Friday, November 29, 2019

CBT for Anxiety in Children with Autism



  Introduction
Children with autism spectrum disorder (ASD) frequently have co-occurring (comorbid) psychiatric conditions, with estimates as high as 70 to 84 percent. A Comorbid disorder is defined as a disorder that co-exists or co-occurs with another diagnosis so that both share a primary focus of clinical and educational attention. Although anxiety is not a defining characteristic of ASD, prevalence rates are significantly higher in children with ASD than in typically developing children, children with language disorders, chronic medical conditions, disruptive behavior disorders, and intellectual disability or epilepsy. In fact, research suggests that approximately one-half of children with ASD would meet the criteria for at least one anxiety disorder. Several studies have also reported a bidirectional association between internalizing disorders and autistic symptoms. For example, both a higher prevalence of anxiety disorders has been found in ASD and a higher rate of autistic traits has been reported in youths with mood and anxiety disorders. Individuals with ASD also appear to display more social anxiety symptoms compared to typical control individuals, even when these symptoms are clinically overlapping with the characteristic social problems typical of ASD. With comorbidity rates so elevated in the ASD population, treatment options for anxiety have become increasingly important.
Cognitive-Behavioral Therapy
There is a strong evidence base for the use of cognitive-behavioral therapy (CBT) interventions for depression and anxiety in non-ASD populations. There are a variety of CBT approaches, but most share some common elements. The primary goals of traditional CBT are to identify and challenge dysfunctional beliefs, catastrophic cognitions, and automatic thoughts as well as change problematic behavior. With a therapist’s help, the individual is encouraged to challenge his or her beliefs and automatic thoughts through a variety of techniques. Through CBT, the individual learns skills to modify thoughts and beliefs, as well as problem-solving strategies to improve interaction with others in effective and appropriate ways, thereby promoting self-regulation.
CBT models for the treatment of anxiety attempt to create a new coping pattern by using behavioral techniques such as modeling, exposure, and relaxation as well as cognitive techniques addressing cognitive distortions and deficiencies. These treatment models generally emphasize four critical components of therapy: assessment, psychoeducation, cognitive restructuring, and exposure. Using these four components, CBT has been shown to be an empirically supported treatment for typically developing children with anxiety issues. The most commonly used techniques to treat anxiety in children are exposure, relaxation, cognitive restructuring, and modeling in that order.
Cognitive-Behavioral Therapy for ASD
Although CBT has been shown to be an effective empirically supported treatment for typical children, there is a question as to whether or not it can be used with other populations. In recent years, there have been a number of attempts to adapt CBT for children and teens on the autism spectrum. Although there is no agreed upon set of modifications, there appears to be a general consensus that with certain specific modifications, CBT can be used to effectively lessen anxiety symptoms in higher functioning children with ASD. Evidence from the current literature supports a specific blend of techniques and strategies as the most effective approach to modify CBT for use with children who have an ASD. The primary modifications to CBT that have been shown to make them more viable for anxious children with ASD are the development of disorder specific hierarchies, the use of more concrete, visual tactics, the incorporation of child specific interests, and parent participation.
A study published in the Journal of Child Psychology and Psychiatry illustrates how a standard CBT program can be adapted to include multiple treatment components designed to accommodate or remediate the social and adaptive skill deficits of children with ASD that serve as barriers to anxiety reduction. The study tested a modular CBT program incorporating separate modules focusing specifically on deficits associated with ASD such as poor social skills, self-help skills, and stereotypies as well as a modified version of a traditional CBT protocol utilizing primarily cognitive restructuring and exposure techniques. 

