Cognitive Behavioural Therapy (CBT) programs adapted to children with Autism Spectrum Disorder (ASD) effectively reduce anxiety when run in university clinics. Forty-nine children aged 8-14 years participated in a waitlist controlled study in a general child psychiatric hospital setting. Post-treatment 30% of the children were free of their primary anxiety diagnoses and 5% were free of all anxiety diagnoses. No statistically significant difference between the two trial conditions were found on primary outcomes. However, statistically significant differences were found on secondary outcomes indicating clinically meaningful treatment responses. Together with high program satisfaction this study shows the CBT program to be feasible and potentially efficacious in treating anxiety in children with ASD in a general child psychiatric hospital setting.
Young adults with autism spectrum disorder (ASD) experience increased rates of anxiety and depression which can impact academic success. The Stepped Transition in Education Program for Students with ASD (STEPS) applies cognitive-behavioral principles to help young adults with ASD improve their adjustment to postsecondary education. We aimed to determine if STEPS had an effect on anxiety and depression. Treatment-seeking adults with ASD (n = 32; Mage = 19.74) were randomized to STEPS or transition as usual (TAU; i.e., waitlist control group). STEPS participants evinced significantly greater declines in depressive symptoms from pre-treatment to post-treatment compared to the waitlist. Anxiety symptoms did not significantly change. Results suggest that transition support for young people with ASD may improve mental health.
Adults with autism spectrum disorder (ASD) experience high rates of depression and anxiety, and some evidence suggests mindfulness-based stress reduction (MBSR) is effective in reducing these symptoms. However, the neural mechanisms of symptom alleviation, and benefit of MBSR beyond education/support groups are unknown. Maladaptive forms of self-reflection are linked to ASD, depression, and anxiety. In this pilot study, we hypothesized (a) MBSR would reduce depression and anxiety in adults with ASD and (b) a mechanism of symptom alleviation would be increased blood oxygen level-dependent signal in neural self-reflection hubs. Twenty-eight adults were randomly assigned to an 8-week MBSR group (n = 15) or a support group (n = 13) that met for the same amount of time with relaxation education materials. Based on previous self-reflection literature in ASD, regions of interest (ROIs) were middle cingulate cortex (MCC) and ventromedial prefrontal cortex (vmPFC). Only the MBSR group demonstrated significant reductions in depression, and neither group significantly changed in anxiety. Only the MBSR group increased activity of right MCC during self-reflection, and the increase correlated with depression alleviation. There were no changes in vmPFC for the MBSR group or either ROI for the support/education group. Seed-to-voxel connectivity analysis revealed that only the MBSR group increased functional connectivity between right MCC and pre/postcentral gyrus, suggesting MBSR may increase primary sensorimotor input to higher order cognitive brain regions. Taken together, MBSR may be effective for reducing depression in adults with ASD, and the neural mechanism may be increasing frontal circuit involvement during self-directed thought.
Background: Youth with ASD are at risk to develop low self-esteem, which is related to both co-occurring internalizing- and externalizing problems. In this RCT (N=24) we aimed to test the efficacy of Competitive Memory Training (COMET) for low self-esteem in youth with ASD (8-16y). Method: We compared the combination of COMET and Care As Usual (COMET+CAU) with CAU-only, to explore whether COMET had additional effects on low self-esteem and co-occurring symptoms of youth with ASD. Stability of effects was measured seven weeks later. Results: Participants receiving COMET+CAU showed greater improvement on parent-reported self-esteem and externalizing symptoms than participants receiving CAU-only. Similar improvements between groups were found on self-reported self-esteem and depressive symptoms. Improvements remained stable until seven weeks after having received COMET+CAU, with depressive symptomatology improving even further. Conclusions: Given the small sample size and mixed results, this pilot study does not allow us to declare COMET as being necessary in enhancing low self-esteem in ASD. However, this study indicates that when given parallel to CAU, COMET can help to improve self-esteem and co-occurring externalizing problems in youth with ASD in only a short period of time.
