Training clinicians to deliver group CBT to manage anxiety in youth with ASD: Results of a multisite trial

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.

Effects of Training in Cognitive Behavioural Therapy and Motivational Interviewing on Mental Health Practitioner Behaviour: A Systematic Review and Meta-Analysis

Effective training of mental health professionals is crucial for bridging the gap between research and practice when delivering cognitive behavioural therapy (CBT) and motivational interviewing (MI) within community settings. However, previous research has provided inconclusive evidence regarding the impact of training efforts. The current study aimed to systematically search, review and synthesize the literature on CBT and MI training to assess its effect on practitioner behavioural outcomes. Following prospective registration, a literature search was conducted for studies where mental health practitioners were exposed to training in face-to-face CBT or MI, reporting on at least one quantitative practitioner behavioural outcome. A total of 116 studies were eligible for the systematic review, and 20 studies were included in four meta-analyses. The systematic review highlights the need to establish psychometrically valid outcome measures for practitioner behaviour. Results of the meta-analyses suggest that training has a greater effect on practitioner behaviour change compared to receiving no training or reading a treatment manual. Training combined with consultation/supervision was found to be more effective than training alone, and no differences were found between face-to-face and online training. Results should be interpreted with caution due to methodological limitations in the primary studies, large heterogeneity, and small samples in the meta-analyses. Future directions are discussed.

A cluster randomized controlled trial comparing the effectiveness of two school-based interventions for autistic youth with anxiety

BACKGROUND

Recent systematic reviews have indicated that cognitive behavioral therapy (CBT) is effective in reducing anxiety symptoms for autistic and non-autistic children. However, the vast majority of CBT research for autistic youth has been implemented within university settings and primarily by mental health providers. Schools hold great promise to equitably manage the mental health symptoms of autistic youth. Although preliminary research evaluating CBT within schools has been promising, CBT has not yet been compared to another readily available school mental health program. The goal of this protocol paper is to describe a multi-site study comparing two school-based interventions, Facing Your Fears-School Based (FYF-SB) and Zones of Regulation (ZOR) via a cluster randomized controlled type 1 hybrid effectiveness-implementation trial to determine which of the two interventions will best support autistic youth with anxiety in schools.

METHODS

Up to 100 elementary and middle schools will be randomized into FYF-SB or ZOR. Once schools are randomized, a minimum of two interdisciplinary school providers at each school will be trained to deliver either FYF-SB or ZOR over the course of 12 weeks to groups of 2-5 autistic students ages 8-14 years. Over the course of two years, a total of 200 autistic students will receive either ZOR or FYF-SB. The primary outcome of this trial is child anxiety, as rated by masked evaluators and via caregiver- and student-report, which will be measured at baseline, post-treatment, and 6-month follow-up. Semi-structured interviews will also be conducted with a purposive sample of students, caregivers, and school providers to understand the acceptability, appropriateness, and feasibility of either ZOR or FYF-SB. Stakeholder engagement is a central component of this project via two stakeholder advisory boards that will directly inform and oversee the project.

DISCUSSION

Results of this study will provide evidence about the relative impact of two school-based mental health interventions on outcomes reported as meaningful by caregivers and school providers. The additional focus on evaluating factors that support the implementation of FYF-SB and ZOR will allow future studies to test targeted implementation strategies that support mental health programming uptake and implementation within public schools.

TRIAL REGISTRATION

This trial is registered with clinicaltrials.gov (NCT05863520).

Promoting Quality of Life: Suggestions for Mental Health Care Providers Working with Young Autistic Adults

There is a growing population of autistic adults in need of supports from a service delivery system that, at present, fails to accommodate their needs adequately and equitably. Unfortunately, there is a shortage of trained behavioral health service providers to meet the needs of young autistic adults. Quality of life (QoL), or one's perception of, and satisfaction with, life in relation to held goals and expectations, has been identified as a key outcome of interest by autistic self-advocates. By supporting autistic clients to hone their strengths and interests, integrate various aspects of their identity, identify goals, and connect to appropriate resources, providers can promote clients' self-knowledge and self-determination, in the service of improving QoL. In this Perspectives article, we offer concrete recommendations to mental health providers, including those who do not specialize in autism, with the goal of supporting implementation of evidence-based strategies that improve QoL and promote self-determination among young autistic clients.