The participants were forty children (7–11 years of age) who met the criteria for ASD and one of the following anxiety disorders: separation anxiety disorder (SAD), social phobia, or obsessive-compulsive disorder (OCD). They were randomly assigned to 16 sessions of CBT or a 3-month waitlist (36 children completed treatment or waitlist). The CBT model emphasized coping skills training (e.g., affect recognition, cognitive restructuring, and the principle of exposure) followed by in vivo exposure. The parent training components focused on supporting in vivo exposures, positive reinforcement, and communication skills. Independent evaluators blind to treatment condition conducted structured diagnostic interviews and parents and children completed anxiety symptom checklists at baseline and posttreatment/postwaitlist. The researchers found that 92.9% of children in the active treatment group met criteria for positive treatment response post-treatment compared to only 9.1% of children in the waitlist condition. In addition, 80% of children in the active treatment group were diagnosis free at follow up. From these results, it is reasonable to draw the conclusion that with specific modifications, CBT can be an effective treatment for children with ASD and comorbid (concurrent) anxiety disorders.
Implications
The above referenced study, together with case studies and other clinical trials, provides evidence that incorporating disorder specific hierarchies, use of more concrete, visual tactics, incorporation of child specific interests, and parental involvement can facilitate successful results when conducting CBT for anxiety in children with ASD. Although there is support for the efficacy of an enhanced CBT program, there are some limitations to these modifications and adapted models. Specifically, the child’s level of functioning, variation in the use of each modification, and the utilization of different CBT programs across studies affect the generalization of the outcomes. Moreover, there is a need to examine to what extent CBT with these modifications could be used with more severe cases of ASD or in cases where there is more severe intellectual impairment. Children with higher functioning ASD may be able to better process the cognitive components of traditional and modified CBT than those who are lower functioning. Additionally, different CBT programs may emphasize different components of CBT making it difficult to determine which components are the most critical for treating anxiety in children with ASD. The next step for future research should be to focus on developing a standardized approach to treatment which incorporates specific modifications, randomized clinical trials to test the approach, and explorations of the boundaries within the ASD population for use and effectiveness of treatment. Given the elevated comorbidity rates, finding an effective, empirically supported treatment for anxiety in children with ASD is critical.

Key References and Further Reading

Kurz, René et al. (2018). Cognitive behavioral therapy for children with autism spectrum disorder: A prospective observational study. European Journal of Paediatric Neurology, 22 (5), 803 – 806.
Moree, B. N., & Davis III, T. E. (2010). Cognitive-behavioral therapy for anxiety in children diagnosed with autism spectrum disorders: Modification trends. Research in Autism Spectrum Disorders, 4, 346–354.

National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author. http://www.nationalautismcenter.org/national-standards-project/

National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices. http://autismpdc.fpg.unc.edu/evidence-based-practices

Wilkinson, L. A. (2015). Overcoming Anxiety on the Autism Spectrum: A Self-Help Guide Using CBTLondon and Philadelphia: Jessica Kingsley Publishers.

Wilkinson, L. A. (2017).  A best practice guide to assessment and intervention for autism spectrum disorder in schools. Philadelphia & London: Jessica Kingsley Publishers.

Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S… Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group. cidd.unc.edu/Registry/Research/Docs/31.pdf

Weitlauf AS, McPheeters ML, Peters B, Sathe N, Travis R, Aiello R, Williamson E, Veenstra-VanderWeele J, Krishnaswami S, Jerome R, Warren Z. Therapies for Children With Autism Spectrum Disorder: Behavioral Interventions Update. Comparative  Effectiveness Review No. 137. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2012-00009-I.) AHRQ Publication No. 14-EHC036-EF. Rockville,  MD: Agency for Healthcare Research and Quality; August 2014. http://www.effectivehealthcare.ahrq.gov/reports/final.cfm

Weston, L., Hodgekins, J., &  Langdon, P. E. (2016). Effectiveness of cognitive behavioural therapy with people who have autistic spectrum disorders: A systematic review and meta-analysis. Clinical Psychology Review, Volume 49, 41-54.

Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224–234. http://doi.org/10.1111/j.1469-7610.2008.01948.x

Wood, J. J., Ehrenreich-May, J., Alessandri, M., Fujii, C., Renno, P., Laugeson, E., … Storch, E. A. (2015). Cognitive behavioral therapy for early adolescents with autism spectrum disorders and clinical anxiety: a randomized, controlled trial. Behavior therapy46(1), 7–19. doi:10.1016/j.beth.2014.01.002

Wood JJ, Kendall PC, Wood KS, et al. Cognitive Behavioral Treatments for Anxiety in Children With Autism Spectrum DisorderA Randomized Clinical TrialJAMA Psychiatry. Published online November 22, 2019. doi:10.1001/jamapsychiatry.2019.4160

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Thursday, November 14, 2019

Best Practice Guidelines for Assessment of Autism Spectrum Disorder (ASD)


Best Practice Guidelines for Assessment of Autism Spectrum Disorder

The number of children identified with autism has more than doubled over the last decade. School-based and mental health professionals are now being asked to participate in the screening, assessment, and educational planning for children and youth on the spectrum more than at any other time in the recent past. Moreover, the call for greater use of evidence-based practice has increased demands that professionals be prepared to recognize the presence of risk factors, engage in case finding, and be knowledgeable about “best practice” guidelines in assessment and intervention for autism spectrum disorder (ASD) to ensure that students are being identified and provided with the appropriate programs and services.