Children with autism spectrum disorder (ASD) have significant difficulty in social functioning to include engaging in natural play with peers. Many children with ASD exhibit significantly less interactive play and more physiological stress during benign social encounters with same-age peers on a playground. Theatrical role-playing and performance with expert role models may provide a unique opportunity for children with ASD to learn to engage with other children in a safe, supportive environment. SENSE Theatre® is a peer-mediated, theater-based program aimed at improving social competence in youth with ASD. Previous studies have shown significant improvements in social and communication skills following SENSE Theatre® intervention. The current project examined play with novel peers and self-reported anxiety before and after participation in SENSE Theatre®. Participants included 77 children between 8 and 16 years with high-functioning (IQ ≥ 70) ASD. The combined sample of three cohorts was randomized to the experimental (EXP, N = 44) or waitlist control (WLC, N = 33) group. Participants in the EXP group received 40 h (10, 4-h sessions) of SENSE Theatre®. The Peer Interaction Paradigm (PIP), an ecologically valid measure of natural play, was administered before and after the intervention. Group Play and Self Play on the playground equipment during solicited (T4) and unsolicited (T1) play were used in the current study. The State Trait Anxiety Scale for Children (STAIC; Spielberger et al., 1983) was used to measure self-reported current and persistent anxiety, respectively. Following treatment, children in the EXP group engaged in significantly more Group Play with novel peers [F(2,73) = 7.78, p = 0.007] and much less Self Play [F(2,73) = 6.70, p = 0.01] during solicited play compared to the WLC group. Regression analysis revealed that pretreatment play and group status were significant predictors of solicited Group Play. Children in the EXP group reported significantly less Trait anxiety following intervention [F(2,71) = 6.87, p = 0.01]; however, State anxiety was comparable. Results corroborate previous findings of significant changes in social and play behavior in children with ASD following the peer-mediated, theater-based intervention. Acting and theatrical performance with supportive role models facilitates social engagement in everyday settings with novel peers and reductions in self-reported anxiety.
Anxiety is a common and impairing condition in youth with autism spectrum disorders (ASD). Evidence supports the use of cognitive behavioral therapy for treating anxiety in this population; however, available treatment protocols may be difficult to implement outside of research settings. The present study examined the efficacy of family-based exposure-focused treatment (FET) compared to a treatment as usual (TAU) control in 32 youth aged 6-17 years with ASD and co-occurring anxiety. Fourteen youth were randomized to FET, which included 12 face-to-face weekly therapy sessions lasing 45-55 min, while 18 youth completed the TAU control where engagement in psychotherapy or pharmacotherapy was at the discretion of the families. Results strongly supported FET with a 79% (versus 0% in TAU) response rate, 86% (versus 0% in TAU) remission in primary anxiety diagnosis, and large between-group effects on clinician-rated anxiety severity and most parent-rated domains of anxiety-related impairment. Among treatment responders, 2-month follow-up supported maintenance of gains. Overall, the study supported FET as a relatively brief intervention for the treatment of anxiety in youth with ASD, although further research is needed to replicate these findings and compare FET outcomes to more comprehensive interventions.
LAY ABSTRACT: Anxiety in autism is an important target for psychological therapies because it is very common and because it significantly impacts upon quality of life and well-being. Growing evidence suggests that cognitive behaviour therapies and mindfulness-based therapies can help autistic individuals learn to manage feelings of anxiety but access to such therapies remains problematic. In the current pilot study, we examined whether existing online cognitive behaviour therapy and mindfulness-based therapy self-help tools can help reduce anxiety in autistic adults. Specifically, 35 autistic adults were asked to try either an existing online cognitive behaviour therapy (n = 16) or mindfulness-based therapy (n = 19) programme while a further 19 autistic adults served as a waitlist comparison group. A first important finding was that 23 of the 35 (66%) participants who tried the online tools completed them, suggesting that such tools are, in principle, acceptable to many autistic adults. In addition, adults in the cognitive behaviour therapy and mindfulness-based therapy conditions reported significant decreases in anxiety over 3 and to some extent also 6 months that were less apparent in the waitlist group of participants. On broader measures of mental health and well-being, the benefits of the online tools were less apparent. Overall, the results suggest that online self-help cognitive behaviour therapy and mindfulness-based therapy tools should be explored further as a means of providing cost-effective mental health support to at least those autistic individuals who can engage effectively with such online tools.