The Role of Maternal Anxiety in Treatment Response for Youth with ASD and Co-occurring Anxiety

Anxiety disorders occur at higher rates in youth with ASD than in neurotypical youth. Although the efficacy of CBT for anxiety in children with ASD is widely supported, factors that influence treatment outcomes are not well understood. This study examined the role of maternal anxiety in treatment outcomes for youth with ASD. Youth with ASD and anxiety (ages 8 to 14), along with their mothers (n = 87), participated in a group CBT intervention. Results indicated that maternal anxiety did not improve over the course of treatment. However, findings suggest that high levels of maternal anxiety at pre-treatment predicted higher levels of youth anxiety post-treatment. Importantly, the relationship between parent anxiety and youth outcomes was moderated by child age. The findings of the present study may provide initial insight into the role that maternal anxiety plays in treatment outcomes for children with ASD and co-occurring anxiety, particularly when considering child age.

Longitudinal follow-up of subsequent psychiatric comorbidities among children and adolescents with autism spectrum disorder

BACKGROUND

The mental health of children and adolescents with autism spectrum disorder (ASD) is a concern of recent years. However, a large-scale longitudinal study investigating the risk and the time course of subsequent psychiatric comorbidities is still lacking.

METHODS

Using the Taiwan National Health Insurance Research Database, 13,382 children and adolescents with ASD, and 53,528 age- and sex-matched non-ASD controls were enrolled between 2001 and 2009, and followed to the end of 2011. The adjusted hazard ratio (HR) with a corresponding 95 % confidence interval for psychiatric comorbidities among children and adolescents with ASD vs matched controls was estimated. The subjects who developed schizophrenia, bipolar disorder, depressive disorder, anxiety disorder, and obsessive-compulsive disorder (OCD) were identified during the follow-up.

RESULTS

Children and adolescents with ASD compared with controls were more likely to be diagnosed with schizophrenia (19.21; 13.74, 26.88), bipolar disorder (17.59; 12.66, 24.44), depressive disorder (5.56; 4.72, 6.56), anxiety disorder (5.01; 4.49, 5.59), and OCD (16.12; 11.66, 22.30) later in life. The time course of subsequent psychiatric comorbidity showed that anxiety disorder occurred first, usually in late childhood, with psychotic and affective disorders proceeding in adolescence. Those with ASD and anxiety disorder had an additionally increased likelihood of developing subsequent psychiatric comorbidity compared with those with ASD only.

LIMITATION

In claims data analysis, clinical parameters or possible confounders may not be fully captured.

CONCLUSION

Patients with ASD are predisposed to the development of anxiety disorder in late childhood, as well as schizophrenia, bipolar disorder, depressive disorder, and OCD in adolescence.

Effect of Co-occurring Psychiatric Disorders on Treatment of Children with Autism Spectrum Disorder and Anxiety

Co-occurring psychiatric diagnoses are very common in individuals with ASD. Little is known about the effect that co-occurring psychiatric conditions may have on treatment response to CBT for children with ASD and anxiety. The present study examined the relationship between co-occurring psychiatric diagnoses and response to CBT for anxiety in ninety youth with ASD. Psychiatric complexity did not appear to differentially impact treatment response. A notable portion of youth with anxiety and externalizing disorders such as ADHD, no longer met criteria for those externalizing diagnoses following intervention. Results indicate that youth with ASD and anxiety present with complex psychiatric profiles and CBT for anxiety may positively affect co-occurring diagnoses. In addition, thorough and nuanced assessment of psychiatric symptoms in youth with ASD is needed to ensure the differentiation between diagnoses of anxiety and other co-occurring psychiatric symptoms.

Predictors of expert providers' familiarity with intervention practices for school- and transition-age youth with autism spectrum disorder

LAY ABSTRACT

School-age children, adolescents, and young adults with autism spectrum disorder encounter many different types of providers in their pursuit of treatment for anxiety, behavior problems, and social difficulties. These providers may all be familiar with different types of intervention practices. However, research has not yet investigated patterns in expert providers' familiarity with different practices nor how these patterns are related to the characteristics of providers (years in practice, academic discipline, setting) and the youth (age and intellectual disability) they typically support. A panel of 53 expert transdisciplinary providers rated their familiarity with 55 intervention practices (derived from research and expert nominations) via an online Delphi poll. Advanced statistical methods were used to identify types of intervention practices with which providers were familiar, which included two approaches (cognitive and behavioral) and two strategies (engagement and accessibility). Providers who practiced outside a school setting or treated clients without intellectual disability were more familiar with cognitive approaches. Clinical psychologists, behavior analysts, and school-based providers were more familiar with behavioral approaches. Providers practicing outside school settings were also more familiar with engagement strategies, and providers with more years in practice were more familiar with accessibility strategies. These results may help families and researchers to better anticipate how services may vary depending on the types of autism spectrum disorder providers seen and work to reduce disparities in care that may result.