Best practice guidelines are developed using the best available research evidence in order to provide professionals with evidence-informed recommendations that support practice and guide practitioner decisions regarding assessment and intervention. Best practice requires the integration of professional expertise, each student’s unique strengths and needs, family values and preferences, and the best research evidence (rigorous peer-review) into the delivery of services. Professionals and families collaborate and work together as partners to prioritize domains of functioning for assessment and intervention planning. Best practices for school-based practitioners are best practices for students and their families.    
    
Comprehensive Developmental Assessment

The primary goals of conducting an autism spectrum assessment are to determine the presence and severity of an autism spectrum disorder (ASD), develop interventions for intervention/treatment planning, and collect data that will help with progress monitoring. Professionals must also determine whether an ASD has been overlooked or misclassified, describe co-occurring (comorbid) disorders, or identify an alternative classification. There are several important considerations that should inform the assessment process. First, a developmental perspective is critically important. While the core symptoms of are present during early childhood, ASD is a lifelong disability that affects the individual’s adaptive functioning from childhood through adulthood. Utilizing a developmental assessment framework provides a yardstick for understanding the severity and quality of delays or atypicality. Because ASD affects multiple developmental domains, the use of an interdisciplinary team constitutes best practice for assessment and diagnosis of ASD. A team approach is essential for establishing a developmental and psychosocial profile of the child in order to guide intervention planning. The following principles should guide the assessment process.
  • Children who screen positive for ASD should be referred for a comprehensive assessment.  Although screening tools have utility in broadly identifying children who are at-risk for an autism spectrum condition, they are not recommended as stand alone diagnostic instruments or as a substitute for a more inclusive assessment.
  • Assessment should involve careful attention to the signs and symptoms consistent with ASD as well as other coexisting childhood disorders.
  • When a student is suspected of having an ASD, a review of his or her developmental history in areas such as speech, communication, social and play skills is an important first step in the assessment process.
  • A family medical history and review of psychosocial factors that may play a role in the child’s development is a significant component of the assessment process. 
  • The integration of information from multiple sources will strengthen the reliability of the assessment results.
  • Evaluation of academic achievement should be included in assessment and intervention planning to address learning and behavioral concerns in the child’s overall school functioning.
  • Assessment procedures should be designed to assist in the development of  instructional objectives and intervention strategies based on the student’s unique pattern of strengths and weaknesses.
  • Because impairment in communication and social reciprocity are core features of ASD, a comprehensive developmental assessment should include both domains
  • Restricted, repetitive patterns of behavior, interests, or activities (RRB) are a defining feature of ASD and should be a focus of assessment.
A comprehensive developmental assessment approach requires the use of multiple measures including, but not limited to, verbal reports, direct observation, direct interaction and evaluation, and third-party reports. Assessment is a continuous process, rather than a series of separate actions, and procedures may overlap and take place in tandem. While specific activities of the assessment process will vary and depend on the child’s age, history, referral questions, and any previous evaluations and assessments, the following components should be included in a best practice assessment and evaluation of ASD in school-age children.
  •  Record review
  •  Developmental and medical history
  •  Medical screening and/or evaluation
  • Parent/caregiver interview
  • Parent/teacher ratings of social competence/interaction
  • Direct child observation
  • Cognitive assessment
  • Academic assessment
  • Adaptive behavior assessment
  • Social communication and language assessment
  • Assessment of RRB (including sensory issues)
Children with ASD often demonstrate additional problems beyond those associated with the core domains. Therefore, other areas should be included in the assessment battery depending on the referral question, history, and core evaluation results. These may include:
  • Sensory processing
  • Executive function, memory, and attention
  •  Motor skills
  • Family system 
  • Co-occurring (comorbid) behavioral/emotional problems   
The above referenced principles and procedures for the assessment of school-age children with ASD are reflected in recommendations of the American Academy of Neurology, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and a consensus panel with representation from multiple professional societies. A detailed description of the comprehensive developmental assessment model and specific assessment tools recommended for each domain can be found in A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).
© Lee A. Wilkinson, PhD

Tuesday, November 5, 2019

Autism and Childhood Trauma


 Trauma and Adverse Childhood Experiences (ACEs)

Research is advancing our understanding of the nature of childhood stress and trauma in autistic individuals and its subsequent impact on mental health and wellbeing. The DSM-5 notes that psychological distress associated with stress and trauma is varied and may include anxiety or fear-based reactions, changes in mood, anger, irritability, aggression or dissociation. Although there is a specific diagnostic category for trauma and stressor-related disorders, stress and trauma are identified as risk factors for several other disorders including depression and anxiety.

