASTOS exhibited promising interrater reliability, internal consistency, convergent validity at post-treatment, and treatment sensitivity. The PASTOS may be a useful tool for studying process and outcome in psychotherapy research on children with ASD.

Independent living in adults with autism spectrum disorder: Stakeholders' perspectives and experiences

Independent living is a basic human right that enables individuals with disabilities to determine where they live, who they live with and what kind of support that they receive. Limited research exists regarding the challenges that adults with autism spectrum disorder (ASD) may face when attempting to live independently. Given the importance of independent living for adults with ASD, this study aimed to examine the perspectives of stakeholders about independent living among adults with ASD.

METHODS

We recruited a total of 19 stakeholders including adults with ASD and parents of adults with ASD from Canadian provinces. In-depth, semi-structured interviews were conducted to identify factors affecting independent living among adults with ASD. Interviews were transcribed and analyzed using thematic analysis to identify overarching themes.

RESULTS

Three themes emerged in our findings, including: a) Psychophysical stability and daily living; b) Financial management and planning; and c) Integrated community living and independence.

CONCLUSION

The findings from this study suggest that adults with ASD face several challenges related to independent living. Factors related to psychophysical stability and daily living, financial management, and integrated community living and housing were all found to influence the ability of adults with ASD to live independently. By exploring stakeholders' perspectives of independent living for adults with ASD, this study provides some insight that can help inform the development of programs and services to facilitate independent living for adults with ASD.

Metacognition Mediates the Effect of Social Communication and Internalizing Behaviors on Self-management of Daily Life Tasks for Diploma-Track Autistic Youth

Social communication and executive functioning challenges as well as co-occurring anxiety/depression may make acquiring the skills needed to manage daily life tasks difficult for diploma-track autistic youth, thus limiting their participation in adult roles. This study describes the associations between executive function, social communication skills, and internalizing behaviors on task management in academically capable autistic adolescents (n = 46) using multiple regression with mediator analysis. The three predictors and youth age explained a moderate amount of variance in task management. Metacognition mediated the effect of social communication skills and internalizing behaviors on task management. Relations between underlying factors that influence self-management of daily life tasks are complex, supporting the need for multifaceted assessment and intervention approaches for academically capable autistic youth.

A cluster analysis of daily living skills in school aged children with autism spectrum disorder

For individuals with autism spectrum disorder (ASD) daily living skills (DLS) fall below chronological age and have been linked to factors such as language. Given the impact of DLS on daily life, it is critical to gain a comprehensive understanding of DLS profiles in children to guide effective treatment. Using a large dataset from the Autism Speaks Autism Treatment Network, the current study sought to (1) examine whether there are subgroups of children with ASD defined by both their Vineland-II DLS scores and language abilities and (2) explore the relationship between internalizing and externalizing symptoms on subgroups using the Child Behavior Checklist. A five-cluster solution was found, but one group was subsequently dropped. Four clusters were examined: Low Language-Low DLS (n = 143); Low-Language High DLS (n = 170); High Language-Low DLS (n = 189); and High Language-High DLS (n = 203). The High Language-Low DLS group had significantly higher internalizing and externalizing symptoms as compared to the other groups. The results highlight the importance of targeting DLS in school-age children with ASD, especially for those with comorbid internalizing and externalizing symptom to ensure that the gap between age and functional DLS does not continue to widen.

Behavioural and cognitive behavioural therapy for obsessive compulsive disorder (OCD) in individuals with autism spectrum disorder (ASD)

BACKGROUND

Autistic spectrum disorder (ASD) is an increasingly recognised neurodevelopmental condition; that is, a neurologically-based condition which interferes with the acquisition, retention or application of specific skills. ASD is characterised by challenges with socialisation and communication, and by stereotyped and repetitive behaviours. A stereotyped behaviour is one which is repeated over and over again and which seems not to have any useful function. ASD often co-occurs with mental health disorders, including obsessive compulsive disorder (OCD). People with ASD may show certain cognitive differences (i.e. differences in ways of thinking) which influence their response to therapies. Thus, there is a need for evidence-based guidelines to treat mental health issues in this group. OCD, a common condition characterised by repeated obsessional thoughts and compulsive acts, occurs with greater frequency in persons with ASD than in the general population. Genetic, anatomic, neurobiological and psychological factors have been proposed to explain this co-occurrence. However, care should be taken to distinguish stereotyped and repetitive behaviours characteristic of ASD from obsessive compulsive acts in OCD. Cognitive behavioural therapy (CBT) is the recommended treatment for OCD, but studies have suggested that this treatment may be less effective in those with OCD co-occurring with ASD. Hence, modifications to CBT treatment may be helpful when treating OCD co-occurring with ASD to optimise outcomes.

OBJECTIVES

To assess the effectiveness of behavioural and cognitive behavioural therapy for obsessive compulsive disorder (OCD) in children and adults with autism spectrum disorder (ASD).

SEARCH METHODS

We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, five other bibliographic databases, international trial registries and other sources of grey literature (to 24 August 2020). We checked the reference lists of included studies and relevant systematic reviews to identify additional studies missed from the original electronic searches. We contacted subject experts for further information when needed.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cross-over, cluster- and quasi-randomised controlled trials involving both adults and children with diagnoses of OCD and ASD. We included studies of participants with co-occurring conditions (i.e. those experiencing other mental illnesses or neurodevelopmental conditions at the same time), but we did not include individuals who had a co-occurring global learning difficulty. Treatment could be in any setting or format and include behavioural therapy (BT) and cognitive behavioural therapy (CBT), which may have been adapted for those with ASD. Comparator interventions included no treatment, waiting list, attention placebo (where the control group receives non-specific aspects of therapy, but not the active ingredient) and treatment as usual (TAU, where the control group receives the usual treatment, according to accepted standards).

DATA COLLECTION AND ANALYSIS

Three review authors independently screened studies for inclusion. The authors extracted relevant data from the one eligible study, assessed the risk of bias and certainty of evidence (GRADE). Outcomes of interest were changes in OCD symptoms and treatment completion (primary outcome), and severity of depressive symptoms, anxiety symptoms and behavioural difficulties, as well as degree of family accommodation (secondary outcomes). We did not conduct meta-analyses as only one study met the selection criteria.