Interventions for Sensory Over-Responsivity in Individuals with Autism Spectrum Disorder: A Narrative Review

Individuals with autism spectrum disorder (ASD) often exhibit sensory over-responsivity (SOR), which is characterized by an overwhelmingly negative reaction to or avoidance of sensory stimulation. Despite the detrimental effects of SOR on people’s personal and social lives, the knowledge of and interventions for the issue remain limited. This paper collates and reviews studies on SOR and information on the potential for effective interventions for people with ASD. This review reveals evidence that SOR has a close relationship with anxiety, depression, insomnia, and family life impairment and an underlying mechanism related to SOR. Four interventions and their theoretical bases in sensory-motor processing are discussed in this paper, namely, physical activity (PA), sensory integration therapy (SIT), mindfulness-based cognitive therapy (MBCT), and cognitive behavioral therapy (CBT). These interventions focus on establishing coping strategies for regulating the emotional response to sensory information, and they have been found to be effective and to have the potential to help children with ASD reduce their SOR behaviors. This paper provides guidance for selecting appropriate interventions and for further investigation of more effective interventions in the future.

Mental health Project ECHO Autism: Increasing access to community mental health services for autistic individuals

LAY ABSTRACT

Although many autistic individuals have additional mental health conditions, most have a hard time getting services from mental health providers. One reason why these services can be hard to access is that many mental health providers do not feel confident in their ability to provide services to autistic individuals. To share autism expertise with local community providers and boost their confidence in working with autistic individuals, we created a mental health version of the Extension for Community Healthcare Outcomes (Project ECHO) Autism virtual teleconsultation program. In this pilot study, we recruited 51 community mental health providers to participate in Project ECHO Autism. During each biweekly session, providers received information from autism experts about how to tailor mental health interventions (e.g. attention-deficit hyperactivity disorder or anxiety interventions) for use with autistic individuals. They also had the opportunity to ask questions and get advice on their current cases. At the end of the 6-month study, mental health providers showed improvements in their confidence, in their knowledge of autism, and in their problem-solving skills. Nearly half (45%) of these providers participated from rural counties, suggesting that the Project ECHO Autism teleconsultation model was able to reach mental health providers who might not have been able to get training otherwise. This study supports the feasibility of using Project ECHO Autism to share autism knowledge with mental health providers, consequently expanding mental health service options for autistic individuals with co-occurring mental health conditions.

From Clinic to Classroom: Two Case Studies of Youth With ASD and Anxiety From the School-Based Facing Your Fears Program

Cognitive behavioral therapy (CBT) is considered best practice for treating anxiety in youth with autism spectrum disorder (ASD) in clinic settings. However, there is significant need to translate CBT into school settings. This paper presents two case illustrations of students who participated in the Facing Your Fears: School-Based program (FYF-SB), a manualized, group CBT intervention for anxiety in ASD, adapted for delivery in schools by interdisciplinary school providers. Students showed improvement in anxiety across multiple domains following intervention, according to clinical interview and parent- and self-report. These outcomes suggest that anxious youth with ASD can benefit from CBT delivered by interdisciplinary school providers. Importantly, decreases in anxiety symptoms were evident in domains that were not explicitly targeted during intervention. Overall, these case illustrations help frame areas of future research, including examining how treatment gains may generalize across anxiety domains as well as whether corresponding improvement in school functioning occurs.

DINOSAUR: an integrated cognitive-behavioral treatment for anxiety in young children with ASD

Background

Anxiety disorders are highly prevalent in children and adolescents with autism spectrum disorder and often emerge before the age of 6 years. Yet, only a few studies have examined anxiety treatment for this group. Preliminary evidence from these studies suggests that utilizing cognitive behavioral therapy (CBT) as well as strategies to target intolerance of uncertainty (IU) and parental accommodation, known mechanistic and maintaining factors of anxiety may improve anxiety and optimize outcomes in this age group.

Main body

To meet this need, we developed an integrated treatment called DINO Strategies for Anxiety and intolerance of Uncertainty Reduction (DINOSAUR), a 12-week group telehealth treatment for 4- to 6-year-old children with ASD. DINOSAUR works with young children and their parents to deliver CBT along with interventions targeting IU and parental accommodation. In this paper, we first discuss the rationale for developing this treatment and then describe a pilot study of its feasibility and preliminary efficacy.