An important development in understanding the impact of stress and trauma on mental health in the general population has been the adverse childhood experience (ACE) studies. Adverse childhood experiences (ACEs) are potentially traumatic events that can have negative, lasting effects on health and well-being. The more adversities an individual has experienced, the higher the likelihood that individual will have serious mental and physical health problems later in life. ACEs include all types of abuse, neglect, and other stressful and traumatic experiences (e.g., bullying, peer rejection, neighborhood violence, poverty, financial hardship, parental divorce, incarceration, death, domestic violence, household substance abuse problems, and family mental health concerns).
Trauma and ACEs in Autism 

There is mounting evidence for stress and trauma as a risk factor for comorbidity and the worsening of the core symptoms in autism. These findings are consistent with research on the psychological consequences of adverse childhood experiences (ACEs) in the general population. A recent study to identify rates of ACEs in autistic children found that a diagnosis of ASD was significantly associated with a higher probability of reporting one or more ACEs. The number of autistic children who were exposed to four or more ACEs was twice as high compared to their typically developing peers.

The core symptoms of autism may themselves predispose children to stressful and traumatic situations. For example, difficulty with socialization could lead to increased social anxiety or peer rejection. Experiences known to be distressing for autistic individuals such as unexpected schedule changes, the prevention or discouragement of repetitive or preferred behaviors, and sensory sensitivities, could be perceived as traumatic particularly when such distress occurs on a consistent basis, adding to the potential for comorbidity. These core symptoms would make  every day social situations and new or unexpected experiences highly stressful for an autistic individual. It is possible that consistent rumination on stressful or traumatic experiences could lead to co-occurring symptoms of depression, anxiety or even PTSD if a significant traumatic event has taken place.

 Implications

Research suggests that autistic individuals may be at high risk for experiencing stressful and traumatic life events, the consequences of which can negatively impact mental health through the development of comorbid disorders (e.g., anxiety, depression) and/or worsening of the core symptoms of autism. Exposure to stressful and potentially traumatic events may manifest as symptoms of aggression, difficulty concentrating, social isolation, increased relational difficulties, regression in daily living skills, and increased repetitive or stereotypic behavior. As many of these symptoms are commonly associated with autism, the stress and/or trauma underlying these symptoms may go untreated. Stressful and traumatic life events should be considered by mental health professionals when conducting assessments and determining appropriate treatment plans for autistic individuals experiencing comorbid symptomatology and or/an exacerbation of core symptoms to help ensure that underlying causes of these symptoms are not overlooked. Formal screening and identification of ACEs can lead to trauma-informed interventions and treatment goals that can help to mitigate negative outcomes while promoting an environment that is supportive and affirmative of the experience of autism.
 
Key Resources and Further Reading

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders ( 5th ed.). Washington, DC: American Psychiatric Association.

Beck, J. (2011). Cognitive behavior therapy: Basics and beyond ( 2nd ed.). New York: Guilford Press.

Berg, K. L., Shiu, C. S., Acharya, K., Stolbach, B. C., & Msall, M. E. (2016). Disparities in adversity among children with autism spectrum disorder: A population based study. Developmental Medicine & Child Neurology, 58, 1124–1131. https://doi.org/10.1111/ dmcn.13161.

Bishop Fitzpatrick, L., Mazefsky, C. A., Minshew, N. J., & Eack, S. M. (2015). The relationship between stress and social functioning in adults with autism spectrum disorder and without intellectual disability. Autism Research, 8(2), 164–173.

Doepke, K. J., Banks, B. M., Mays, J. F., Toby, L. M., & Landau, S. (2014). Co-occurring emotional and behavior problems in children with Autism Spectrum Disorders. In L. Wilkinson (Ed.), Autism Spectrum Disorders in Children and Adolescence: Evidence-based Assessment and Intervention in Schools (pp. 125-148). Washington, DC: American Psychological Association.

