Assessment of the prerequisite skills for cognitive behavioral therapy in children with and without autism spectrum disorders

Approaches to improving mental health care for autistic children and young people: a systematic review and meta-analysis

Autistic children and young people (CYP) experience mental health difficulties but face many barriers to accessing and benefiting from mental health care. There is a need to explore strategies in mental health care for autistic CYP to guide clinical practice and future research and support their mental health needs. Our aim was to identify strategies used to improve mental health care for autistic CYP and examine evidence on their acceptability, feasibility, and effectiveness. A systematic review and meta-analysis were carried out. All study designs reporting acceptability/feasibility outcomes and empirical quantitative studies reporting effectiveness outcomes for strategies tested within mental health care were eligible. We conducted a narrative synthesis and separate meta-analyses by informant (self, parent, and clinician). Fifty-seven papers were included, with most investigating cognitive behavioral therapy (CBT)-based interventions for anxiety and several exploring service-level strategies, such as autism screening tools, clinician training, and adaptations regarding organization of services. Most papers described caregiver involvement in therapy and reported adaptations to communication and intervention content; a few reported environmental adjustments. In the meta-analyses, parent- and clinician-reported outcomes, but not self-reported outcomes, showed with moderate certainty that CBT for anxiety was an effective treatment compared to any comparison condition in reducing anxiety symptoms in autistic individuals. The certainty of evidence for effectiveness, synthesized narratively, ranged from low to moderate. Evidence for feasibility and acceptability tended to be positive. Many identified strategies are simple, reasonable adjustments that can be implemented in services to enhance mental health care for autistic individuals. Notable research gaps persist, however.

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.

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.

A comparison of the eating disorder service experiences of autistic and non-autistic women in the UK

Objective

Qualitative studies report that autistic women have poor experiences when being treated for an eating disorder (ED) and express that ED services are not appropriately tailored to meet their needs. It is unclear whether their experience differs to other women accessing ED services. The aim of the current study was to compare autistic and non‐autistic women's ED illness history and experiences in ED services.

Method

An online survey about ED illness history and their experience with ED treatment was completed by 46 autistic women with a restrictive ED and 110 non‐autistic women with a restrictive ED.

Results

Despite some similarities, there were three key differences in the experiences reported by autistic and non‐autistic women. First, autistic women reported a longer duration of ED and being diagnosed with an ED at a younger age than non‐autistic women. Second, autistic women reported accessing a broader range of healthcare settings and ED treatments than non‐autistic women when being treated for an ED. Finally, autistic women rated their experiences of inpatient care, dietetic input, and cognitive behavioural therapy (CBT) as significantly less beneficial than non‐autistic women when being treated for an ED.

Conclusion

These findings increase understanding of autistic women's ED experience and can help to shape ED services and treatments to better accommodate the needs of their autistic clients.

The current study is the first to compare the eating disorder (ED) illness history and treatment experiences of autistic and non‐autistic women.

Autistic women with EDs are diagnosed at a younger age and report longer illness duration than non‐autistic women.

Autistic women with EDs tend to access a broader range of healthcare settings and ED treatments than non‐autistic women, but report these to be less beneficial.

Cognitive assessment using ERP in child and adolescent psychiatry: Difficulties and opportunities

Event related potentials (ERPs) represent powerful tools to investigate cognitive functioning in child and adolescent psychiatry. So far, the available body of research has largely focused on advancements in analysis methods, with little attention given to the perspective of assessment. The aim of this brief report is to provide recommendations for cognitive ERPs assessment that can be applied across diagnostic categories in child and adolescent psychiatry research. First, we discuss major issues for ERPs testing using examples from common psychiatric disorders. We conclude by summing up our recommendations for methodological standards and highlighting the potential role of ERPs in the field.

Therapeutic Riding or Mindfulness: Comparative Effectiveness of Two Recreational Therapy Interventions for Adolescents with Autism

Therapeutic riding (THR) and HeartMath (HM) mindfulness-based interventions have promise for reducing stress in adolescents with autism spectrum disorder. In three 10-week periods, this study compared THR, HM, and control on salivary cortisol, self-reported stress, parent-reported social responsiveness, and heart-rate variability. This crossover design included 27 participants (12-21 years) randomly assigned to order of intervention. Findings suggest that HM and THR manualized protocols are equally beneficial in decreasing cortisol levels immediately following a session, but HM sessions had more impact on heart-rate variability. There was no significant effect on follow-up cortisol levels within a week after either intervention, but THR had more impact on decreasing some self-reported stressors.

