LAY ABSTRACT: Nearly three out of four autistic people experience mental health problems such as stress, anxiety or depression. The research already done does not guide us on how best to prevent or treat mental health problems for autistic people. Our aim was to look at the benefits and harms of different interventions on mental health outcomes in autistic people. We searched all the published randomised controlled trials (RCTs) about interventions for mental health conditions in autistic people until 17 October 2020. We also searched for RCTs that were not published in peer-reviewed journals. These were obtained from registers of clinical trials online. We then combined the information from all these trials using advanced statistical methods to analyse how good the interventions are. Seventy-one studies (3630 participants) provided information for this research. The studies reported how participants were responding to the intervention for only a short period of time. The trials did not report which interventions worked for people with intellectual disability. In people without intellectual disability, some forms of cognitive behavioural therapy and mindfulness therapy may be helpful. However, further research is necessary. Many trials used medications to target core features of autism rather than targeting mental health conditions, but these medications did not help autistic people. Until we have more evidence, treatment of mental health conditions in autistic people should follow the evidence available for non-autistic people. We plan to widely disseminate the findings to healthcare professionals through medical journals and conferences and contact other groups representing autistic people.
CONTEXT: In several studies, authors have reported on cognitive behavioral therapy (CBT) for children and adolescents with autism spectrum disorders (ASDs), but inconsistent treatment effectiveness was revealed from these studies.
OBJECTIVE: To evaluate the effectiveness of CBT on the symptoms of ASD and social-emotional problems in children or adolescents with ASD by using a meta-analytic approach.
DATA SOURCES: Data sources included PubMed, Embase, and the Cochrane Library.
STUDY SELECTION: We selected randomized controlled trials (RCTs) in which authors reported effectiveness of CBT on the symptoms of ASD and social-emotional problems in children or adolescents with ASD from database inception to May 2019.
DATA EXTRACTION: For each study, 2 authors extracted data on the first author's surname, publication year, country, sample size, mean age, CBT target, intervention, outcome measurement, follow-up duration, and investigated outcomes.
RESULTS: Forty-five RCTs and 6 quasi RCTs of 2485 children and adolescents with ASDs were selected for the final meta-analysis. There was no significant difference between CBT and control for symptoms related to ASD based on self-reported outcomes (standard mean difference: -0.09; 95% confidence interval: -0.42 to 0.24; P = .593), whereas CBT significantly improved the symptoms related to ASD based on informant-reported outcomes, clinician-rated outcomes, and task-based outcomes. Moreover, the pooled standard mean differences indicated that CBT has no significant effect on symptoms of social-emotional problems based on self-reported outcomes.
LIMITATIONS: The quality of included studies was low to modest, significant heterogeneity among the included studies for all investigated outcomes was detected, and publication bias was inevitable.
CONCLUSIONS: These findings indicate that CBT may significantly improve the symptoms of ASD and social-emotional problems in children or adolescents with ASD.
BACKGROUND: Anxiety is common in youth on the autism spectrum and cognitive behavioural therapy (CBT) has been adapted to address associated symptoms. The aim of the current systematic review and meta-analysis was to examine the efficacy of CBT for reducing anxiety in autistic youth.
METHOD: Searches of PubMed and Scopus databases were undertaken from January 1990 until December 2020. Studies were included if they consisted of randomised controlled trials (RCTs) using CBT to reduce anxiety in autistic youth. Separate random effects meta-analyses assessed anxiety ratings according to informant (clinician; parent; child), both at end-of-trial and at follow-up.
RESULTS: A total of 19 RCTs met our inclusion criteria (833 participants: CBT N = 487; controls N = 346). Random effects meta-analyses revealed a large effect size for clinician rated symptoms (g = 0.88, 95% CI 0.55, 1.12, k = 11), while those for both parent (g = 0.40, 95% CI 0.24, 0.56; k = 18) and child-reported anxiety (g = 0.25, 95% CI 0.06, 0.43; k = 13) were smaller, but significant. These benefits were not however maintained at follow-up. Moderator analyses showed that CBT was more efficacious for younger children (for clinician and parent ratings) and when delivered as individual therapy (for clinician ratings). Using the Cochrane Risk of Bias 2 tool, we found concerns about reporting bias across most trials.