MAIN RESULTS

We included only one RCT of 46 participants in our analysis. This study compared CBT for OCD in persons with high-functioning ASD with a control group who received anxiety management only. There were no differences in rates of treatment completion between the CBT (87%) and anxiety management (87%) groups (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.80 to 1.25; low-certainty evidence). Behavioural difficulties were not included as an outcome measure in the study. This study showed that there may be a benefit at the end of treatment favouring CBT compared with anxiety management in OCD symptoms (mean difference (MD) -3.00, 95% CI -8.02 to 2.02), depression symptoms (MD -1.80, 95% CI -11.50 to 7.90), anxiety symptoms (MD -3.20, 95% CI -11.38 to 4.98), and quality of life (MD 5.20, 95% CI -1.41 to 11.81), but the evidence was of low certainty.  AUTHORS' CONCLUSIONS: Evidence is limited regarding the efficacy of CBT for treatment of OCD in ASD. There is much scope for future study, not only examining the efficacy of CBT for OCD in ASD, but also the particular ways that OCD manifests in and affects people with ASD and the role of the family in treatment response.

Sleep quality, functional skills, and communication in preschool-aged children with autism spectrum disorder

AIM

This study aimed to correlate sleep quality, the performance of functional skills (mobility, self-care, and social function), communication, independence, and severity of ASD in children with ASD.

METHOD

58 children between 3 and 5 years and 11 months old were investigated. The Childhood Autism Rating Scale was applied to determine the severity of autism; the Sleep Disturbance Scale for Children was used to investigate sleep quality, and the Pediatric Evaluation of Disability Inventory to investigate functional abilities and independence of the children.

RESULTS

68.9 % of the children showed indicative of sleep disorders. There was no correlation between the different sleep disorders and communication. Sleep disorders showed a negative correlation with functional performance and a positive correlation with ASD severity.

INTERPRETATION

The current study offers an exploration between sleep and functional skills in children with ASD. These findings provide important clinical implications in the diagnosis and intervention process of children with ASD and also stimulate reflections on the importance in minimize the impact of sleep disorders and functional abilities on the quality of life of these individuals and their families.

Resources, Problems and Challenges of Autism Spectrum Disorder Diagnosis and Support System in Poland

The article refers to resources, problems and challenges of autism diagnosis and support system in Poland. The resources include: the increasing number of specialists, diagnostic and therapeutic centres, well-established course of education for people working with youths, standardised and normalised diagnostic tools. The diagnostic process is not without some areas in need of our focus: the tendency of some specialists to make unauthorised diagnosis, overshadowing; underestimation of comorbidity of ASD with other disorders. The challenges refer to introducing an effective system of monitoring the services provided in form of certification and control in order to prevent their abuse, initiating category of temporary diagnosis; paying more attention on individual's resources, better cooperation among specialists, teachers and families, developing and unifying diagnostic standards.

Occupational Therapy Interventions for Children and Youth Ages 5 to 21 Years

Evidence Connection articles provide a clinical application of practice guidelines developed in conjunction with the American Occupational Therapy Association’s (AOTA’s) Evidence-Based Practice Program. Each article in the series summarizes the evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. The articles illustrate how the research evidence from the practice guidelines can be used to inform and guide clinical decision making. In this Evidence Connection article, we describe a case report of a child receiving occupational therapy services and summarize the evaluation and intervention processes for supporting sleep, activities of daily living, and social participation. The practice guideline on this topic was published in the July/August 2020 issue of the American Journal of Occupational Therapy (Cahill & Beisbier, 2020).

Informing Developmental Milestone Achievement for Children With Autism: Machine Learning Approach

Background

Care for children with autism spectrum disorder (ASD) can be challenging for families and medical care systems. This is especially true in low- and- middle-income countries such as Bangladesh. To improve family–practitioner communication and developmental monitoring of children with ASD, mCARE (Mobile-Based Care for Children with Autism Spectrum Disorder Using Remote Experience Sampling Method) was developed. Within this study, mCARE was used to track child milestone achievement and family sociodemographic assets to inform mCARE feasibility/scalability and family asset–informed practitioner recommendations.

Objective

The objectives of this paper are threefold. First, it documents how mCARE can be used to monitor child milestone achievement. Second, it demonstrates how advanced machine learning models can inform our understanding of milestone achievement in children with ASD. Third, it describes family/child sociodemographic factors that are associated with earlier milestone achievement in children with ASD (across 5 machine learning models).

Methods

Using mCARE-collected data, this study assessed milestone achievement in 300 children with ASD from Bangladesh. In this study, we used 4 supervised machine learning algorithms (decision tree, logistic regression, K-nearest neighbor [KNN], and artificial neural network [ANN]) and 1 unsupervised machine learning algorithm (K-means clustering) to build models of milestone achievement based on family/child sociodemographic details. For analyses, the sample was randomly divided in half to train the machine learning models and then their accuracy was estimated based on the other half of the sample. Each model was specified for the following milestones: Brushes teeth, Asks to use the toilet, Urinates in the toilet or potty, and Buttons large buttons.

Results

This study aimed to find a suitable machine learning algorithm for milestone prediction/achievement for children with ASD using family/child sociodemographic characteristics. For Brushes teeth, the 3 supervised machine learning models met or exceeded an accuracy of 95% with logistic regression, KNN, and ANN as the most robust sociodemographic predictors. For Asks to use toilet, 84.00% accuracy was achieved with the KNN and ANN models. For these models, the family sociodemographic predictors of “family expenditure” and “parents’ age” accounted for most of the model variability. The last 2 parameters, Urinates in toilet or potty and Buttons large buttons, had an accuracy of 91.00% and 76.00%, respectively, in ANN. Overall, the ANN had a higher accuracy (above ~80% on average) among the other algorithms for all the parameters. Across the models and milestones, “family expenditure,” “family size/type,” “living places,” and “parent’s age and occupation” were the most influential family/child sociodemographic factors.