Treatment effectiveness for Vocal Cord Dysfunction in adults and adolescents: A systematic review

OBJECTIVE

To determine whether treatment effectiveness can be established for a range of vocal cord dysfunction (VCD) interventions in adolescents and adults.

DESIGN

A systematic review of the literature and risk of bias appraisal was completed using the Joanna Briggs Institute Critical Appraisal Tools. Data were qualitatively synthesized in the broad intervention groups of glottic airway and respiratory retraining, pharmacological therapies, airway device therapies and psychological therapies.

DATA SOURCES

Nine electronic databases, two clinical trial registries and the grey literature were searched from inception to September 2021 for articles on VCD interventions or equivalent terms.

ELIGIBILITY CRITERIA

Studies were included if they were randomized controlled trials, non-randomized controlled trials, quasi-experimental pre- and post-test studies and within-subject repeated measure designs, participants were 13 years or older, VCD was diagnosed using laryngoscopy or CT larynx, VCD intervention was provided and outcome measures reported on VCD symptoms.

RESULTS

The search yielded no randomized controlled trials. There were 17 quasi-experimental studies that met the eligibility criteria, and these studies reported on glottic airway and respiratory retraining, botulinum toxin injections, inspiratory muscle strength training and amitriptyline; all were associated with VCD symptom reduction. In addition, 2 within-subject repeated measure studies reported inspiratory muscle strength training and respiratory retraining to be effective in reducing symptoms in participants with exertional VCD. The included studies were reported in full-text publications (11) and conference proceedings (8). There was a high risk of bias and low quality of evidence across all intervention areas.

CONCLUSION

Glottic airway and respiratory retraining, botulinum toxin injections, low-dose amitriptyline and inspiratory muscle strength training devices have been associated with symptom reduction in adults and adolescents with vocal cord dysfunction. Limited objective data exist to support the effectiveness of these interventions, and robust controlled trials are needed in this area. Systematic Review Registration: CRD42018092274 (PROSPERO).

Overlap of anxiety, depression, irritability and aggressiveness in autism spectrum disorder: an exploratory study using cluster analysis

Purpose

This study aims to explore the overlap between symptoms of depression, anxiety, irritability and aggressiveness in autism spectrum disorder (ASD), to measure specific and idiosyncratic emotional responses.

Design/methodology/approach

A total of 42 high functioning adolescents and adults, between 12 and 39 years old, meeting the diagnostic and statistical manual of mental disorders – 5 criteria for ASD were selected from the InFoR Autism cohort. Data were analyzed in an exploratory way using Hill and Smith and K-medoids cluster analysis.

Findings

The authors found an aggregation of anxiety, depression, aggressive behaviors and irritability. Cluster analysis was maximized for two groups with 17 and 25 participants, respectively. The first group was characterized by high levels of symptoms of irritability, aggressiveness, hyperactivity and intermediate levels of anxiety and depression. In the first group, participants had significantly higher levels of autistic symptoms considering the social responsiveness scale and repetitive behavior scale-revised scales (relatives’ reports) suggesting that a particular group of subjects with a high level of ASD specific symptoms may express anxiety and depression in a specific way based on externalizing behaviors in addition to the common mood and anxiety symptoms.

Research limitations/implications

Improved understanding of the aggregation of externalized symptoms with symptoms of anxiety and mood disorders in ASD should lead to a better understanding of the underlying mechanisms related to emotion dysregulation in ASD.

Practical implications

Improved knowledge of the symptoms could lead to enhanced detection of psychiatric comorbidities in ASD.

Originality/value

The study was based on a transdiagnostic approach of psychiatric symptoms in individuals with ASD. Aggregation and clustering analysis was used to explore naive patterns of these psychiatric symptoms.

Assessment and Treatment of Anxiety in Children with Autism Spectrum Disorder in School Settings: A Systematic Review and Meta-Analysis

Anxiety is the most common mental health problem that occurs with Autism Spectrum Disorder (ASD), and due to creating a more inclusive learning environment, children with ASD are placed in general education classrooms. Thus, addressing anxiety problems for children with ASD in school settings become critically important. This systematic review and meta-analysis investigated the current qualities of studies and the effects of school-based interventions for reducing anxiety in children with ASD. The study included six studies with a total of 165 participants. A random-effect meta-analysis yielded a moderate overall effect (g =  - 0.58, 95% CI [- 0.96, - 0.20], z =  - 3.01, p < .05) with no significant heterogeneity, Q (5) = 7.31, p = 0.20. Findings of the systematic review indicated that school-based interventions for anxiety problems are still in the early stages, and studies showed significant issues with adaptations of current clinical-based interventions and anxiety measurements to use in school settings for children with ASD. Interpretation of these findings and implications are discussed.