CONCLUSIONS: The efficacy of CBT for anxiety in autistic youth was supported in the immediate intervention period. However, substantial inconsistency emerged in the magnitude of benefit depending upon who was rating symptoms (clinician, parent or child). Follow-up analyses failed to reveal sustained benefits, though few studies have included this data. It will be important for future trials to address robustness of treatment gains overtime and to further explore inconsistency in efficacy by informant. We also recommend pre-registration of methods by trialists to address concerns with reporting bias.
LAY ABSTRACT: Cognitive behavioral therapy is a common treatment for emotional problems in people with autism. Most studies of cognitive behavioral therapy and autism have focused on efficacy, meaning whether a treatment produces results under "ideal" conditions, like a lab or research setting. Effectiveness trials, by contrast, investigate whether a treatment produces results under "real-world" conditions, like a community setting (e.g. hospital, community mental health center, school). There can be challenges in bringing a cognitive behavioral therapy treatment out of a lab or research setting into the community, and the field of implementation science uses frameworks to help guide researchers in this process. In this study, we reviewed efficacy and effectiveness studies of cognitive behavioral therapy treatments for emotional problems (e.g. anxiety, depression) in children and youth with autism. Our search found 2959 articles, with 33 studies meeting our criteria. In total, 13 studies were labelled as effectiveness and 20 as efficacy. We discuss how the effectiveness studies used characteristics of an implementation science framework, such as studying how individuals learn about the treatment, accept or reject it, how it is used in the community over time, and any changes that happened to the individual or the organization (e.g. hospital, school, community mental health center) because of it. Results help us better understand the use of cognitive behavioral therapy in the community, including how a framework can be used to improve effectiveness studies.
PLAIN LANGUAGE SUMMARY: Cognitive behavioural therapy for anxiety in school-aged children with autism spectrum disorder can reduce anxiety Cognitive behavioural therapy interventions to reduce the level of anxiety in students with autism spectrum disorder are moderately effective. What is this review about? Anxiety is a common problem in school-aged children with autism spectrum disorder (ASD). Cognitive behavioural therapy (CBT) and other psychosocial interventions have been developed as alternatives to pharmacological intervention to treat anxiety in students with ASD. What is the aim of this review? This Campbell systematic review examines the effects of interventions for reducing anxiety in school-aged children with autism spectrum disorder, compared to treatment-as-usual. The review summarises evidence from 24 studies using an experimental or quasi-experimental design. What studies are included? Twenty-four studies, involving 931 school-aged children with ASD (without co-occurring intellectual disability) and clinical anxiety, are summarised in this review. The studies were experimental or quasi-experimental control-treatment trials, deemed to be of sufficient methodological quality and with reduced risk of bias. Studies spanned the period 2005 to 2018 and were mostly carried out in Australia, the UK and the USA. Examined interventions ranged across clinical, school-based, or home-based settings, with group or individual treatment formats. Twenty-two of the studies used a CBT intervention. One study used peer-mediated theatre therapy and one study examined the benefits of Thai traditional massage for reducing anxiety. Most interventions involved parents/caregivers and were conducted face-to-face. What are the main findings of this review? Overall, the effects of interventions on anxiety show a statistically significant moderate to high effect, compared to waitlist and treatment-as-usual control conditions at post-treatment. However, effects differ depending on who reports on the student’s anxiety. Clinician reports indicate a very high statistically significant effect, parent reports indicate a high significant effect, and self-reports indicate only a moderate significant effect on the reduction of anxiety in students with ASD. There are larger effects for treatments that involve parents than for student-only interventions. Effects are also larger for individual one-on-one interventions compared to treatments delivered in a group with peers. There are several risk-of-bias issues in most studies included in the review, mainly due to the unavoidable limitation that participants cannot be blinded to the treatment group, which may upwardly bias the estimated effects. There are also limitations in the description of randomisation in a third of the studies, so findings should be treated with caution. What do the findings of this review mean? The findings provide evidence in support of interventions, particularly CBTs, designed to reduce anxiety symptoms in school-aged children with ASD. These findings accord with and build upon the findings of previous systematic reviews into the effectiveness of interventions to reduce anxiety in children and youth with ASD. However, because of the risk of bias in current findings, it would be useful to have further studies with larger sample sizes and to reduce potential biases where possible. How up-to-date is this review? The review authors searched for studies up to the end of 2018.