Conclusions

mCARE was successfully deployed in a low- and middle-income country (ie, Bangladesh), providing parents and care practitioners a mechanism to share detailed information on child milestones achievement. Using advanced modeling techniques this study demonstrates how family/child sociodemographic elements can inform child milestone achievement. Specifically, families with fewer sociodemographic resources reported later milestone attainment. Developmental science theories highlight how family/systems can directly influence child development and this study provides a clear link between family resources and child developmental progress. Clinical implications for this work could include supporting the larger family system to improve child milestone achievement.

Daily living skills in adolescents with autism spectrum disorder: Implications for intervention and independence

BACKGROUND

Challenges in adaptive behaviors are present in individuals with autism spectrum disorder (ASD), while variation in IQ, social skills, and comorbidities are possible influences on adaptive behaviors. However, adaptive behaviors do not consistently map onto cognitive abilities in ASD, as high IQ is not protective against challenges in adaptive behaviors. Additionally, individuals with both ASD and elevated levels of externalizing problem behaviors experience even worse adaptive behaviors. Identifying factors that contribute to the variance in adaptive behaviors, particularly daily living skills (DLS), may inform strategies to improve adaptive behaviors necessary for independence in adulthood.

METHOD

Adolescents with typical cognitive development (TD, n=84), intellectual disability (ID, n=30), or ASD (n=45) were included in this study to examine group differences in adaptive behaviors, identify relations between IQ and DLS, and determine factors that contribute to variance in DLS at youth age 13. The Vineland Adaptive Behavior Scales, 2nd Edition (VABS-II) was used to measure adaptive behaviors.

RESULTS

All domains of adaptive behavior were significantly higher in TD groups compared to ASD and ID youth. Significant positive correlations were observed between IQ and DLS in the ASD and ID groups. In the ASD youth group, higher externalizing behavior problems explained the most variance in DLS.

CONCLUSIONS

DLS are below age-expected levels in young adolescents with ASD, in part because of the higher externalizing behavior problems in this group. Incorporating adaptive skills training and behavior management strategies into current interventions may serve to prepare adolescents and families for the transition to adulthood.

Assessing Activity of Daily Living Task Performance Among Autistic Adults

Activities of daily living (ADLs) are activities that people engage in on a routine basis, such as brushing their teeth, preparing a meal, and caring for their child. Independence with ADLs is associated with better outcomes in independent living, education, employment, relationships, and mental health. Therefore, this perspective piece includes a review of the literature and assessment databases to identify and summarize ADL assessments for Autistic adults. These assessments were compared and analyzed using the neurodiversity paradigm. Specifically, we compared assessments using predetermined priorities the authors identified: (1) assessment type, (2) inclusivity, and (3) performance factors. We identified five unique norm-referenced measures, four performance-based measures, and a variety of checklists, surveys, questionnaires, and/or interviews used to assess ADL performance among Autistic adults. The authors present their perspectives regarding the challenges with the current assessments, including the high-frequency use of norm-referenced assessments, lack of inclusivity, and failure to consider performance factors (e.g., sensory, motor, and emotional), and the paucity of assessments designed specifically for Autistic adults older than 30 years. In response to these challenges, we recommend researchers partner with Autistic adults to develop a new assessment tool. If researchers or clinicians are using existing measures, we recommend that they utilize self-report over proxy-report and include methods to improve the accessibility of the assessment. We also recommend that clinicians and researchers offer breaks, comfort objects, or sensory modifications during the assessment to decrease anxiety; and ask follow-up questions to understand whether environment or emotional health are impacting one's ADL performance.

Lay summary

Why is this topic important?: Activity of daily living (ADL) assessments are used to determine what Autistics can and cannot do in their day-to-day life, what services they may be eligible for, and to monitor gains. However, we struggled to find an assessment that was useful and relevant from an Autistic point-of-view.What is the purpose of this article?: The purpose of this article was to review and evaluate current ADL assessments usefulness for Autistics and provide recommendations for improving the ADL assessment process.What is the perspective of the authors?: The first author is an Autistic social worker and the second author is an occupational therapist and postdoctoral fellow. The authors' perspective is based in the neurodiversity paradigm and social model of disability, which centers on respecting and acknowledging differences in the brain and their effects on Autistics' lives. We believe in strengths-based approaches versus deficit-based models.What did you find about this topic?: We found 17 measurement tools, some that compared Autistic ADL performance with neurotypical performance, a few that were observation-based meaning the researcher or clinician watched the Autistic person complete the ADLs, and many forms or guides that asked questions about ADL performance. Only six measures allowed Autistic people to respond to the questions themselves, whereas the rest of the measures had someone else respond for them. These measures did not include questions about how sensory differences (e.g., feeling upset by the feeling of jeans or the taste of minty toothpaste) or feeling sad or nervous may also impact ADL performance.What do the authors recommend?: We recommend that researchers partner with Autistic adults to make new ADL assessments. If researchers or clinicians are using previously made ADL assessments, we recommend that they use self-report and adapt the materials to make it easier to understand (e.g., using pictures). We also recommend that researchers and clinicians ask Autistics what they need or want to make the assessment easier and more comfortable for them. Finally, researchers and clinicians should ask follow-up questions about sensory differences and whether someone is feeling sad or nervous to know how this impacts their ability to do their ADL tasks.How will these recommendations help autistic adults now or in the future?: These recommendations will help Autistic adults be more involved in the evaluation process, which will make the assessments more trustworthy and relevant to Autistics. This also could help more Autistic people get services and supports that are useful to them. Finally, this may help researchers when monitoring if these supports or services actually work.

Non- Pharmacological Approaches on the Improvement of Sleep Disturbances in Patients with Autism Spectrum Disorder (ASD)

Abstract

Autism is a type of neurodegenerative disorder, caused by genetic and environmental factors. Children with autism spectrum disorder (ASD) have symptoms of attention deficit and behavioral problems. Child’s sleep pattern has a significant effect on mood. Sleep problems are more common in children with ASD. The current study aimed to investigate the effect of non-pharmacological approaches on the improvement of sleep disturbances in patients with ASD.

