Danielle Ung

The Effect of Cognitive-Behavioral Therapy Versus Treatment as Usual for Anxiety in Children With Autism Spectrum Disorders: A Randomized, Controlled Trial

OBJECTIVE To examine the efficacy of a modular cognitive-behavioral therapy (CBT) protocol relative to treatment as usual (TAU) among children with high-functioning autism spectrum disorders (ASD) and clinically significant anxiety. METHOD A total of 45 children (7-11 years of age) with high-functioning ASD and clinically significant anxiety were randomized to receive 16 sessions of weekly CBT or TAU for an equivalent duration. After screening, assessments were conducted at baseline, post-treatment, and 3-month follow-up. Raters were blind to treatment condition. RESULTS Youth receiving CBT showed substantial improvement relative to TAU on primary anxiety outcomes. Of 24 children randomized to the CBT arm, 18 (75%) were treatment responders, versus only 3 of 21 children (14%) in the TAU arm. Gains were generally maintained at 3-month follow-up for CBT responders. CONCLUSIONS Relative to usual care, CBT adapted for anxious youth with high-functioning ASD demonstrates large effects in reducing anxiety symptoms. This study contributes to the growing literature supporting adapted CBT approaches for treating anxiety in youth with ASD.

Treating trichotillomania: A meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors

Few randomized controlled trials (RCTs) exist examining the efficacy of behavior therapy (BT) or serotonin reuptake inhibitors (SRIs) for the treatment of trichotillomania (TTM), with no examination of treatment moderators. The present meta-analysis synthesized the treatment effect sizes (ES) of BT and SRI relative to comparison conditions, and examined moderators of treatment. A comprehensive literature search identified 11 RCTs that met inclusion criteria. Clinical characteristics (e.g., age, comorbidity, therapeutic contact hours), outcome measures, treatment subtypes (e.g., SRI subtype, BT subtype), and ES data were extracted. The standardized mean difference of change in hair pulling severity was the outcome measure. A random effects meta-analysis found a large pooled ES for BT (ES = 1.41, p < 0.001). BT trials with greater therapeutic contact hours exhibited larger ES (p = 0.009). Additionally, BT trials that used mood enhanced therapeutic techniques exhibited greater ES relative to trials including only traditional BT components (p = 0.004). For SRI trials, a random effects meta-analysis identified a moderate pooled ES (ES = 0.41, p = 0.02). Although clomipramine exhibited larger ES relative to selective serotonin reuptake inhibitors, the difference was not statistically significant. Publication bias was not identified for either treatment. BT yields large treatment effects for TTM, with further examination needed to disentangle confounded treatment moderators. SRI trials exhibited a moderate pooled ES, with no treatment moderators identified. Sensitivity analyses highlighted the need for further RCTs of SRIs, especially among youth with TTM.

Clinical characteristics of high-functioning youth with autism spectrum disorder and anxiety.

AIM & METHODS Clinical characteristics were examined in 108 high-functioning youth (children with a full IQ scale of at least 70) with an autism spectrum disorder (ASD; aged 7-15 years) who were presenting for inclusion in one of four clinical trials examining the efficacy of cognitive behavioral therapy in youth with ASD and anxiety. RESULTS We present baseline characteristics of this cohort, including prevalence rates of anxiety and comorbid disorders, and correlates of anxiety (e.g., comorbid diagnoses, impairment, anxiety severity and mental health services received) as a function of age and ASD diagnosis in treatment-seeking youth. Primary anxiety disorders were: 41.7% (n = 45) social phobia, 25.9% (n = 28) generalized anxiety disorder, 15.7% (n = 17) separation anxiety disorder, 12.0% (n = 13) obsessive-compulsive disorder and 4.6% (n = 5) specific phobia. Overall, 91.6% of participants (n = 99) met criteria for two or more anxiety disorders. Parents reported considerable functional impairment as measured by the Columbia Impairment Scale and anxiety severity as measured by the Pediatric Anxiety Rating Scale; this did not statistically differ as a function of ASD diagnosis or age. Anxiety severity, the number of comorbid anxiety diagnoses and total comorbid diagnoses were directly associated with parent-reported child impairment. Youth with ASD and anxiety present as a heterogeneous cohort with significant impairments and complex diagnostic presentations. CONCLUSION These data provide information about the nature of anxiety in youth with ASD, which may foster the development of tailored treatment protocols.