ABSTRACT: Children with autism spectrum disorder (ASD) are at greater risk for experiencing high levels of anxiety symptoms. Recent evidence suggests Cognitive behavioral therapy (CBT) may also be effective for anxiety reduction in some presentations of ASD. This meta-analysis evaluated twenty-three studies. Results yielded a moderate effect size (g = - 0.66) for the reduction of anxiety symptoms. Moderators indicated larger effects for studies were achieved with parental involvement (g = - 0.85, p < .05) than with child-only treatments (g = - 0.34, p < .05). Short-term interventions generated a smaller effect (g = - 0.37 p < .05) than either standard-term (g = - 1.02, p < .05) or long-term interventions (g = - 0.69, p < .05).Implications for children with ASD are discussed.
BACKGROUND: Children with an autism spectrum disorder (ASD) are at risk for developing co-morbid mental health disorders, with anxiety being the most common. Anxiety symptoms significantly interfere with a child's ability to participate in school and community settings. Over the past 17 years, there has been an increase in empirical evidence of Cognitive Behavioral Therapy (CBT) as a treatment for anxiety in children with ASD. The purpose of this systematic review was to evaluate this body of research to determine whether CBT could be classified as an empirically supported treatment (EST) for this population. A secondary purpose was to identify the extent to which schools have been involved in this line of research. METHOD: A systematic review of group comparison and single case research was conducted. Each study was evaluated using quality indicators recommended by the Council for Exceptional Children (CEC), including an evaluation of study effects. Information regarding school involvement was also extracted. RESULTS: A total of 30 studies were included in the analysis. Results indicated that modified CBT interventions for children with ASD met CEC criteria for an EST. Among the studies evaluated, only two (6%) involved a school setting in which educators participated in the intervention. CONCLUSION: The results of this review offer empirically support for modified CBT for children with autism as an EST. Findings also indicate that little research has included the school context when implementing CBT treatments for children with autism and anxiety. Implications for dissemination and future research are presented.