Materials & Methods

We systematically searched PubMed, EMBASE, Web of Science, Scopus, and Science Direct to identify relevant articles published from January 2009 to May 2019. All original articles from observational and interventional studies were reviewed. The CONSORT Statement and Strengthening the Reporting of Observational Studies in Epidemiology(STROBE) checklist were used to assess the quality of selected papers.

Results

Reviewing 18 eligible articles according to the CONSORT checklist(for interventional studies) and STROBE (for descriptive studies) demonstrated that behavioral interventions, such as cognitivebehavioral therapy, bedtime fading with response cost, and functional behavioral assessment, physical activity such as aerobic exercise, swimming, and aquatic exercise and weighted blankets can improve sleep disturbances.

Conclusion:

Restlessness, tantrums, increased stereotypic activities, and reduced

learning level and speaking power in children with autism were. caused by poor sleep quality and sleep deficiency, which may affect other dimensions of life. Non- pharmacological approaches to sleep disturbances could improve both sleep quality and quality of life of children with ASD with no adverse effect.

Occupation- and Activity-Based Interventions to Improve Performance of Activities of Daily Living, Play, and Leisure for Children and Youth Ages 5 to 21: A Systematic Review

IMPORTANCE

The findings support the use of occupation- and activity-based interventions to improve the occupational participation of children and youth with disabilities.

OBJECTIVE

To examine the effectiveness of occupation- and activity-based interventions to improve participation and performance in activities of daily living (ADLs), play, and leisure in children and youth.

DATA SOURCES

MEDLINE, PsycINFO, CINAHL, ERIC, OTseeker, and Cochrane Database of Systematic Reviews; reference lists of retrieved articles; and tables of contents of selected journals were searched to identify peer-reviewed studies published between 2000 and 2017.

STUDY SELECTION AND DATA COLLECTION

Studies addressing occupation- and activity-based interventions and outcomes for children ages 5 to 21 were selected and appraised using Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines, evaluated for risk of bias, and synthesized to develop practice recommendations.

FINDINGS

Fifteen Level I (meta-analyses, systematic reviews, and randomized controlled trials), 5 Level II (two groups, nonrandomized), and 3 Level III (one group, pretest-posttest, retrospective) studies were examined and categorized by type of intervention and outcome. Each study used occupation- or activity-based interventions and reported ADL, play, or leisure outcomes. Intervention themes identified include supporting engagement in occupations, supporting participation with cognitive supports, and using technology to support occupational participation and performance.

CONCLUSIONS AND RELEVANCE

Strong evidence indicates that engagement in occupations and activities, practice within and across environments, and coaching and feedback improve participation and performance in ADLs and functional mobility. Moderate evidence supports the use of collaborative goal setting, modeling, and guided participation in play and leisure. Moderate evidence also supports technological interventions for ADL, play, and leisure performance.

WHAT THIS ARTICLE ADDS

Engaging children and youth in occupations and activities; providing guidance in goal direction, planning, and feedback to enhance their participation; coaching caregivers in effective carryover; and providing technology-based intervention can improve the occupational participation and performance of children and youth.

Sensory Processing and Gastrointestinal Manifestations in Autism Spectrum Disorders: No Relation to Clostridium difficile

The role of the gut microbiota in triggering autism is a rapidly emerging field of research. Gut microbiota have been incriminated because autistic children often have gastrointestinal symptoms. Pathogenic gut bacteria in children with autism spectrum disorders (ASD) have been reported. The present study aimed to assess Clostridium difficile in the stool of children with ASD and its relation to gastrointestinal (GI) comorbidities, autism severity, and sensory impairment. The study included 58 ASD patients, 45 of their neurotypical siblings, and 45 unrelated controls. Childhood Autism Rating Scale (CARS) was used to assess the severity of autism. Sensory problems were evaluated using the Short Sensory Profile (SSP). GI symptoms were assessed with a modified six-item GI Severity Index (6-GSI) questionnaire. Quantitative real-time PCR was done for the detection and quantitation of C. difficile and its toxins A and B. C. difficile was detected in 25.9%, 40%, and 15.6% of ASD cases, siblings, and unrelated control respectively. Regarding toxin A and B production, 73.3%, 77.8%, and 71.4% of C. difficile in positive ASD, siblings, and unrelated control cases respectively were toxigenic. There was no statistically significant difference between the three groups as regards C. difficile qualitative, quantitative, and toxin production results. In conclusion, C. difficile is not specifically prevalent in the gut of children with ASD. Although most of the strains are toxigenic, there were no GI symptoms in the control groups and no statistically significant association with GI Severity Index in autistic cases. Gastrointestinal dysfunction and sensory impairment are common comorbidities in ASD.

Occupational Therapy Practice Guidelines for Children and Youth Ages 5-21 Years

IMPORTANCE

Demand is increasing for activity- and occupation-based interventions to address occupational performance and support maximal participation of children and youth.

OBJECTIVE

This Practice Guideline was developed to guide decision making and support best practices in service delivery for children and youth ages 5-21 yr at home, at school, and in the community.

METHOD

The results from three systematic reviews (SRs) of activity- and occupation-based interventions for children and youth ages 5-21 yr were reviewed, synthesized, and translated into recommendations for education, practice, and research.

RESULTS

One hundred eighty-five articles were included in the three SRs examining the evidence for interventions to promote activities of daily living, instrumental activities of daily living, play and leisure, and rest and sleep; to improve mental health, positive behavior, and social participation; and to enhance learning, academic achievement, and successful participation in school. The reviews provide evidence for interventions associated with typical concerns addressed by occupational therapy practitioners.

