Elysse B. Arnold

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.

Multiple Informant Agreement on the Anxiety Disorders Interview Schedule in Youth with Autism Spectrum Disorders

OBJECTIVE The purpose of this study was to examine child, parent, and clinicians consensus agreement on the Anxiety Disorders Interview Schedule, Child and Parent versions (ADIS-C/P) in a sample of children and adolescents with autism spectrum disorders (ASD). METHOD Youth with ASD (n=85; age range=7-17 years) and their parents were each administered the ADIS-C/P by a trained clinician. Consensus diagnoses were determined in a clinical conference using best estimate procedures that incorporated all available information. RESULTS Children and youth with ASD diagnoses generally showed poor diagnostic agreement with parents and clinical consensus, whereas parents showed good-to-excellent diagnostic agreement with clinical consensus diagnoses. Diagnostic agreement between parents and consensus was moderated by the specific ASD diagnosis. Otherwise, the pattern of relationships did not systematically differ as a function of age or externalizing comorbidity. CONCLUSIONS These data suggest that parent and youth agreement regarding the presence of clinical levels of anxiety is markedly poor among youth with ASD. Additionally, clinicians are likely to base their diagnostic impressions on parent report, placing minimal emphasis on child report.

Psychometric Properties of the Obsessive Compulsive Inventory: Child Version in Children and Adolescents with Obsessive–Compulsive Disorder

The psychometric properties of the Obsessive Compulsive Inventory–Child Version (OCI-CV) were examined in ninety-six youth with a primary/co-primary diagnosis of obsessive–compulsive disorder (OCD). A confirmatory factor analysis revealed an acceptable model of fit with factors consisting of doubting/checking, obsessing, hoarding, washing, ordering, and neutralizing. The internal consistency of the OCI-CV total score was good, while internal consistency for subscale scores ranged from poor to good. The OCI-CV was modestly correlated with obsessive–compulsive symptom severity on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) Severity Scale, as well as with clinician-reported OCD severity. All OCI-CV subscales significantly correlated with the corresponding CY-BOCS Symptom Checklist dimension. The OCI-CV significantly correlated with child-reported depressive symptoms and OCD-related functional impairment, but was not significantly correlated with parent-reported irritability or clinician-reported overall functioning. Taken together, these data suggest the psychometric properties of the OCI-CV are adequate for assessing obsessive–compulsive symptom presence among youth with OCD.

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.

Hoarding behaviors among nonclinical elderly adults: Correlations with hoarding cognitions, obsessive–compulsive symptoms, and measures of general psychopathology

This study examines correlates of hoarding behaviors among nonclinical elderly adults, focusing upon hoarding cognitions, obsessive-compulsive symptoms, and measures of general psychopathology. Two hundred and sixty-nine adults aged 56-93 years (M=72.49 years) completed the Saving Inventory-Revised, Savings Cognitions Inventory-Revised, Obsessive Compulsive Inventory-Revised, Social Interaction Anxiety Scale, Penn State Worry Questionnaire, and Beck Depression Inventory. Our geriatric sample evidenced significantly greater severity of hoarding behaviors than did a younger community sample (24-72 years; M=44.4 years; Frost, Steketee, & Grishman, 2004). Within our sample, moderate correlations were found between hoarding behaviors and hoarding cognitions; however, controlling for obsessive-compulsive and depressive symptoms resulted in reduced-magnitude associations. As well, relationships between obsessive-compulsive symptoms and both hoarding behaviors and hoarding cognitions were generally strong, with most relationships diminishing after controlling for depressive symptoms. Associations between hoarding symptoms and symptoms of social anxiety, general worry, and depression were generally moderate. A significant regression model showed depressive symptoms explaining the most unique variance in hoarding behaviors. Findings confirm a relatively greater severity of hoarding behaviors in older adults (as compared to younger adults) and suggest that related psychopathology plays a critical role in hoarding expression among older adults. As well, the current study contributes to the ongoing investigation of the diagnostic categorization of compulsive hoarding.