When to Raise Our White Flag-A Discussion of Scope of Practice in a Resource Scarce World

Thomas is a 13-year-old boy with autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder, separation anxiety disorder, and major depressive disorder who presented for a follow-up to his developmental and behavioral pediatrician (DBP). His mother describes an increase in symptoms of anxiety and depression for the last 6 weeks, accompanied by suicidal ideation and thoughts of self-mutilation.Before this increase in symptoms, he had been doing well for the last several months with the exception of increasing weight gain, and Abilify was decreased from 5 mg to 2.5 mg at his last visit. Other medications at that time included Zoloft 100 mg twice daily, Focalin XR 40 mg every morning, and Focalin 5 mg every night. Without seeking the guidance of our developmental and behavioral pediatrics clinic, his mother increased his intake of Zoloft to 150 mg each morning and continued 100 mg each evening because of worsening anxiety and depression.Religion is very important to Thomas and his family. He acknowledges that he does not want to die and feels badly because "suicide is against our religion."Helping Thomas receive appropriate care has been a challenge. He was diagnosed with ADHD and Asperger disorder at the age of 5. Thomas is homeschooled and is very attached to his mother. His parents have very different parenting styles, with his mother being more permissive and his father more authoritarian. At the time of initial diagnosis, the behavioral health services (BHS) in Thomas' community, which is about an hour away from the DBP, were limited to older children, and he was followed by a DBP for ADHD medication management. At the age of 11, he expressed passive suicidal ideation and described that he imagined his mother as "the devil with fire coming out of her eyes" when she corrected him. He was evaluated by BHS, diagnosed with anxiety disorder, and started on Lexapro. BHS linked to the DBP were out of network for his insurance. The family was unable to pay out of pocket, so care was subsequently transferred to a DBP clinic that was in network. Soon after, Thomas developed auditory hallucinations, and Abilify was added after consultation with BHS.Over the last few years, Thomas' symptoms have waxed and waned. He did well for a short time and then again developed auditory hallucinations, worsening symptoms of anxiety and depression, and increasing somatic symptoms including vomiting and penile pain. Medications were adjusted with input from BHS, and further attempts were made to link him to local BHS but were unsuccessful. With his current concerns of suicidal ideation and self-mutilation, what would be your next steps?

"Less stress": a pilot study on a cognitive behavioral treatment program for anxiety in children with autism spectrum disorders

Background:

Comorbid anxiety disorders are prevalent in children with autism spectrum disorders (ASD), but only a minority receives adequate treatment for anxiety. Cognitive behavioral therapy (CBT) has been shown to be effective in treating anxiety disorders. The objectives of the present pilot study were to test the feasibility of the CBT program “Less stress” for comorbid anxiety disorders in children with ASD and explore whether an improvement in diagnostic outcomes for anxiety disorders and symptoms of anxiety was found after treatment.

Methods:

Participants were ten children diagnosed with ASD and anxiety disorders (eight boys, mean age = 9.5 years, range 8 - 12 years). The “Less Stress” program includes three months of weekly treatment sessions followed by three monthly booster sessions. Five therapists participated. A standardized semi-structured diagnostic interview with the mothers was used to assess comorbid disorders. Child anxiety symptoms were measured with the Revised Child Anxiety and Depression Scale (RCADS).

Results:

The therapists found the manual easy to use but adaptations were necessary, particularly shorter sessions due to frequent (n = 7) comorbid Attention-Deficit/Hyperactivity Disorder. The participants found the program useful and the parents noted that they had learned methods they could continue using after the end of the program.

Eight of ten children completed the treatment. Seven of the eight completers benefited from the program. Five of those seven children were free from all anxiety disorders, while two had fewer anxiety disorders. On a group level, a significant mean reduction of anxiety symptoms (RCADS) was found after treatment.

Conclusion:

The therapists found the “Less stress” program to be a feasible intervention in a sample of children with ASD and comorbid anxiety. The significant reduction of anxiety after treatment is promising, but a replication in a larger and more rigorous study is needed to investigate the effectiveness of the intervention.

Role of anxiety, depression and neurocognition for cognitive behavioural therapy pre-therapy skills in people living with dementia, older and younger adults✰

BACKGROUND

Anxiety and depression are common in people living with dementia (PLWD) and Cognitive behavioural therapy (CBT) seems to be one of the few efficacious interventions. However, PLWD's ability to engage with CBT has been questioned due to the presumed impact of neurocognitive impairment on core skills necessary to engage with CBT (pre-therapy skills). Here, we (i) compare CBT pre-therapy skills in PLWD to older and younger adults (OA, YA), (ii) examine potential confounders and mediators and (iii) explore associations of neurocognition, anxiety and depression with pre-therapy skills in PLWD.