CONCLUSIONS AND RECOMMENDATIONS

On the basis of the evidence, this guideline recommends that occupational therapy practitioners consistently collaborate with families and caregivers and provide services in the natural context of the desired occupation. The evidence also supports group service models and models that include peer mediation; these models can promote participation across areas of occupation. Skills-based training and therapeutic practice in the context of valued occupations are recommended over isolated sensorimotor approaches. Technology, manualized programs, and sports activities can be effective but should be evaluated and matched to age, diagnosis, and outcomes as guided by the evidence.

WHAT THIS ARTICLE ADDS

When guided by evidence, activity- and occupation-based interventions are effective in promoting participation and enhancing performance in valued occupations of children and youth ages 5-21 yr.

Assessing treatment efficacy by examining relationships between age groups of children with autism spectrum disorder and clinical anxiety symptoms: Prediction by correspondence analysis

INTRODUCTION

Autism spectrum disorders (ASD) are neurodevelopmental in nature and are frequently accompanied by anxiety. To fully assess treatment efficacy, we examined rates of anxiety symptom change by age groups following either cognitive behavioral therapy (CBT) or treatment as usual (TAU).

METHODS

One hundred sixty-three children with ASD and ASD-related anxiety symptoms were randomly assigned to either CBT or TAU. Utilizing prediction by correspondence analysis (CA), we evaluated the age effect (defined in three groups; ages 6-9, 10-12, and 13-16) and the changes in correlations between age and anxiety severity levels over the course of treatment.

RESULTS

Significantly greater anxiety symptom reduction was associated with CBT compared with TAU across the three age groups. Of particular note, the children ages 10-12 who received CBT showed the greatest improvement compared to all other groups. Late childhood, prior to adolescence, showed the best response to CBT for anxiety in ASD.

DISCUSSION

These findings suggest that treatment programs need to more closely address developmental factors within narrower bands of age groups. The present results are limited in their generalization to the CBT efficacy for a specific age band (ages 10-12). Longitudinal investigations are recommended to confirm whether the similar age group children who receive CBT experience the greatest benefit in reducing their ASD-related anxiety symptoms.

Update on the effectiveness of psychotherapy for anxiety disorders in children and adolescents with ASD

A growing body of research has examined the efficacy of varying formats (individual, group, linear, modular) of cognitive-behavioral therapy (CBT) as a treatment for anxiety disorders in children and youth with autism spectrum disorders (ASD). The present review utilized Chambless and Hollon's (1998) criteria for efficacious treatments to: (1) critically review the current evidence base for the efficacy of CBT for anxiety disorders in ASD; and (2) provide recommendations for future research. Findings identify two probably efficacious CBT programs (one group and one individual program) and five possibly efficacious programs, but no well-established programs. Similarities and differences in the components of these programs, which range from unmodified to specifically developed for ASD populations, are highlighted. In addition, the steps required to demonstrate well-established efficacy, and ultimately effectiveness, are discussed alongside other recommendations for refined future research.

Priorities for Advancing Research on Youth with Autism Spectrum Disorder and Co-occurring Anxiety

Research on anxiety disorders in youth with autism spectrum disorder (ASD) has burgeoned in the past two decades. Yet, critical gaps exist with respect to measuring and treating anxiety in this population. This study used the nominal group technique to identify the most important research priorities on co-occurring anxiety in ASD. An international group of researchers and clinicians with experience in ASD and anxiety participated in the process. Topics ranked as most important focused on understanding how ASD symptoms affect treatment response, implementing treatments in real world settings, developing methods to disentangle overlapping symptoms between anxiety and ASD, and developing objective measures to assess anxiety. Collectively, these priorities can lead to collaborative studies to accelerate research in the field.

Systematic review and guide to management of core and psychiatric symptoms in youth with autism

OBJECTIVE

Evidence-based guidance of clinical decision-making for the management of Autism Spectrum Disorder (ASD) is lacking, particularly for co-occurring psychiatric symptoms. This review evaluates treatment evidence for six common symptom targets in children/adolescents with ASD and provides a resource to facilitate application of the evidence to clinical practice.

METHOD

A systematic search identified randomized controlled trials (RCTs) and high-quality systematic reviews published between 2007 and 2016, focused on: social interaction/communication impairment, stereotypic/repetitive behaviours, irritability/agitation, attention-deficit/hyperactivity disorder symptoms, mood or anxiety symptoms, and sleep difficulties. We then completed qualitative evaluation of high-quality systematic reviews/meta-analyses and quantitative evaluation of recently published RCTs not covered by prior comprehensive systematic reviews.

RESULTS

Recently published RCTs focused on social interaction and communication impairment (trials = 32) using psychosocial interventions. Interventions for irritability/agitation (trials = 16) were mainly pharmacological. Few RCTs focused on other symptom targets (trials = 2-5/target). Integration of these results with our qualitative review indicated that few established treatment modalities exist, and available evidence is limited by small studies with high risk of bias.

CONCLUSION

Given the current evidence-base, treatment targets must be clearly defined, and a systematic approach to intervention trials in children/adolescents with ASD must be undertaken with careful consideration of the limitations of safety/efficacy data.

Prevalence and Risk Factors of Anxiety in a Clinical Dutch Sample of Children with an Autism Spectrum Disorder

Anxiety is highly prevalent in children with an autism spectrum disorder (ASD). However, there is inconsistency in studies investigating the prevalence and risk factors of anxiety in children with ASD. Therefore, the first aim of this study was to give an overview of the prevalence of anxiety symptoms in a clinical Dutch sample of children with ASD. The second aim was to investigate age, gender, ASD subtype, and IQ as potential risk factors for anxiety in this sample. In total, 172 children with ASD (age, 8-15 years) and their parents participated in this study. Specialized services in which children with ASD were recruited were two mental health institutes and one secondary special education school. The findings showed that more than 60% of the participating children with ASD had at least subclinical anxiety symptoms according to children. More than 80% of the children with ASD had at least subclinical anxiety symptoms according to parents. It was found that younger children and girls with ASD had more anxiety symptoms than older children and boys with ASD. Moreover, it was found that children with a higher performance (non-verbal) IQ and lower verbal IQ had more specific phobia symptoms. The findings suggest that in a clinical context, children with ASD have a high risk to have co-occurring anxiety symptoms, especially girls and younger children with ASD. Therefore, early prevention and treatment of anxiety in children with ASD who are most at risk is important.