Conclusions

There is a great need to develop anxiety treatments for young children with ASD. We proposed a novel integrated treatment approach that aims to alter the way young children and parents respond to fear, which could potentially improve short- and long-term mental health outcomes for this age group.

Trial registration

ClinicalTrials.govNCT04432077 on June 03, 2020

A Systematic Review of Mental Health Interventions for ASD: Characterizing Interventions, Intervention Adaptations, and Implementation Outcomes

Youth with autism spectrum disorder (ASD) have high rates of co-occurring mental health needs that necessitate mental health interventions. Given the unique clinical characteristics of youth with ASD, there have been significant efforts to adapt and test mental health interventions for this population. Yet, characterization of the nature and types of interventions adaptations is limited, especially across the wide range of interventions tested for youth with ASD with a focus on implementation factors. Additionally, understanding how these interventions may be implemented in community services is limited. The aims of this systematic review are to characterize the (1) types of interventions tested for co-occurring mental health conditions for youth with ASD; (2) adaptations to mental health interventions for use with youth with ASD; and (3) implementation strategies, outcomes, and determinants of mental health interventions to inform their translation to community service settings. Eighty-three articles testing interventions targeting mental health symptoms in youth with ASD that included implementation factors in analyses were reviewed. The Stirman et al. (2013; 2019) FRAME adaptation, Powell et al. (2012;2015) implementation strategies, and Proctor et al. (2011) implementation outcomes taxonomies were applied to characterize the nature and types of adaptations for use with youth with ASD and types of implementation strategies, outcomes, and determinants used, when available, respectively. Of the interventions examined, the majority (64.1%) were originally designed to target youth mental health concerns and were then adapted to be used with ASD. The most common adaptations included those to the intervention content, particularly adding elements with tailoring or refining aspects of the intervention while maintaining core functions. Half of the articles described at least one implementation strategy used during intervention testing. Fidelity and acceptability were the most frequently examined implementation outcomes, with some examination of appropriateness and feasibility. Nineteen percent of articles described implementation determinants (i.e. barriers/facilitators) of these implementation outcomes. The common adaptations for ASD provide direction for future intervention development and for training community therapists. Further examination, specification, and reporting of implementation strategies and outcomes within ongoing efforts to adapt and interventions to meet the co-occurring mental health needs of youth ASD are needed to facilitate their translation to community settings. Areas for future research as well as clinical implications are discussed.

Correction to: A Systematic Review of Mental Health Interventions for ASD: Characterizing Interventions, Intervention Adaptations, and Implementation Outcomes

Due to the errors occurred in the originally published version, this article is being reprinted in its entirety as Correction. All errors have been corrected. It is the correct version.

"Intolerance of uncertainty" mediates the relationship between social profile and anxiety in both Williams syndrome and autism

Anxiety is the most significant mental health concern for both Williams syndrome (WS) and autism. Whilst WS and autism are characterized by some syndrome-specific social differences, less is known about cross-syndrome profiles of anxiety symptoms. Previous research has shown that Intolerance of Uncertainty (IU) is a core mechanism of anxiety maintenance for clinically anxious populations and for autistic children, adolescents, and adults. The only published study in this area for WS has shown some similar patterns-with an added emphasis on the role of sensory sensitivities-in a sample of older teens and adults (mean age = 24), with the authors highlighting the need for younger samples to consider developmental influences. Here we report a cross-syndrome, cross-sectional mediation analyses of children diagnosed with WS or autism, including data from parent surveys of 90 children with WS (n = 48) or autism (n = 42). Group differences showed higher trait levels on all measures for the autism group. Importantly, the relationship between social profile and anxiety was fully mediated by IU level for both groups. This suggests possible similar core mechanisms underlying anxiety in these conditions, and the possibility of generalized intervention approaches especially related to managing distress related to uncertainty in multiple contexts. LAY SUMMARY: Autism and Williams Syndrome share some similarities in social profile and also in anxiety traits, but there are also some key differences as well. Comparing them side-by-side at the same time improved identification of ways to reduce feelings of anxiety. We found that the intolerance of uncertainty affected the relationship between social profile and anxiety in the same way for young children diagnosed with autism or Williams syndrome, meaning that intervention approaches could be similar for both.