METHODS

Pre-therapy skills were compared between PLWD (n = 102), OA (n = 77) and YA (n = 56). Structural equation modelling was used to assess mediators and confounders of differences in pre-therapy skills between groups. Spearman's rank correlations were used to examine the relationship of pre-therapy skills with neurocognition and mood in PLWD.

RESULTS

Group differences in pre-therapy skills were found, following the pattern YA>OA>PLWD. Neurocognition mediated the difference between OA and PLWD. In PLWD, language was associated with performance on all skills. There was little evidence that anxiety or depression contributed to variability in skill performance within PLWD.

LIMITATIONS

Cross-sectional design limited ability to ascertain cause and effect. Pre-therapy skill measures have not been used in the context of actual CBT; consequently, their relationship with CBT outcomes needs to be established.

CONCLUSIONS

PLWD may have a relative difficulty in CBT pre-therapy skills. Yet, there seems to be substantial variability of skill level, independent of mood. Therefore, mild dementia does not necessarily preclude CBT readiness.

Development of the Macquarie Anxiety Behavioural Scale (MABS): A parent measure to assess anxiety in children and adolescents including young people with autism spectrum disorder

OBJECTIVE

This study examined measurement variance for Autism Spectrum Disorder (ASD) in the Spence Children's Anxiety Scale - Parent Form (SCAS-P; Spence, 1999). In addition, we developed and evaluated a new parent report measure for anxiety (Macquarie Anxiety Behavioural Scale; MABS).

METHOD

The sample consisted of 734 parents of children aged 3-19 years (i) who were seeking help for their child's anxiety, (ii) who had received a diagnosis of ASD, or (iii) from the community.

RESULTS

Evidence for measurement variance of the SCAS-P and MABS was found, revealing different factor structures between the ASD and non-ASD groups. MIMIC modelling showed that the scales performed significantly different across ASD and non-ASD groups. Differential item functioning on a number of the SCAS-P and MABS items was also found.

LIMITATIONS

This study relied on parent report of symptoms and of community acquired diagnoses of ASD.

CONCLUSION

The MABS is a new parent measure to assess anxiety in children and adolescents and the proposed factor structure produced a reasonably good fit for the data. Similar to the SCAS-P, ASD was found to impact on some of the MABS items indicating that ASD influences parental responding. Eighteen MABS items showed measurement invariance across the anxious and ASD groups and can be considered suitable items for the assessment of anxiety in ASD.

Identification, Evaluation, and Management of Children With Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder with reported prevalence in the United States of 1 in 59 children (approximately 1.7%). Core deficits are identified in 2 domains: social communication/interaction and restrictive, repetitive patterns of behavior. Children and youth with ASD have service needs in behavioral, educational, health, leisure, family support, and other areas. Standardized screening for ASD at 18 and 24 months of age with ongoing developmental surveillance continues to be recommended in primary care (although it may be performed in other settings), because ASD is common, can be diagnosed as young as 18 months of age, and has evidenced-based interventions that may improve function. More accurate and culturally sensitive screening approaches are needed. Primary care providers should be familiar with the diagnostic criteria for ASD, appropriate etiologic evaluation, and co-occurring medical and behavioral conditions (such as disorders of sleep and feeding, gastrointestinal tract symptoms, obesity, seizures, attention-deficit/hyperactivity disorder, anxiety, and wandering) that affect the child's function and quality of life. There is an increasing evidence base to support behavioral and other interventions to address specific skills and symptoms. Shared decision making calls for collaboration with families in evaluation and choice of interventions.  This single clinical report updates the 2007 American Academy of Pediatrics clinical reports on the evaluation and treatment of ASD in one publication with an online table of contents and section view available through the American Academy of Pediatrics Gateway to help the reader identify topic areas within the report.

Thought-feeling discrimination in people with dementia: adaptation and preliminary validation of the first dementia-specific measure

OBJECTIVE

There is emerging evidence that cognitive behavioral therapy (CBT) can be effective for treating anxiety and depression in people living with dementia (PLWD). Discriminating between thoughts and feelings is a critical element of CBT and also of relevance to emotional understanding more generally. The aim of the present study was the structured adaptation and preliminary validation of an existing measure of thought-feeling discrimination for use in PLWD.

METHODS/DESIGN

The Behavior Thought Feeling Questionnaire (BTFQ) was adapted via expert and service-user consultation for use in PLWD. One hundred two PLWD and 77 people aged over 65 years who did not have measurable cognitive impairments completed the adapted measure along with two measures of emotional recognition and reasoning. The factor structure of this measure was examined and the measure reduced.