Brief report: Reduced anxiety following Pivotal Response Treatment in young children with Autism Spectrum Disorder

Up to 40% of children with Autism Spectrum Disorder (ASD) exhibit co-occurring anxiety symptoms. Despite recent success in mitigating anxiety symptoms in school-aged children with ASD (mean age >9 years) using adapted versions of Cognitive Behavioural Therapy, little is known about potential treatment outcomes for younger children. To address the gap in the literature, this open-label study evaluated change in anxiety following a 16-week open-label trial of Pivotal Response Treatment (PRT) in children with ASD aged 4-8 years. PRT is a behavioural treatment based on the principles of Applied Behaviour Analysis and has a primary aim of increasing social communication skills in children with ASD through natural reinforcements. To minimise conflation of anxiety and other co-occurring symptoms such as disruptive behaviour and attention-deficit hyperactivity disorder, we measured anxiety using the autism anxiety subscale of the Child and Adolescent Symptom Inventory (CASI) devised by Sukhodolsky et al. (2008). We observed significant anxiety reduction over 16-weeks of PRT. Furthermore, anxiety reduction was independent of changes in autism symptom severity. This study shows promising results for PRT as an intervention for reducing anxiety in young children with ASD.

Preliminary efficacy of a daily living skills intervention for adolescents with high-functioning autism spectrum disorder

Daily living skills deficits are strongly associated with poor adult outcomes for individuals with high-functioning autism spectrum disorder, and yet, there are no group interventions targeting daily living skills. Seven adolescents with autism spectrum disorder and their parents participated in a feasibility pilot of a 12-week manualized group treatment targeting specific daily living skills (i.e. morning routine, cooking, laundry, and money management). Outcomes included the Vineland Adaptive Behavior Scales, Second Edition (Vineland-II) age equivalence scores and four goal attainment scaling scores. Adolescents demonstrated significant improvement on two Vineland-II subdomains and on all goal attainment scaling scores at post-treatment and 6-month follow-up. The intervention has promise for improving critical daily living skills' deficits that affect independent living and employment. Limitations and implications for future studies are discussed.

Practitioner Review: Empirical evolution of youth psychotherapy toward transdiagnostic approaches

BACKGROUND

Psychotherapy for children and adolescents (herein, 'youths') has grown more precise and focused over the decades, shifting toward empirically supported treatments standardized via therapist manuals. The manuals have increasingly emphasized precise targeting of single disorders or problems, or homogenous clusters. These focal treatments represent a valuable advance, with intervention benefit documented in hundreds of studies. However, relatively few of these treatments are widely used in everyday clinical practice, and their level of benefit may not be ideal, particularly in practice contexts and when compared to usual clinical care.

THESIS

These limitations may be due, in part, to a mismatch between focal treatment design and the young people treated in real-world clinical care, who are diagnostically heterogeneous, and very frequently present with comorbidity. Improved fit may be achieved via transdiagnostic treatment approaches designed to address multiple disorders and problems, if these approaches can retain the benefits of manualization and the substantive clinical strength that has generated empirical support to date.

SCOPE

Here we review the evolution of empirically-based youth psychotherapy from focal treatment manuals toward transdiagnostic approaches, and we describe and illustrate three transdiagnostic treatment strategies: (a) a core dysfunction approach, (b) a common elements and modular design approach, and (c) a principle-guided approach.

CLINICAL APPLICATIONS

We complement research findings with a clinical perspective based on our use of manual-guided transdiagnostic intervention in clinical care settings, and we propose directions for research and practice.

[Modular psychotherapy with children and adolescents]

The implementation of evidence-based psychotherapy with children and adolescents has been limited so far. This is mainly due to the fact that patients in service settings tend to have higher rates of comorbidities and more frequently changing therapy needs than those in research settings. Thus, modular psychotherapies are promising, as they allow the treatment protocol to be adapted to patients’ individual needs. Because no review on modular psychotherapy for children and adolescents exists, we conducted a systematic literature research. The results of the 15 randomized controlled trials identified demonstrate that modular psychotherapy is associated with significant reductions in symptom levels as well as with higher rates of diagnostic remission compared to control conditions. Because of the lack of evidence, future studies should investigate the incremental efficacy of modular approaches and test the validity of underlying theoretical models as well as of decision flowcharts. Modular psychotherapy approaches have the potential to personalize evidence-based interventions for children and adolescents across various therapeutical traditions, and to facilitate their implementation into clinical practice.

The Treatment of Anxiety in Autism Spectrum Disorder (TAASD) Study: Rationale, Design and Methods

This paper describes the rationale, design, and methods of the Treatment for Anxiety in Autism Spectrum Disorders study, a three-site randomized controlled trial investigating the relative efficacy of a modular CBT protocol for anxiety in ASD (Behavioral Interventions for Anxiety in Children with Autism) versus standard CBT for pediatric anxiety (the Coping Cat program) and a treatment-as-usual control. The trial is distinct in its scope, its direct comparison of active treatments for anxiety in ASD, and its comprehensive approach to assessing anxiety difficulties in youth with ASD. The trial will evaluate the relative benefits of CBT for children with ASD and investigate potential moderators (ASD severity, anxiety presentation, comorbidity) and mediators of treatment response, essential steps for future dissemination and implementation.

Annual Research Review: Building a science of personalized intervention for youth mental health

BACKGROUND

Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs). The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health.

FINDINGS

The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths' environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics.

CONCLUSION

The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians' use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families.

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.