Validity of the Revised Children’s Anxiety and Depression Scale for youth with autism spectrum disorders:

High rates of anxiety and depression are reported among youth with autism spectrum disorders. These conditions are generally assessed using measures validated for typically developing youth. Few studies have investigated their validity for autism spectrum disorders, which is crucial for accurate assessment and the provision of proper treatment. The Revised Children’s Anxiety and Depression Scale was evaluated with 67 youth with autism spectrum disorders to examine its utility in measuring anxiety and depression in this population. Parents and children (aged 11–15 years) referred to a multisite intervention study completed the Pediatric Anxiety Rating Scale, Multidimensional Anxiety Scale for Children, Anxiety Disorders Interview Schedule, Child Behavior Checklist, and Revised Children’s Anxiety and Depression Scale. Results suggest acceptable internal consistency of the Revised Children’s Anxiety and Depression Scale. Modest convergent validity was found among the Revised Children’s Anxiety and Depression Scale and other standardized measures of anxiety and depression. There were stronger correlations between Revised Children’s Anxiety and Depression Scale Total scores and subscales of measures expected to correlate significantly than those not expected to correlate. One exception was a significant association between the Revised Children’s Anxiety and Depression Scale and Child Behavior Checklist Attention subscale, calling into question the divergent validity in separating anxiety from attention problems. Overall, results suggest preliminary support for the Revised Children’s Anxiety and Depression Scale in youth with high-functioning autism spectrum disorders.

An Open Trial of Cognitive-Behavioral Therapy for Anxiety Disorders in Adolescents With Autism Spectrum Disorders

The frequent co-occurrence of anxiety disorders and autism spectrum disorders (ASD) in youth has spurred study of intervention practices for this population. As anxiety disorders in the absence of ASD are effectively treated using cognitive-behavioral therapy (CBT) protocols, an initial step in evaluating treatments for comorbid youth has necessarily centered on adaptation of CBT. One primary limitation of this research, to date, is that interventions for adolescents with anxiety disorders and ASD have not been systematically tested. In this study, 20 adolescents (90% male) with ASD and a comorbid anxiety disorder, between ages 11 and 14 years (M = 12.2 years, SD = 1.11 years), participated in an open trial of modified CBT targeting anxiety with ASD. Findings demonstrated significant reductions in anxiety severity, as assessed by clinician and parent ratings, from baseline to post-treatment. In addition, reductions in parent-rated externalizing symptoms were observed. Gains were maintained at a 1-month follow-up.

The Role of Co-Occurring Disruptive Behavior in the Clinical Presentation of Children and Adolescents with Anxiety in the Context of Autism Spectrum Disorders

This study explored the impact of disruptive behavior disorder (DBD) comorbidity on theoretically relevant correlates among 87 children and adolescents with autism spectrum disorders (ASD) and clinically significant anxiety. Relative to youth with ASD and anxiety alone, participants with ASD, anxiety, and DBD: (a) presented with significantly more severe anxiety symptoms per clinician-, parent-, and self-report; (b) were more likely to be prescribed antipsychotic medication but were no more likely to receive additional psychosocial and educational interventions; and (c) experienced significantly greater functional impairment and family interference. These results suggest that co-occurring DBD in the context of ASD and anxiety confers greater risk for heightened symptom severity and functional impairment, and may be linked with increased prescription of antipsychotic medication.

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.

Family Cognitive-Behavioral Treatment for a Child With Autism and Comorbid Obsessive Compulsive Disorder

Cognitive-behavioral therapy (CBT) with exposure/response prevention is effective among youth with autism spectrum disorders (ASDs) and comorbid anxiety symptoms. This case illustrates the application of a modularized family-based CBT approach with a school-aged boy with autistic disorder and comorbid obsessive-compulsive disorder (OCD). Following 16 family sessions over 21 weeks, “Jerry,” a 9-year-old Caucasian male, showed significant reduction in obsessive-compulsive symptoms. Jerry’s parents also reported improvements in emotional regulation, participation in school activities, and in his parent–child relationships. This case study illustrates the use of family-based CBT, which has been modified to account for social and behavioral deficits endemic to ASDs, for school-aged youth with autism and comorbid OCD.