Preliminary study of family accommodation in youth with autism spectrum disorders and anxiety: Incidence, clinical correlates, and behavioral treatment response

Anxiety symptoms are common in youth with autism spectrum disorders (ASD) and directly associated with symptom severity and functional impairment. Family accommodation occurs frequently among individuals with obsessive-compulsive and anxiety disorders; to date, no data exist on the nature and correlates of family accommodation in youth with ASD and anxiety, as well as its relationship to cognitive-behavioral therapy outcome. Forty children with ASD and a comorbid anxiety disorder participated. Clinicians administered measures of ASD and anxiety disorder caseness, anxiety symptom severity, and family accommodation; parents completed questionnaires assessing social responsiveness, internalizing and externalizing behaviors, and functional impairment. A subsample of youth (n = 24) completed a course of cognitive-behavioral therapy. Family accommodation was common and positively correlated with anxiety symptom severity, but not functional impairment, general internalizing symptoms, externalizing behavior, or social responsiveness. Family accommodation decreased following cognitive-behavioral therapy with decreases in family accommodation being associated with decreases in anxiety levels. Treatment responders reported lower family accommodation frequency and lower parent impact relative to non-responders. Clinical implications of this study in assessing and psychotherapeutically treating youth with ASD and comorbid anxiety are discussed.

Treatment of sexual obsessions in childhood obsessive-compulsive disorder

As many as 25 % of youth diagnosed with obsessive-compulsive disorder (OCD) experience sexual obsessions. These youth have repetitive intrusive unwanted thoughts that can include sexual, possibly aggressive, acts with children, family members, the opposite sex, and strangers. Recurrent fears of being homosexual and/or a pedophile are also considered to be sexual obsessions. These thoughts are distressing to the youth who experience them and often lead to reassurance-seeking behaviors, avoidant behaviors, and anxiety or depressive symptoms. This chapter describes the nature and phenomenology of sexual obsessions, the impact of having sexual obsessions, and effective treatments for these obsessions. A case study of treating sexual obsession with exposure and response prevention (ERP) is presented to demonstrate individualized assessment and treatment. The chapter concludes with key points for clinicians working with youth with sexual obsessions.

Psychometric properties of the Autism Mental Status Examination in a pediatric sample

ABSTRACT The Autism Mental Status Examination (AMSE) is an 8-item assessment in which the clinician evaluates the presence of autism spectrum symptoms in the context of a brief, observational, clinical exam. Given the need for accurate, timely, and cost-effective clinical evaluation, the brief nature of the AMSE may aid in filling this gap in developmental assessment. However, other than two studies by the measure developers, no other research group has examined the psychometric properties of the AMSE. The current study examined the psychometric properties of the AMSE in 68 children seeking developmental evaluation and/or services related to anxiety in the context of autism spectrum disorders (ASD). The AMSE exhibited adequate internal consistency and excellent inter-rater reliability. Known groups validity was supported and there was preliminary evidence for convergent validity. The current data partially supports the AMSE as a psychometrically sound assessment tool.

The Association Between Quality of Life and Clinical Characteristics Youth with Headaches

ABSTRACT Headaches are common among youth, and frequently comorbid with psychological symptoms (e.g., anxiety/depressive symptoms), sleep problems, social and school interference, and decreased quality of life (QoL). In this study, 92 youth ages 7–17 years and their caregivers completed questionnaires examining ;headache severity, physical and emotional functioning, clinical characteristics, and QoL of the youth. Child reported QoL was negatively correlated with child reported anger, anxiety and depressive symptoms, catastrophizing, sleep disturbance, and directly correlated with social role. However, child and caregiver reported QoL was not significantly associated with headache severity. Missed school days were negatively correlated with social roles and directly correlated with fatigue and sleep disturbance. Anger, anxiety and depressive symptoms, age, and gender did not moderate the relationship between headache severity and functional disability. Among youth with headaches, QoL is directly associated with worse psychosocial functioning, suggesting that pediatric headaches can have pervasive and debilitating effects on life.

Quality and Correlates of Peer Relationships in Youths with Chronic Pain

Youths with chronic pain may experience difficulties with peer relationships. We investigated the quality and correlates of peer relationships in a sample of 181 youths with chronic pain. A majority of youths were satisfied with their relationships with peers; however, levels were highly variable. Higher functional impairment and depression levels predicted lower peer relationship quality, controlling for demographic and other pain-related factors. In addition, peer relationship quality and pain severity predicted child depression and anxiety symptoms, whereas peer relationship quality only predicted anger symptoms. Relationship quality moderated the association between pain severity and functional impairment, suggesting that strong relationships with peers may buffer the effects of pain on functioning. Peer relationships seem particularly important for the adjustment and psychological well-being of youths with chronic pain. Particular attention should be given to functionally impaired and depressed children, who may be at higher risk of peer difficulties.

Optimal management of pediatric obsessive-compulsive disorder

The last two decades have seen an increase in evidence supporting behavioral and pharmacologic treatments of pediatric obsessive-compulsive disorder, a debilitating anxiety disorder that affects about 1% of youth. However, dissemination of knowledge about these treatments to pediatric health care providers and families of affected children has been less successful. Following best practice guidelines, specific evidence for cognitive-behavioral therapy with exposure and response prevention and pharmacotherapy with serotonin reuptake inhibi- tors are presented. A discussion of clinical features and their impact on treatment delivery and empirically based suggestions for overcoming these barriers are also presented. Future directions for enhancing treatment implementation and dissemination are discussed.