Preliminary study of family accommodation in youth with autism spectrum disorders and anxiety: Incidence, clinical correlates, and behavioral treatment response

Anxiety symptoms are common in youth with autism spectrum disorders (ASD) and directly associated with symptom severity and functional impairment. Family accommodation occurs frequently among individuals with obsessive-compulsive and anxiety disorders; to date, no data exist on the nature and correlates of family accommodation in youth with ASD and anxiety, as well as its relationship to cognitive-behavioral therapy outcome. Forty children with ASD and a comorbid anxiety disorder participated. Clinicians administered measures of ASD and anxiety disorder caseness, anxiety symptom severity, and family accommodation; parents completed questionnaires assessing social responsiveness, internalizing and externalizing behaviors, and functional impairment. A subsample of youth (n = 24) completed a course of cognitive-behavioral therapy. Family accommodation was common and positively correlated with anxiety symptom severity, but not functional impairment, general internalizing symptoms, externalizing behavior, or social responsiveness. Family accommodation decreased following cognitive-behavioral therapy with decreases in family accommodation being associated with decreases in anxiety levels. Treatment responders reported lower family accommodation frequency and lower parent impact relative to non-responders. Clinical implications of this study in assessing and psychotherapeutically treating youth with ASD and comorbid anxiety are discussed.

The effect of the video game Mindlight on anxiety symptoms in children with an Autism Spectrum Disorder

BACKGROUND

In the clinical setting, a large proportion of children with an autism spectrum disorder (ASD) experience anxiety symptoms. Because anxiety is an important cause of impairment for children with an ASD, it is necessary that effective anxiety interventions are implemented for these children. Recently, a serious game called Mindlight has been developed that is focused on decreasing anxiety in children. This approach is based on recent research suggesting that video games might be suitable as an intervention vehicle to enhance mental health in children. In the present study it will be investigated whether Mindlight is effective in decreasing (sub) clinical anxiety symptoms in children who are diagnosed with an ASD.

METHODS/DESIGN

The present study involves a randomized controlled trial (RCT) with two conditions (experimental versus control), in which it is investigated whether Mindlight is effective in decreasing (sub) clinical anxiety symptoms in children with an ASD. For this study, children of 8-16 years old with a diagnosis of an ASD and (sub) clinical anxiety symptoms will be randomly assigned to the experimental (N = 60) or the control (N = 60) condition. Children in the experimental condition will play Mindlight for one hour per week, for six consecutive weeks. Children in the control condition will play the puzzle game Triple Town, also for one hour per week and for six consecutive weeks. All children will complete assessments at baseline, post-intervention and 3-months follow-up. Furthermore, parents and teachers will also complete assessments at the same time points. The primary outcome will be child report of anxiety symptoms. Secondary outcomes will be parent report of child anxiety, child/parent report of depressive symptoms, and parent/teacher report of social functioning and behavior problems.

DISCUSSION

This paper aims to describe a study that will examine the effect of the serious game Mindlight on (sub) clinical anxiety symptoms of children with an ASD in the age of 8-16 years old. It is expected that children in the experimental condition will show lower levels of anxiety symptoms at 3-months follow-up, compared to children in the control condition. If Mindlight turns out to be effective, it could be an important contribution to the already existing interventions for anxiety in children with an ASD. Mindlight could then be implemented as an evidence-based treatment for anxiety symptoms in children with an ASD in mental health institutes and special education schools.

TRIAL REGISTRATION

Dutch Trial Register NTR5069 . Registered 20 April 2015.

Daily living skills in individuals with autism spectrum disorder from 2 to 21 years of age

Daily living skills (DLS), such as personal hygiene, meal preparation, and money management, are important to independent living. Research suggests that many individuals with autism spectrum disorder exhibit impairments in daily living skills relative to their cognitive skills. This study examined predictors of daily living skills attainment and trajectories of daily living skills in a longitudinal sample referred for possible autism spectrum disorder and followed from 2 to 21 years of age. Consistent with previous studies, participants with autism spectrum disorder and nonspectrum diagnoses showed continual development of daily living skills throughout childhood and adolescence. Early childhood nonverbal mental age was the strongest predictor of daily living skills attainment for both diagnostic groups. Group-based modeling suggested two distinct trajectories of daily living skills development for participants with autism spectrum disorder. Skill levels for both groups of young adults with autism spectrum disorder remained considerably below age level expectations. Whereas the "High-DLS" group gained approximately 12 years in daily living skills from T2 to T21, the "Low-DLS" group's daily living skills improved 3-4 years over the 16- to 19-year study period. Nonverbal mental age, receptive language, and social-communication impairment at 2 years predicted High- versus Low-DLS group membership. Receiving greater than 20 h of parent-implemented intervention before age 3 was also associated with daily living skills trajectory. Results suggest that daily living skills should be a focus of treatment plans for individuals with autism spectrum disorder, particularly adolescents transitioning to young adulthood.

Cognitive behavioral therapy for early adolescents with autism spectrum disorders and clinical anxiety: a randomized, controlled trial

Clinically elevated anxiety is a common, impairing feature of autism spectrum disorders (ASD). A modular CBT program designed for preteens with ASD, Behavioral Interventions for Anxiety in Children with Autism (BIACA; Wood et al., 2009) was enhanced and modified to address the developmental needs of early adolescents with ASD and clinical anxiety. Thirty-three adolescents (11-15 years old) were randomly assigned to 16 sessions of CBT or an equivalent waitlist period. The CBT model emphasized exposure, challenging irrational beliefs, and behavioral supports provided by caregivers, as well as numerous ASD-specific treatment elements. Independent evaluators, parents, and adolescents rated symptom severity at baseline and posttreatment/postwaitlist. In intent-to-treat analyses, the CBT group outperformed the waitlist group on independent evaluators' ratings of anxiety severity on the Pediatric Anxiety Rating Scale (PARS) and 79% of the CBT group met Clinical Global Impressions-Improvement scale criteria for positive treatment response at posttreatment, as compared to only 28.6% of the waitlist group. Group differences were not found for diagnostic remission or questionnaire measures of anxiety. However, parent-report data indicated that there was a positive treatment effect of CBT on autism symptom severity. The CBT manual under investigation, enhanced for early adolescents with ASD, yielded meaningful treatment effects on the primary outcome measure (PARS), although additional developmental modifications to the manual are likely warranted. Future studies examining this protocol relative to an active control are needed.