ABSTRACT: Cognitive Behavior Therapy (CBT) is a well-established treatment for childhood anxiety disorders. Meta-analyses have concluded that approximately 60% of children recover following treatment, however these include studies using a broad range of diagnostic indices to assess outcomes including whether children are free of the one anxiety disorder that causes most interference (i.e. the primary anxiety disorder) or whether children are free of all anxiety disorders. We conducted a meta-analysis to establish the efficacy of CBT in terms of absence of all anxiety disorders. Where available we compared this rate to outcomes based on absence of primary disorder. Of 56 published randomized controlled trials, 19 provided data on recovery from all anxiety disorders (n = 635 CBT, n = 450 control participants). There was significant heterogeneity across those studies with available data and full recovery rates varied from 47.6 to 66.4% among children without autistic spectrum conditions (ASC) and 12.2 to 36.7% for children with ASC following treatment, compared to up to 20.6% and 21.3% recovery in waitlist and active treatment comparisons. The lack of consistency in diagnostic outcomes highlights the urgent need for consensus on reporting in future RCTs of childhood anxiety disorders for the meaningful synthesis of data going forwards. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
BACKGROUND: Interventions using cognitive–behavioural approaches have been suggested to be effective for children with autism spectrum disorder (ASD). In the current review, the authors attempt to clarify how these cognitive–behavioural approach interventions may deliver their intended effects by examining the relationships between their aims, content/skills addressed, and outcome measures. METHOD: A total of 39 studies reporting on cognitive–behavioural approaches for children with ASD were located through a database search, examined, and relevant data were subsequently extracted. Result: There was a notable lack of correspondence between the intervention aims, content/skills taught, and the outcome variables measured. Mastery of intermediate knowledge and skills, which were presumed to indirectly facilitate desired behaviour change, was not typically assessed. CONCLUSION: It is very difficult to determine the contribution of components to the effectiveness of multiple-component approach interventions. More cost-effective cognitive–behavioural approach interventions may be possible with research focusing on examining the effectiveness of individual components, in particular with single-subject experimental design research. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
La ansiedad es un problema común en los niños y adolescentes con trastorno del espectro autista (TEA). Este meta-análisis tuvo como objetivo evaluar sistemáticamente las pruebas para el uso de las intervenciones psicosociales para manejar la ansiedad en esta población. La terapia cognitivo conductual (TCC) fue la modalidad de intervención primaria estudió. Se realizó un amplio proceso de búsqueda y selección de los estudios sistemáticos. Análisis estadísticos se llevaron a cabo por separado para clinician-, entre padres, y las medidas de resultado de auto-reporte. Los análisis de sensibilidad se realizaron mediante la eliminación de cualquier estudio periféricas y estudios que no utilizaron una intervención de TCC. Se realizó un análisis de subgrupos para comparar entrega individual y grupo de tratamiento. Se incluyeron diez ensayos controlados aleatorios con un total de 470 participantes. La DME global fue d = 1,05 (IC del 95%: 0,45, 1,65; z = 3.45, p = 0,0006) para clinician- informó medidas de resultado; d = 1,00 (IC del 95%: 0,21, 1,80; z = 2.47, p = 0.01) para las medidas de resultado informados por los padres; y d = 0,65 (IC del 95% -0.10, 1.07; z = 1.63, p = 0.10) para las medidas de resultado de auto-reporte. Medidas de resultado Clinician- y reportado por los padres mostraron que las intervenciones psicosociales fueron superiores a la lista de espera y las condiciones de control de tratamiento por uso habitual después del tratamiento. Sin embargo, los resultados de las medidas de resultado de auto-reporte no alcanzaron significación. El análisis de sensibilidad no cambió significativamente los resultados y el análisis de subgrupos indicó que el trato individual era más eficaz que el tratamiento grupal. Las principales limitaciones de esta revisión fueron el pequeño número de estudios incluidos, así como la variabilidad clínica y metodológica entre los estudios.
Nearly three out of four autistic people experience mental health problems such as stress, anxiety or depression. The research already done does not guide us on how best to prevent or treat mental health problems for autistic people. Our aim was to look at the benefits and harms of different interventions on mental health outcomes in autistic people. We searched all the published randomised controlled trials (RCTs) about interventions for mental health conditions in autistic people until 17 October 2020. We also searched for RCTs that were not published in peer-reviewed journals. These were obtained from registers of clinical trials online. We then combined the information from all these trials using advanced statistical methods to analyse how good the interventions are. Seventy-one studies (3630 participants) provided information for this research. The studies reported how participants were responding to the intervention for only a short period of time. The trials did not report which interventions worked for people with intellectual disability. In people without intellectual disability, some forms of cognitive behavioural therapy and mindfulness therapy may be helpful. However, further research is necessary. Many trials used medications to target core features of autism rather than targeting mental health conditions, but these medications did not help autistic people. Until we have more evidence, treatment of mental health conditions in autistic people should follow the evidence available for non-autistic people. We plan to widely disseminate the findings to healthcare professionals through medical journals and conferences and contact other groups representing autistic people.