RESULTS

Factor analysis suggested a two-factor solution with thought and feeling items loading on separate factors. The behavior items were not included in scoring due to high cross-loading and ceiling effects, leaving a 14-item measure with two subscales. Thus, an adapted measure was created (named the BTFQ-D), which showed moderate convergent validity in the PLWD but not the older adult sample. Both thought and feeling subscales showed good internal consistency.

CONCLUSIONS

The BTFQ-D showed preliminary validity as a measure of thought-feeling discrimination in PLWD. It may have utility in measuring readiness for CBT as part of clinical assessment. Further validation is required.

Feeding difficulties in children with autism spectrum disorder: Aetiology, health impacts and psychotherapeutic interventions

Feeding difficulties are common and significant issues for children with autism spectrum disorder and their families. Key features of autism are intrinsically linked with factors contributing to these children's feeding difficulties. Following a multidisciplinary assessment to exclude non-behavioural reasons for the feeding difficulty, there are two mainstay modalities of treatment: operant conditioning and systematic desensitisation. Currently, evidence points towards operant conditioning as the most efficacious psychotherapy. However, recent research into cognitive behavioural therapy for older children with feeding difficulties has shown promising results and will be an area to monitor in the coming years. This review outlines the causes and health impacts and evaluates current evidence supporting the available psychotherapeutic interventions for children with autism spectrum disorder experiencing feeding difficulties.

Improving emotion regulation ability in autism: The Emotional Awareness and Skills Enhancement (EASE) program

Emotion regulation impairments are common among individuals with autism spectrum disorder and are believed to often underlie commonly seen problems with aggression, depression, and anxiety. The Emotional Awareness and Skills Enhancement program was developed to reduce emotion regulation impairment and thereby improve behavioral disturbance, via mindfulness. Emotional Awareness and Skills Enhancement consists of a 16-week individual therapy treatment targeting emotion regulation impairments among individuals with autism spectrum disorder. We describe the conceptual framework and development of the program and present data on feasibility and preliminary efficacy from a pilot trial. The Emotional Awareness and Skills Enhancement manual was developed using a participatory action framework, based on emotion regulation research specific to autism spectrum disorder and input from individuals with autism spectrum disorder, therapists, and parents of children with autism spectrum disorder. Emotional Awareness and Skills Enhancement was piloted in a two-site open trial with 20 participants with autism spectrum disorder (12-17 years old, confirmed autism spectrum disorder diagnosis, IQ > 80).Outcome data support program feasibility and acceptability to participants, as well as significant improvement in emotion regulation impairments and related concerns.Findings offer preliminary support for both the feasibility and clinical effectiveness of the Emotional Awareness and Skills Enhancement program.

Novel four-session treatment intervention for anxiety and high-functioning autism: A single case report for Externalizing Metaphors Therapy

TOPIC

The Brief Services psychotherapy paradigm has evolved to produce cost-effective and clinically significant outcomes in children's mental health. Though its clinical evaluation is still in its infancy, it has been utilized to a much lesser degree with autism spectrum disorders, which typically require a longer-term approach to psychotherapy treatment.

PURPOSE

The current paper introduces a novel, four-session intervention that aims to decrease anxiety experienced by clients presenting with high-functioning autism. Externalizing Metaphors Therapy is based upon the externalization of problems, transformation of metaphoric imagery, shifting of maladaptive emotional schemas, and the generalization of problems. A case study is utilized to visually aid in the understanding of this new treatment intervention.

SOURCE

A composite literature review was conducted with regards to significant works in Narrative Therapy, treatment interventions for anxiety and high functioning autism, evidence-based treatments for anxiety, and practice based approaches in psychotherapy. Works were selected based on their relevance to the research filed of anxiety and autism.

CONCLUSIONS

This clinical research challenges the children's mental health field in addressing anxiety and high-functioning autism from a brief framework. Further clinical research is needed to clinically evaluate the current model.

Rationale and design for cognitive behavioral therapy for anxiety disorders in children with autism spectrum disorder: a study protocol of a randomized controlled trial

Background

Autism spectrum disorder (ASD) is found in approximately 1% of the population and includes core symptoms that affect general and social development. Beside these core symptoms, it is suggested that up to 60% of children with ASD suffer from comorbid anxiety disorders which may further affect educational, social and general development as well as quality of life. The main goal of this study is to examine the effectiveness of a manualized cognitive behavioral therapy (CBT) anxiety program adapted for children with ASD.