Although small-scale studies have described the effects of oxytocin on social deficits in autism spectrum disorder (ASD), no large-scale study has been conducted. In this randomized, parallel-group, multicenter, placebo-controlled, double-blind trial in Japan, 106 ASD individuals (18-48 y.o.) were enrolled between Jan 2015 and March 2016. Participants were randomly assigned to a 6-week intranasal oxytocin (48IU/day, n = 53) or placebo (n = 53) group. One-hundred-three participants were analyzed. Since oxytocin reduced the primary endpoint, Autism Diagnostic Observation Schedule (ADOS) reciprocity, (from 8.5 to 7.7; P < .001) but placebo also reduced the score (8.3 to 7.2; P < .001), no between-group difference was found (effect size -0.08; 95% CI, -0.46 to 0.31; P = .69); however, plasma oxytocin was only elevated from baseline to endpoint in the oxytocin-group compared with the placebo-group (effect size -1.12; -1.53 to -0.70; P < .0001). Among the secondary endpoints, oxytocin reduced ADOS repetitive behavior (2.0 to 1.5; P < .0001) compared with placebo (2.0 to 1.8; P = .43) (effect size 0.44; 0.05 to 0.83; P = .026). In addition, the duration of gaze fixation on socially relevant regions, another secondary endpoint, was increased by oxytocin (41.2 to 52.3; P = .03) compared with placebo (45.7 to 40.4; P = .25) (effect size 0.55; 0.10 to 1.0; P = .018). No significant effects were observed for the other secondary endpoints. No significant difference in the prevalence of adverse events was observed between groups, although one participant experienced temporary gynecomastia during oxytocin administration. Based on the present findings, we cannot recommend continuous intranasal oxytocin treatment alone at the current dose and duration for treatment of the core social symptoms of high-functioning ASD in adult men, although this large-scale trial suggests oxytocin's possibility to treat ASD repetitive behavior.
BACKGROUND: Intranasal administration of the "prosocial" neuropeptide oxytocin is increasingly explored as a potential treatment for targeting the core characteristics of autism spectrum disorder (ASD). However, long-term follow-up studies, evaluating the possibility of long-lasting retention effects, are currently lacking.
METHODS: Using a double-blind, randomized, placebo-controlled, parallel design, this pilot clinical trial explored the possibility of long-lasting behavioral effects of 4 weeks of intranasal oxytocin treatment (24 International Units once daily in the morning) in 40 adult men with ASD. To do so, self-report and informant-based questionnaires assessing core autism symptoms and characterizations of attachment were administered at baseline, immediately after 4 weeks of treatment (approximately 24 h after the last nasal spray administration), and at two follow-up sessions, 4 weeks and 1 year post-treatment.
RESULTS: No treatment-specific effects were identified in the primary outcome assessing social symptoms (Social Responsiveness Scale, self- and informant-rated). In particular, with respect to self-reported social responsiveness, improvements were evident both in the oxytocin and in the placebo group, yielding no significant between-group difference (p = .37). Also informant-rated improvements in social responsiveness were not significantly larger in the oxytocin, compared to the placebo group (between-group difference: p = .19). Among the secondary outcome measures, treatment-specific improvements were identified in the Repetitive Behavior Scale and State Adult Attachment Measure, indicating reductions in self-reported repetitive behaviors (p = .04) and reduced feelings of avoidance toward others (p = .03) in the oxytocin group compared to the placebo group, up to 1 month and even 1 year post-treatment. Treatment-specific effects were also revealed in screenings of mood states (Profile of Mood States), indicating higher reports of "vigor" (feeling energetic, active, lively) in the oxytocin, compared to the placebo group (p = .03).
CONCLUSIONS: While no treatment-specific improvements were evident in terms of core social symptoms, the current observations of long-term beneficial effects on repetitive behaviors and feelings of avoidance are promising and suggestive of a therapeutic potential of oxytocin treatment for ASD. However, given the exploratory nature of this pilot study, future studies are warranted to evaluate the long-term effects of OT administration further.
TRIAL REGISTRATION: The trial was registered with the European Clinical Trial Registry (Eudract 2014-000586-45) on January 22, 2014 (https://www.clinicaltrialsregister.eu/ctr-search/trial/2014-000586-45/BE).
