Assignment #2 Research Article Summary Instructor: Brenda Fossett Course: EPSE 449 Katherine Turner Student # 17298100

Over the past 30 years, Cognitive Behaviour Therapy (CBT) has offered an efficient, cost effective, safe alternative to psychotropic medication for the treatment for many mental health concerns, including anxiety. I recently became interested in the effectiveness of CBT as a treatment choice for the adolescents that I work with who have concurrent diagnoses of ASD and an anxiety disorder. As a resource to many families, I chose to examine research that investigates the efficacy of CBT in this specific population so I could provide current information on this option for the management of anxiety disorders. The principals of CBT can be applied to other behavioural changes such as weight management, pain management and depression making CBT an effective and adaptable tool that can be used in multiple circumstances.

Wood, J.J., Drahota, A., Sze, K., Har, K., Chiu, A., and Langer, D.A. (2009). Cognitive behavioural therapy for anxiety in children with autism spectrum disorders: a randomized, controlled trial. The Journal of Child Psychology and Psychiatry, 50:3, 224-234. doi:10.1111/j.1469-7610.2008.0948.x This study is a randomized control trial evaluating the efficacy of a modified cognitive behavioural therapy (CBT) program for children who present with a diagnosis of autism spectrum disorder and a co-morbid anxiety disorder. It was hypothesized that CBT would outperform a waitlist condition on series of child anxiety measures. The 40 study participants ranged in age from 7 to 11 years with a mean age of 9.2 years (SD = 1.49). Participants met the inclusion criteria: a diagnosis of autism, Aspergers Syndrome or PDD-NOS, a diagnosis of separation anxiety (SAD), social phobia, a generalized anxiety disorder (GAD) or obsessive-compulsive disorder (OCD). Participants were not taking any psychiatric medication at the baseline assessment or were taking a stable dose of psychiatric medication and if medication was being used, children maintained the same dosage throughout the period of study. Total child DSM-IV diagnoses including ASD, anxiety disorders, and additional co-morbid diagnosis range from two to six diagnosis per child with an average of 4.28 (SD = 1.18). Subjects were randomly assigned to either immediate treatment (IT) or the waitlist (WL). Evaluators blind to the intervention condition of each participant conducted diagnostic interviews pre and post treatment or waitlist using the ADIS-C/P (Silverman & Albano, 1996). The Clinical Global Impression (CGI) Improvement Scale rated each subjects improvement or decline at the post treatment / post waitlist assessment. The Multidimensional Anxiety Scale for Children (MASC; March 1998) was administered to children while primary parents completed

the parent report version. Participants in the IT group received 16 weeks of treatment in the form of modules based on the child's clinic requirements. Children received 30 minutes of a modified version of the CBT program Building Confidence, while parents/families received 60 minutes of training by a randomly assigned therapist. Modifications were made to the CBT with the intent to enhance social acceptance and theory of mind. Two sessions occurred at the childs school to provide training to relevant school personnel. Post treatment assessments occurred on the final day of treatment; post waitlist assessments occurred three months post baseline assessment but prior to CBT. Taped sessions were randomly selected from each case for evaluation of therapist adherence to the intervention protocol; results reveal a 94% adherence rate. All but one participant of the IT condition (92.9%) met criteria for a positive treatment response, compared to 2 of 22 (9.1%) children in the waitlist (WL) section. Child-reports indicate no significant differences between IT and WL conditions at post treatment/post waitlist reporting similar levels of anxiety. Improvement of all anxiety disorders was noted for over half the children (78.5%) in IT group at post treatment and follow-up. Child-reported anxiety did not yield a significant treatment effect. The results of this study indicate that remission of anxiety disorders seems to be an achievable objective among high functioning children with a diagnosis of AS and that children with ASD may use self-report anxiety measures in a unique way. While this study has merit, the sample size is small and consisted of only male participants. All subjects lived in a major metropolitan area of the western United States. Ideally, a larger sample size with representation from both genders and a diverse geographic base would ensure a sample more representative of the population. Often researchers in this field find it difficult to

have larger sample sizes, multiple replications of this study would increase the validity of the results.

Chalfant, A.M., Rapee, R., Carroll, L. (2007). Treating anxiety disorders in children with high functioning autism spectrum disorders: a controlled trial. Journal of Autism and Developmental Disorders 35, 1842-1857. doi:10.1007/s10803-006-0318-4 The purpose of this study was the evaluation of a family based, cognitive behavioural treatment (CBT) for anxiety disorders in individuals with High Functioning Autism (HFA). Researchers hypothesise the active treatment condition would produce a significantly greater change in the level of anxiety experienced by participants than the WL control condition. The 47 research participants ranged in age from 8-13 years with a mean age of 10.8 years (SD = 1.35). Participants had a diagnosis of HFA or Aspergers Disorder. Children selected for this study met the criteria for a primary anxiety disorder beyond their ASD related symptomatology. Thirty-five (74.4%) of the children met the criteria for two or more anxiety disorders. A comorbid secondary diagnosis of ADHD presented in thirteen (27.7%) of the children. Children were randomly assigned to one of four treatment groups. Assignment to the 12session CBT or waitlist (WL) within the four treatment groups was also random. CBT groups consisted of 6-8 children. Structured diagnostic measures, self-report, parent report and teacherreport measures were employed pre and post treatment to assess anxiety levels. Adaptations were made to the Cool Kids program (Lyneham, Abbott, Wignall, & Rapee, 2003) to account for the learning style of subjects. Children participated in CBT for six months with nine weekly treatment sessions and three monthly booster sessions. A parallel run parent program provided information and discussion opportunities for parents of children in the CBT group. No significant differences were found between groups at pre-treatment. An ANOVA used for analysis reveals a significant main effect for Time indicating an overall reduction in anxiety diagnosis in both conditions. Independent sample t-tests revealed a significant difference at post