Methods

This study is a randomized controlled trial (RCT). Fifty children with ASD and anxiety, aged 7 to 13 years, will be randomly assigned to group CBT or a wait-list control (WL) condition. The design will follow a two (CBT and WL) by two (pre–post assessment) mixed between–within design. The control group will receive intervention after the waitlist period of 13 weeks. Primary outcomes are diagnostic status and severity of the anxiety disorders, measured with The Anxiety Disorder Interview Schedule for DSM-IV, Parent and Child Versions. Secondary outcomes are parent and child ratings on questionnaires on the child’s level of anxiety and impact on everyday life. Additional outcomes entail information gathered from parents, child and teachers on the child’s behavior and negative self-statements, together with social and adaptive skills. Follow-up data will be collected 3 months after intervention.

Discussion

This study aims to evaluate the effectiveness of a manualized CBT program in Danish children with ASD and anxiety within a mental health clinic setting. The hypothesis is that training anxiety reduction skills will decrease anxiety in children, as well as ensure better psychosocial development for the child in general.

Trial registration

https://ClinicalTrials.gov (NCT02908321). Registered 19th of September 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2591-x) contains supplementary material, which is available to authorized users.

Comorbid autism spectrum disorder and anxiety disorders: a brief review

Appearing in 40% of the cases of autism spectrum disorder (ASD), comorbid anxiety presents unique challenges for practitioners by amplifying problem behaviors such as social skills deficits, resistance to change and repetitive behaviors. Furthermore, comorbid ASD/anxiety strains familial relationships and increases parental stress. Research indicates that the neurobiological interactions between anxiety and ASD require comprehensive assessment approaches, modified cognitive behavioral therapy and carefully managed pharmacological interventions. Meta-analyses indicate that cognitive behavioral therapy with exposure is an effective treatment option when adequately accounting for social, familial and cognitive variables. The purpose of this focused review is to update readers on the latest research advances in comorbid ASD and anxiety, including prevalence, assessment, psychosocial and pharmacological treatment.

Emotion awareness and cognitive behavioural therapy in young people with autism spectrum disorder

Young people with autism spectrum disorder experience high levels of emotional problems, including anxiety and depression. Adapted cognitive behavioural therapy is recommended for such difficulties. However, no evidence suggests whether emotion awareness is important in treatment outcome for young people on the autism spectrum. This study aimed to investigate the potential differences in emotion awareness between (1) young people on the autism spectrum and typically developing youth and (2) young people on the autism spectrum with and without experience of cognitive behavioural therapy. Three groups (aged 11-20 years) participated: (1) typically developing young people ( n = 56); (2) young people on the autism spectrum with no experience of cognitive behavioural therapy ( n = 23); and (3) young people on the autism spectrum who had attended cognitive behavioural therapy ( n = 33). All participants completed the Emotion Awareness Questionnaire-30 item version. Young people on the autism spectrum differed significantly from typically developing young people on the emotional awareness measure. Young people on the autism spectrum who had attended cognitive behavioural therapy scored significantly lower on the Differentiating Emotions subscale, and significantly higher on the Attending to Others' Emotions subscale, compared to young people on the autism spectrum who had not attended cognitive behavioural therapy. This study highlights the importance of psycho-educational components of cognitive behavioural therapy when adapting for young people on the autism spectrum.

Insights into the Feelings, Thoughts, and Behaviors of Children with Visual Impairments: A Focus Group Study Prior to Adapting a Cognitive Behavior Therapy–Based Anxiety Intervention

Introduction

Anxiety is the most common psychological problem reported among children with visual impairments. Although cognitive behavior therapy interventions have proven successful in treating childhood anxiety, it is unclear whether they are suitable and accessible for children who have visual impairments. This study aimed to determine if and how traditional cognitive behavior therapy–based interventions could be adapted for use with this specific population by interviewing children with visual impairments themselves.

Methods

A qualitative research design was used. Sixteen children with visual impairments (aged 9 to 13 years) participated in two focus group interviews. Participants attended two special schools in the Western Cape, South Africa. Interviews were audio-recorded and transcribed verbatim, and content analysis was undertaken.

Results

Three primary themes emerged from the focus group data: (1) difficulties encountered by children with visual impairments; (2) existing coping strategies; and (3) insight into the concepts of feelings, thoughts and behaviors (central to cognitive behavior therapy).

Discussion

The emergent themes and their implications for the adaptation of a cognitive behavior therapy–based anxiety intervention are discussed.

Implications for practitioners

Results provide practitioners with guidelines to consider when using or adapting therapeutic techniques such as cognitive behavior therapy for children with visual impairments.