IMPORTANCE: Anxiety is common among youth with autism spectrum disorder (ASD), often interfering with adaptive functioning. Psychological therapies are commonly used to treat school-aged youth with ASD; their efficacy has not been established.
OBJECTIVE: To compare the relative efficacy of 2 cognitive behavioral therapy (CBT) programs and treatment as usual (TAU) to assess treatment outcomes on maladaptive and interfering anxiety in children with ASD. The secondary objectives were to assess treatment outcomes on positive response, ASD symptom severity, and anxiety-associated adaptive functioning.
DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial began recruitment in April 2014 at 3 universities in US cities. A volunteer sample of children (7-13 years) with ASD and maladaptive and interfering anxiety was randomized to standard-of-practice CBT, CBT adapted for ASD, or TAU. Independent evaluators were blinded to groupings. Data were collected through January 2017 and analyzed from December 2018 to February 2019.
INTERVENTIONS: The main features of standard-of-practice CBT were affect recognition, reappraisal, modeling/rehearsal, in vivo exposure tasks, and reinforcement. The CBT intervention adapted for ASD was similar but also addressed social communication and self-regulation challenges with perspective-taking training and behavior-analytic techniques.
MAIN OUTCOMES AND MEASURES: The primary outcome measure per a priori hypotheses was the Pediatric Anxiety Rating Scale. Secondary outcomes included treatment response on the Clinical Global Impressions-Improvement scale and checklist measures.
RESULTS: Of 214 children initially enrolled, 167 were randomized, 145 completed treatment, and 22 discontinued participation. Those who were not randomized failed to meet eligibility criteria (eg, confirmed ASD). There was no significant difference in discontinuation rates across conditions. Randomized children had a mean (SD) age of 9.9 (1.8) years; 34 were female (20.5%). The CBT program adapted for ASD outperformed standard-of-practice CBT (mean [SD] Pediatric Anxiety Rating Scale score, 2.13 [0.91] [95% CI, 1.91-2.36] vs 2.43 [0.70] [95% CI, 2.25-2.62]; P = .04) and TAU (2.93 [0.59] [95% CI, 2.63-3.22]; P < .001). The CBT adapted for ASD also outperformed standard-of-practice CBT and TAU on parent-reported scales of internalizing symptoms (estimated group mean differences: adapted vs standard-of-practice CBT, -0.097 [95% CI, -0.172 to -0.023], P = .01; adapted CBT vs TAU, -0.126 [95% CI, -0.243 to -0.010]; P = .04), ASD-associated social-communication symptoms (estimated group mean difference: adapted vs standard-of-practice CBT, -0.115 [95% CI, -0223 to -0.007]; P = .04; adapted CBT vs TAU: -0.235 [95% CI,-0.406 to -0.065]; P = .01); and anxiety-associated social functioning (estimated group mean difference: adapted vs standard-of-practice CBT, -0.160 [95% CI, -0.307 to -0.013]; P = .04; adapted CBT vs TAU: -0.284 [95% CI, -0.515 to -0.053]; P = .02). Both CBT conditions achieved higher rates of positive treatment response than TAU (BIACA, 61 of 66 [92.4%]; Coping Cat, 47 of 58 [81.0%]; TAU, 2 of 18 [11.1%]; P < .001 for each comparison).
CONCLUSIONS AND RELEVANCE: In this study, CBT was efficacious for children with ASD and interfering anxiety, and an adapted CBT approach showed additional advantages. It is recommended that clinicians providing psychological treatments to school-aged children with ASD consider developing CBT expertise.
TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02028247.
Cognitive Behavioural Therapy (CBT) programs adapted to children with Autism Spectrum Disorder (ASD) effectively reduce anxiety when run in university clinics. Forty-nine children aged 8-14 years participated in a waitlist controlled study in a general child psychiatric hospital setting. Post-treatment 30% of the children were free of their primary anxiety diagnoses and 5% were free of all anxiety diagnoses. No statistically significant difference between the two trial conditions were found on primary outcomes. However, statistically significant differences were found on secondary outcomes indicating clinically meaningful treatment responses. Together with high program satisfaction this study shows the CBT program to be feasible and potentially efficacious in treating anxiety in children with ASD in a general child psychiatric hospital setting.
Diseño del estudio»Ensayo controlado aleatorizado (ECA)