Modular cognitive behavioral therapy for autism-related symptoms in children: A randomized controlled trial

OBJECTIVE

To date, no one-on-one psychotherapy protocol for elementary and middle school-aged children with autism spectrum disorder (ASD) has been found to be efficacious for treating autism-related symptoms such as failure to initiate social interactions. This study compared modular cognitive behavioral therapy (CBT) with enhanced standard community treatment (ESCT) in terms of impact on the severity of autism-related symptoms.

METHOD

Children with ASD (N = 107; aged 6-13 years) were randomly assigned to a treatment condition (CBT or ESCT). Both treatments provided 32 therapy sessions. The CBT condition utilized a modular design, matching specific evidence-based treatment elements to each child's clinical needs (e.g., social-communication symptoms). The ESCT condition provided social skills training and cognitive behavioral training in a structured and linear group therapy format. The primary outcome measure was independent evaluator ratings of peer engagement during school recess using a structured and validated observation system. Parents also made session-by-session ratings on personalized autism-related symptom profiles throughout treatment.

RESULTS

CBT outperformed ESCT on the primary outcome measure (p < .001; d = .50; 95% CI [.06, .93]) and the secondary outcome measure (p = .003; d = .87; 95% CI [.45, 1.27]).

CONCLUSIONS

The modular one-on-one CBT program evaluated in this study may be beneficial for reducing the severity of autism-related symptoms in some children with ASD. Further research is needed to clarify the extent of the treatment effect and the feasibility of implementation for therapists in the community. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Diametrically opposed associations between academic achievement and social anxiety among university students with and without autism spectrum disorder

Research findings indicate that anxiety, social anxiety in particular, is the most common experience reported by individuals with autism spectrum disorder (ASD) attending postsecondary education. Among students without ASD, higher levels of social anxiety have been postulated to correlate with impaired academic achievement; restriction of one's social network because of anxiety is thought to lead to reduction of access to resources important for learning such as social/emotional support and collaborative learning. However, despite growing interest in the outcomes of young students with ASD, no research has studied the associations between academic achievement and anxiety among students with ASD. This study examined the association between social anxiety and grade point average (GPA) among university students: 55 diagnosed with ASD, 31 without ASD but high levels of social anxiety, and 25 without ASD and with low levels of social anxiety (controls). GPAs were significantly lower for the ASD group than for the two non-ASD groups. Among students without ASD, a negative correlation between social anxiety and grades was observed whereas the reverse pattern was found for the ASD group, meaning that for students with ASD, higher levels of social anxiety were associated with higher grades. Additionally, in a regression analysis, ASD diagnosis, social anxiety, and the interaction of group × social anxiety significantly predicted GPA. Possible explanations for this finding, as well as implications for interventions among this population of high-functioning students with ASD, are discussed. Autism Res 2019, 12: 1376-1385. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This study compared the relationship between levels of social anxiety and grades in students with autism spectrum disorder (ASD) and in students without ASD who had either high social anxiety or low social anxiety (controls). Among the group with ASD, higher levels of social anxiety were associated with higher grades, whereas the reverse pattern was found among the other groups. This finding's implications for interventions among students with ASD are discussed.

Examining the inclusion of diverse participants in cognitive behavior therapy research for youth with autism spectrum disorder and anxiety

Results of randomized controlled trials have demonstrated significant reductions in anxiety symptoms following cognitive behavior therapy participation. Although promising, the extent to which previous research has included families from low socioeconomic status or racially/ethnically diverse backgrounds is unknown. Aims of this study are as follows: (1) What is the race, ethnicity, and educational attainment of youth with autism spectrum disorder and their families who have participated in research examining the efficacy of cognitive behavior therapy for anxiety? and (2) How do the demographics of these participants compare to that of the United States census? A total of 14 studies were reviewed that included 473 participants. Chi-square analyses indicated that there are significant differences between the race/ethnicity of youth with autism spectrum disorder participating in cognitive behavior therapy research for anxiety and that of youth in the United States. Standard residuals indicated significant overrepresentation of White youth and significant underrepresentation of Black and Latino youth in cognitive behavior therapy research (all p-values <0.001). Similarly, there were significant differences in the educational attainment of caregivers participating in cognitive behavior therapy research, with a significant underrepresentation of caregivers from low socioeconomic status backgrounds ( p < 0.001). These findings have implications for the development of cognitive behavior therapy interventions for youth with autism spectrum disorder and anxiety that are both rigorous and inclusive.