Not to be overshadowed or overlooked: functional impairments associated with comorbid anxiety disorders in youth with ASD

This study's objective was to examine associations between comorbid anxiety disorders and difficulties commonly attributed to both anxiety and ASD (autism spectrum disorder) including self-injury, depressive symptoms, functional communication, social skill deficits and parent stress, in a well-characterized sample of youth with ASD. Fifty-nine verbally fluent participants (7-17 years; 93% Caucasian) diagnosed with ASD and their parents completed semistructured diagnostic interviews to confirm ASD diagnosis and assess for anxiety disorders. Parents completed questionnaires on child behavior and social skill as well as parental stress. Co-occurring anxiety disorders were associated with more parent-reported self-injurious behavior, depressive symptoms, and parental stress in youth with ASD, after controlling for other influential variables (e.g., ASD severity, cognitive ability, medication status). In contrast, youth with co-occurring anxiety disorders appeared to have significantly stronger parent-reported functional communication than youth with ASD alone as well as a comparable ability, according to parents, to initiate social interaction and develop relationships. Findings support a profile of challenges and relative strengths associated with the presence of anxiety disorders in youth with ASD. Though more research is needed to determine the direction of these associations, results provide further rationale for improving recognition and targeted treatment of this comorbidity in clinical practice.

Toward the implementation of evidence-based interventions for youth with autism spectrum disorders in schools and community agencies

Evidence-based interventions (EBIs) for youth with autism spectrum disorders (ASD) are rarely found in community settings where most youth with ASD receive services. Implementation research designed to help bridge this gap is needed. However, efforts to implement EBIs in community settings face a number of barriers. The main purpose of this article is to illustrate how making EBIs more flexible and integrative may help improve their utility and may increase their uptake by stakeholders in community mental health and school settings. We conclude with an example of a modular, stepped-care program that might help bridge the science-practice gap in the ASD field by combining elements of a number of existing EBIs into a single, flexible intervention.

Reducing specific phobia/fear in young people with autism spectrum disorders (ASDs) through a virtual reality environment intervention

Anxiety is common in children with autism spectrum disorders (ASD), with specific fears and phobias one of the most frequent subtypes. Specific fears and phobias can have a serious impact on young people with ASD and their families. In this study we developed and evaluated a unique treatment combining cognitive behaviour therapy (CBT) with graduated exposure in a virtual reality environment (VRE). Nine verbally fluent boys with an ASD diagnosis and no reported learning disability, aged 7 to 13 years old, were recruited. Each had anxiety around a specific situation (e.g. crowded buses) or stimulus (e.g. pigeons). An individualised scene was recreated in our ‘wrap-around’ VRE. In the VRE participants were coached by a psychologist in cognitive and behavioural techniques (e.g. relaxation and breathing exercises) while the exposure to the phobia/fear stimulus was gradually increased as the child felt ready. Each child received four 20–30 minute sessions. After participating in the study, eight of the nine children were able to tackle their phobia situation. Four of the participants completely overcame their phobia. Treatment effects were maintained at 12 months. These results provide evidence that CBT with VRE can be a highly effective treatment for specific phobia/fear for some young people with ASD.

Trial Registration

Controlled-Trials.com ISRCTN58483069.

A Cognitive-Behavioral Approach for Anxiety in a Preschool-Aged Child With Autism Spectrum Disorder

Empirical support exists for behaviorally oriented psychosocial interventions to reduce functional impairment related to autism spectrum disorder (ASD) symptoms in young children, but little research exists examining the effectiveness of such treatments when applied to preschool-aged children with comorbid anxiety symptoms. With this in mind, the authors report on the case of “Marcus,” a 4-year-old boy with autistic disorder and impairing comorbid anxiety. Marcus participated in 8 weekly sessions of family-based cognitive-behavioral therapy, addressing his fear-based avoidance of social interactions and sensory stimuli, using an anxiety treatment protocol for youth with ASD modified to account for his young age. This protocol consisted of modular components addressing affective education, exposure, cognitive restructuring, and social coaching. At post-treatment assessment, Marcus exhibited markedly decreased impairment, as evidenced by parent responses to clinical interview and rating scales. In addition, Marcus displayed improvement in severity of anxiety symptoms as illustrated by a decrease in his scores on the Pediatric Anxiety Rating Scale from 17 at baseline to 8 at post-treatment. Therapeutic gains were maintained at 4-month follow-up. Implications and clinical considerations are discussed.

Understanding the gap between cognitive abilities and daily living skills in adolescents with autism spectrum disorders with average intelligence

Daily living skills standard scores on the Vineland Adaptive Behavior Scales-2nd edition were examined in 417 adolescents from the Simons Simplex Collection. All participants had at least average intelligence and a diagnosis of autism spectrum disorder. Descriptive statistics and binary logistic regressions were used to examine the prevalence and predictors of a "daily living skills deficit," defined as below average daily living skills in the context of average intelligence quotient. Approximately half of the adolescents were identified as having a daily living skills deficit. Autism symptomatology, intelligence quotient, maternal education, age, and sex accounted for only 10% of the variance in predicting a daily living skills deficit. Identifying factors associated with better or worse daily living skills may help shed light on the variability in adult outcome in individuals with autism spectrum disorder with average intelligence.

Cognitive behavioral therapy for children with autism: review and considerations for future research

OBJECTIVE

Cognitive behavioral therapy (CBT) is now commonly used for high-functioning children with an autism spectrum disorder. The objective of this article was to describe the methods and results of cognitive behavioral interventions for children with autism.

METHOD

This article reviews CBT programs targeting anxiety, disruptive behavior, and core autism symptoms for children with autism.

RESULTS

There is emerging evidence suggesting that CBT is possibly efficacious for anxiety and autism symptoms, but methodological weaknesses must be addressed before clear conclusions can be drawn.

CONCLUSION

More research needs to be conducted to examine the effectiveness of CBT for children with autism. Specifically, future research should use more stringent methodology and assess the effectiveness of specific cognitive strategies and autism-related adaptations.