treatment with the CBT group having a smaller number of anxiety diagnosis. Self-report analysis shows a significantly greater reduction in anxiety for CBT participant than those in the WL. Analysis of parent and teacher-report measures reveals a trend that parents and teachers of the CBT group reported CBT members tended to have lower scores at post-treatment than scores reported by the parents and teachers of the WL group members. No significant differences were found between CBT and WL groups in gender, type of ASD, intellectual level, socioeconomic status of family makeup; it is plausible to conclude that the primary source of change was the CBT treatment. An argument could be made that the efficacy of treatment extended to both the childrens school and home settings because all report data supported the beneficial effects of CBT intervention. The current findings are comparable to previous studies that tested efficacy of CBT in treating anxiety disorders in typically developing children. Future research could explore the amount of modifications required to the cognitive components of the program to compensate for the subjects impaired communication skills. Monitoring of the CBT participants to determine if treatment gains are maintained would be beneficial. Future studies could measure family quality of life or in ASD children measures of social skills or social functioning. The small sample size of this research may not provide data reflective of a greater anxious HFA population. The researchers did not measure treatment integrity and no therapist spent time with the WL children. Treatment benefits could be attributed to time spent with the therapist not the CBT. The clinicians who collected the data were not blind to the study`s aims which could have impacted their interactions with the participants.

These research articles evaluated modified cognitive behaviour therapy (CBT) programs for the treatment of anxiety in children with a co-morbid diagnosis of ASD. Both studies modified a CBT program for delivery to subjects with typically developing cognitive abilities, an ASD diagnosis and a diagnosed anxiety disorder. Though the sample size was small in both studies the American study participants were male where as the Australian study had participants from both genders. Parents received training and support in these in both studies. The American study therapists provided individual treatment sessions to the CBT children and training to parents over a 16-week period, as well as going into schools and providing training for relevant school service providers on two occasions. The American study CBT program included modified modules for the children, parents and school interventionists to address social skills deficits, social isolation and building independence in self-help skills. Social coaching was provided to the subjects immediately prior to attempting to join a social activity in any environment. Coping skills training and in vivo exposure were included in the CBT program. Parent training focused on supporting the vivo exposures, positive reinforcement, encouraging independence and autonomy in daily routines. The modular approach provides a flexible treatment program with modules selected based on the childs clinical requirements. The Australian study provided group therapy for both the subjects and their parents. The adaptations to the CBT program were made to address the visual and concrete learning style of individuals with HFA. The modified program was increased to six-months in duration with more visual aids and structured worksheets than in the standard CBT program. The majority of the components of the Australian program were devoted to developing relaxation techniques and increasing exposure to stressors due to the concrete nature of these exercises and lack of emphasis placed on communication skills. Changes to the cognitive component of this study

were made to accommodate the childrens language or communication impairments. A parent manual was also developed to address anxiety education, relaxation strategies, cognitive restructuring exercises, graded exposure, parent management training and relapse prevention. Both studies utilized the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-C/P) (Albano & Silverman, 1996) both pre and post treatment with similar results. Though the method of presentation and program content differed between the studies, the results were similar for both studies. Researchers found a decrease post treatment of anxiety disorders. The Australian researchers could increase the validity of the study by employing a blind approach when collecting data both pre and post treatment and running the CBT groups. This is a significant difference between the two studies. The American study included subjects who were taking a stable dosage of medication specific to their anxiety diagnosis where as the Australian study excluded children currently taking medications for anxiety. I am of the opinion that children with both an ASD diagnosis and anxiety can benefit from therapeutic interventions provided in a structured and sequential manner. Implementation of a program that addresses deficits in social skills, adaptive skills, and relaxation techniques can only benefit those children. Many of the children I work with experience heightened levels of anxiety due in part to their lack of social awareness and impaired social skills. Training in social skills assists in their stress management. Both articles mention Theory of Mind (ToM) research and the abilities of the research participants to identify their own emotional states. The results of these research articles suggest that individuals with a diagnosis of HFA may have ToM ability and that ToM impairment is neither specific to children with an ASD diagnosis nor globally impaired across all types of ASDs. Through both individual counselling and small group work the information provided in these research articles is encouraging for individuals who carry out

this type of intervention. Adaptations to CBT resource materials that address learning styles and expressive language skills are easily accommodated. The key to both research articles was the involvement of the parents and schools in the treatment/education program. Treatment did not occur in a vacuum. Subjects learned to implement coping strategies where and when they encounter stressors. Coaching that occurs in the moment is more effective than an analysis of a situation several hours post occurrence in a changed environment. I will encourage parents to consider CBT for their children as an alternative to a pharmacological approach to treatment. An approach based on skill acquisition and development provides a safe alternative to a psychotropic medication approach to management of anxiety symptoms. Future areas of research identified as a result of these studies include whether a simplified version of these programs could be used to treat the anxiety related difficulties in children with a lower functioning form of autism, including children with intellectual impairment. A comparison of the standard CBT program, the current adaptation and the WL to determine the impact of the adapted components could be a future area of research. Long-term follow-up data could be collected to determine if treatment gains are maintained. Replication of these studies with larger sample size would be important for validation of the efficacy of the CBT programs. The implications of parent training and therapeutic support on outcomes could be an area of future investigation.