Earl, R.K., Peterson, J., Wallace, A.S., Fox, E., Ma, R., Pepper, M., & Haidar, G. (2017. Trauma and autism spectrum disorder: A reference guide. Bernier Lab, Center for Human Development and Disability, University of Washington. bernierlab.uw.edu

Fuld, S (2018). Autism spectrum disorder: The impact of stressful and traumatic life events and implications for clinical practice. Clinical Social Work Journal, 46, 210-219.

García Villamisar, D., & Rojahn, J. (2015). Comorbid psychopathology and stress mediate the relationship between autistic traits and repetitive behaviours in adults with autism. Journal of Intellectual Disability Research, 59(2), 116–124. https://doi.org/10.1111/jir.12083.

Harvey, K. (2012). Trauma-informed behavioral intervention: What works and what doesn’t. Washington D.C.: American Association on Intellectual and Developmental Disabilities.

Kerns, C. M., Newschaffer, C. J., & Berkowitz, S. J. (2015). Traumatic childhood events and autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(11), 3475–3486. https://doi.org/10.1007/s10803-015-2392-y.

Kerns, C. M., Rump, K., Worley, J., Kratz, H., McVey, A., Herrington, J., & Miller, J. (2016). The differential diagnosis of anxiety disorders in cognitively-able youth with autism. Cognitive and Behavioral Practice, 23(4), 530–547.

Mannion, A., Brahm, M., & Leader, G. (2014). Comorbid psychopathology in autism spectrum disorder. Review Journal of Autism and Developmental Disorders, 1(2), 124–134. https://doi.org/10.1007/s40489-014-0012-y.

Matson, J. L., & Williams, L. W. (2014). Depression and mood disorders
among persons with autism spectrum disorders. Research in Developmental Disabilities, 35, 2003–2007. https://doi.org/10.1016/j.ridd.2014.04.020

Mayes, S. D., Gorman, A. A., Hillwig-Garcia, J., & Syed, E. (2013). Suicide ideation and attempts in children with autism. Research in Autism Spectrum Disorders, 7(1), 109–119. https://doi.org/10.1016/j.rasd.2012.07.009.

Mehtar, M., & Mukaddes, N. M. (2011). Posttraumatic stress disorder in individuals with diagnosis of autistic spectrum disorders. Research in Autism Spectrum Disorders, 5(1), 539–546. https://doi.org/10.1016/j.rasd.2010.06.020.

Reinvall, O., Moisio, A. L., Lahti-Nuuttila, P., Voutilainen, A., Laasonen, M., & Kujala, T. (2016). Psychiatric symptoms in children and adolescents with higher functioning autism spectrum disorders on the development and well-being assessment. Research in Autism Spectrum Disorders, 25, 47–57. https://doi.org/10.1016/j.rasd.2016.01.009.

Roberts, A. L., Koenen, K. C., Lyall, K., Robinson, E. B., & Weisskopf, M. G. (2015). Association of autistic traits in adulthood with childhood abuse, interpersonal victimization, and posttraumatic stress. Child Abuse & Neglect, 45, 135–142.

Schilling, E. A., Aseltine, R. H., & Gore, S. (2007). Adverse childhood experiences and mental health in young adults: A longitudinal survey. BMC Public Health, 7(1), 30.

Spratt, E. G., Nicholas, J. S., Brady, K. T., Carpenter, L. A., Hatcher, C. R., Meekins, K. A., … & Charles, J. M. (2012). Enhanced cortisol response to stress in children in autism. Journal of Autism and Developmental Disorders, 42(1), 75–81. https://doi.org/10.1007/s10803-011-1214-0.

Taylor, J. L., & Gotham, K. O. (2016). Cumulative life events, traumatic
experiences, and psychiatric symptomatology in transition-aged youth with autism spectrum disorder. Journal of Neurodevelopmental Disorders, 8(1), 28. https://doi.org/10.1186/s11689-016-9160-y.

Wilkinson, L. A. (2015). Overcoming Anxiety on the Autism Spectrum: A Self-Help Guide Using CBT. London and Philadelphia: Jessica Kingsley Publishers.

Wilkinson, L. A. (2017).  A best practice guide to assessment and intervention for autism spectrum disorder in schools (2nd ed.). London & Philadelphia: Jessica Kingsley Publishers.

Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk,
S., … Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental
Disorders, 45(7), 1951–1966. https://doi.org/10.1007/ s10803-014-2351-z.

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).