Cognitive-Behavioral Therapy for a 9-Year-Old Girl With Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder (DMDD) is a relatively new diagnosis in the field of childhood onset disorders. Characterized by both behavior and mood disruption, DMDD is a purportedly unique clinical presentation with few relevant treatment studies to date. The current case study presents the application of cognitive-behavioral therapy (CBT) for anger and aggression in a 9-year-old girl with DMDD, co-occurring attention deficit hyperactivity disorder (ADHD), and a history of unspecified anxiety disorder. At the time of intake evaluation, she demonstrated three to four temper outbursts and two to three episodes of aggressive behavior per week, in addition to prolonged displays of non-episodic irritability lasting hours or days at a time. A total of 12 CBT sessions were conducted over 12 weeks and 5 follow-up booster sessions were completed over a subsequent 3-month period. Irritability-related material was specially designed to target the DMDD clinical presentation. Post-treatment and 3-month follow-up assessments, including independent evaluation, demonstrated significant decreases in the target symptoms of anger, aggression, and irritability. Although the complexities of diagnosing and treating DMDD warrant extensive research inquiry, the current case study suggests CBT for anger and aggression as a viable treatment for affected youth.

Assessment and Treatment of Anxiety in Youth With Autism Spectrum Disorders

OBJECTIVES

Anxiety is one of the most prevalent co-occurring symptoms in youth with autism spectrum disorder (ASD). The assessment and treatment recommendations proposed here are intended to help primary care providers with the assessment and treatment of anxiety in ASD.

METHODS

The Autism Speaks Autism Treatment Network/Autism Intervention Research on Physical Health Anxiety Workgroup, a multidisciplinary team of clinicians and researchers with expertise in ASD, developed the clinical recommendations. The recommendations were based on available scientific evidence regarding anxiety treatments, both in youth with ASD and typically developing youth, and clinical consensus of the workgroup where data were lacking.

RESULTS

Assessment of anxiety requires a systematic approach to evaluating symptoms and potential contributing factors across various developmental levels. Treatment recommendations include psychoeducation, coordination of care, and modified cognitive-behavioral therapy, particularly for children and adolescents with high-functioning ASD. Due to the limited evidence base in ASD, medications for anxiety should be prescribed cautiously with close monitoring of potential benefits and side effects.

CONCLUSIONS

Assessment and treatment of clinical anxiety in youth with ASD require a standardized approach to improve outcomes for youth with ASD. Although this approach provides a framework for clinicians, clinical judgment is recommended when making decisions about individual patients.

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.

Evidence-Based Practice in the Face of Complexity and Comorbidity: A Case Study of an Adolescent With Asperger's Syndrome, Anxiety, Depression, and Chronic Pain

PROBLEM

Working with clients who present with multiple conditions and comorbidities, including mental health difficulties, neurodevelopmental disorders, and physical health conditions, requires the therapist to go beyond the existing evidence base to make decisions about which specific cognitive behavior therapy (CBT) models and resultant treatment approaches to draw on in therapy. Routine outcome monitoring across a number of parameters, including goal progress, symptom improvement, and changes in functioning, are core to maintaining accountability through monitoring the ongoing impact of idiosyncratic interventions.

METHOD

The case of a young person (age 17 years) who presented with mixed anxiety and depression in the context of autism spectrum disorder (ASD) and chronic pain are presented. In addition to evidence-based adaptations to CBT for clients with ASDs, the therapist selected a cognitive model of low self-esteem as a means of collaboratively conceptualizing the client's difficulties.

FINDINGS AND CONCLUSION

Routine outcome measurement demonstrated the effectiveness of the intervention.

Impact of cognitive behavioral therapy on observed autism symptom severity during school recess: a preliminary randomized, controlled trial

This study compared cognitive behavioral therapy (CBT) and treatment-as-usual (TAU) in terms of effects on observed social communication-related autism symptom severity during unstructured play time at school for children with autism spectrum disorders (ASD). Thirteen children with ASD (7-11 years old) were randomly assigned to 32 sessions of CBT or community-based psychosocial treatment (TAU) for 16 weeks. The CBT program is based on the memory retrieval competition model and emphasizes the development of perspective-taking through guided behavioral experimentation supplemented with reflective Socratic discussion and supported by parent training and school consultation to promote generalization of social communication and emotion regulation skills. Trained observers blind to treatment condition observed each child during recess on two separate days at baseline and again at posttreatment, using a structured behavioral observation system that generates frequency scores for observed social communication-related autism symptoms. CBT outperformed TAU at posttreatment on the frequency of self-isolation, the proportion of time spent with peers, the frequency of positive or appropriate interaction with peers, and the frequency of positive or appropriate peer responses to the target child (d effect size range 1.34-1.62). On average, children in CBT were engaged in positive or appropriate social interaction with peers in 68.6% of observed intervals at posttreatment, compared to 25% of intervals for children in TAU. Further investigation of this intervention modality with larger samples and follow-up assessments is warranted.

Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASD

We examined the efficacy of cognitive behavioural therapy (CBT) delivered in groups on the reduction of symptoms of depression, anxiety and stress in young people on the autism spectrum. Utilising a quasi-experimental design, comparisons were made between individuals allocated to a group intervention program and individuals allocated to a waitlist. Following the intervention program, participants who were initially symptomatic reported significantly lower depression and stress scores on the Depression Anxiety Stress Scales in comparison to individuals on the waitlist. There was no significant change in anxiety related symptoms. The benefits were maintained at 3 and 9 month follow-up. Our findings demonstrate the potential of CBT in a small group setting for assisting young people with ASD who have symptoms of depression and stress.

Brief report: The use of self-report measures in young people with autism spectrum disorder to access symptoms of anxiety, depression and negative thoughts

The aims of this study were two-fold; firstly, to investigate whether self-report measures are useful and reflect parent-reported psychiatric symptoms in children with autism spectrum disorder (ASD), and secondly, to investigate whether children with ASD are able to access and report their cognitions, a prerequisite skill for cognitive behavior therapies. Thirty children with ASD and 21 comparison children without ASD completed the Spence Children's Anxiety Scale and the Children's Depression Inventory, with parents completing the parent version of both questionnaires. Intraclass correlations revealed that there was good agreement between ASD children and their parents on both measures, but only on the depression measure in non-ASD children. The children in both groups also completed the Children's Automatic Thoughts Questionnaires; multiple regression analyses indicated that within the ASD group, child-rated scores on the CATS questionnaire were positively related to increased self-reported symptoms of anxiety and depression, but not in the comparison group, suggesting that children with ASD are able to accurately report their anxious and depressed cognitions. The implications of these results for both the practice and theory of CBT for children with ASD are discussed.

Effects of Verbal Ability and Severity of Autism on Anxiety in Adolescents With ASD: One-Year Follow-Up After Cognitive Behavioral Therapy

There is evidence supporting the efficacy of cognitive-behavioral therapy for treatment of anxiety in youth with Autism Spectrum Disorders (ASD), but long-term course of anxiety after treatment and individual predictors of treatment response are unknown. To meet the demands for personalized mental health care, information on the fit between patient and treatment as well as treatment durability is needed. We evaluated change in anxiety symptoms during intervention and 1 year after completion of the treatment, and evaluated predictors of response using an advanced analytical design, with follow-up data from a randomized controlled trial of 22 adolescents (12-17 years) with ASD and 1 or more anxiety disorders. Reduction in anxiety was partially maintained during the year following treatment; greater ASD severity predicted better treatment response. Our finding that brief treatment is associated with sustained gains is promising, given the pervasive and chronic nature of ASD. Implications for the treatment of anxiety in higher functioning adolescents with ASD are considered.

Future directions for research in autism spectrum disorders

This article suggests future directions for research aimed at improving our understanding of the etiology and pathophysiology of autism spectrum disorder (ASD) as well as pharmacologic and psychosocial interventions for ASD across the lifespan. The past few years have witnessed unprecedented transformations in the understanding of ASD neurobiology, genetics, early identification, and early intervention. However, recent increases in ASD prevalence estimates highlight the urgent need for continued efforts to translate novel ASD discoveries into effective interventions for all individuals with ASD. In this article we highlight promising areas for ongoing and new research expected to quicken the pace of scientific discovery and ultimately the translation of research findings into accessible and empirically supported interventions for those with ASD. We highlight emerging research in the following domains as particularly promising and pressing: (a) preclinical models, (b) experimental therapeutics, (c) early identification and intervention, (d) psychiatric comorbidities and the Research Domain Criteria initiative, (e) ecological momentary assessment, (f) neurotechnologies, and (g) the needs of adults with ASD. Increased research emphasis in these areas has the potential to hasten the translation of knowledge on the etiological mechanisms of ASD to psychosocial and biological interventions to reduce the burden of ASD on affected individuals and their families.

Emotion Regulation: Concepts & Practice in Autism Spectrum Disorder

The purpose of this article is to describe emotion regulation, and how emotion regulation may be compromised in patients with autism spectrum disorder (ASD). This information may be useful for clinicians working with children with ASD who exhibit behavioral problems. Suggestions for practice are provided.