A pilot, single-arm feasibility study of an integrated cognitive-behavioral treatment for anxiety in young autistic children.

OBJECTIVE: Anxiety is prevalent in young autistic children under 7 years of age. Yet there is a paucity of empirically based interventions for this age group. DINO Strategies for Anxiety and Uncertainty Reduction (DINOSAUR) is an innovative cognitive behavioral intervention that seeks to optimize treatment response in young autistic children by targeting anxiety and the contributing mechanisms of intolerance of uncertainty and parental accommodation using a telehealth delivery model. This pilot, single-arm study examines the preliminary feasibility of DINOSAUR. METHODS: Fourteen autistic children ages 4-6 years with average language and cognitive skills and their parents received the intervention. Quantitative and qualitative data pertaining to parent satisfaction and treatment outcomes were collected. RESULTS: Attendance, retention, and parent satisfaction ratings offer preliminary support for the feasibility of the treatment model. Change in clinical severity ratings on a semi-structured parent interview of anxiety and parents' qualitative report suggests the potential to benefit young autistic children. CONCLUSIONS: Results support future study of the DINOSAUR model in a larger, randomized controlled trial.

Anxiety in autistic preschool children: Phenomenology and a network analysis of correlates.

Anxiety disorders in autistic children are associated with significant functional impairment. Few studies have examined impairing anxiety presentations in autistic preschool children (i.e., 3-5 years old). This cross-sectional study examined the phenomenology of impairing anxiety and the strongest correlates of anxiety in 75 autistic preschool children. Parents completed a diagnostic interview that assesses two anxiety types, DSM-5 anxiety disorders and impairing distinct anxiety presentations, and measures of anxiety correlates. An exploratory network analysis examined connections between anxiety and its correlates. Forty percent of children had impairing anxiety. Specific phobia followed by 'other social fear,' a type of distinct anxiety, were the most common anxiety types. Child intolerance of uncertainty (IU) was the only correlate that was associated with anxiety in a network analysis framework. Child IU linked anxiety to two other correlates, sensory over-responsivity and somatic symptoms. Findings emphasize the need for early intervention for anxiety and further research on its correlates.

Effect of Co-occurring Psychiatric Disorders on Treatment of Children with Autism Spectrum Disorder and Anxiety.

Co-occurring psychiatric diagnoses are very common in individuals with ASD. Little is known about the effect that co-occurring psychiatric conditions may have on treatment response to CBT for children with ASD and anxiety. The present study examined the relationship between co-occurring psychiatric diagnoses and response to CBT for anxiety in ninety youth with ASD. Psychiatric complexity did not appear to differentially impact treatment response. A notable portion of youth with anxiety and externalizing disorders such as ADHD, no longer met criteria for those externalizing diagnoses following intervention. Results indicate that youth with ASD and anxiety present with complex psychiatric profiles and CBT for anxiety may positively affect co-occurring diagnoses. In addition, thorough and nuanced assessment of psychiatric symptoms in youth with ASD is needed to ensure the differentiation between diagnoses of anxiety and other co-occurring psychiatric symptoms.

The Role of Maternal Anxiety in Treatment Response for Youth with ASD and Co-occurring Anxiety.

Anxiety disorders occur at higher rates in youth with ASD than in neurotypical youth. Although the efficacy of CBT for anxiety in children with ASD is widely supported, factors that influence treatment outcomes are not well understood. This study examined the role of maternal anxiety in treatment outcomes for youth with ASD. Youth with ASD and anxiety (ages 8 to 14), along with their mothers (n = 87), participated in a group CBT intervention. Results indicated that maternal anxiety did not improve over the course of treatment. However, findings suggest that high levels of maternal anxiety at pre-treatment predicted higher levels of youth anxiety post-treatment. Importantly, the relationship between parent anxiety and youth outcomes was moderated by child age. The findings of the present study may provide initial insight into the role that maternal anxiety plays in treatment outcomes for children with ASD and co-occurring anxiety, particularly when considering child age.

Exploring the Symptom Profiles of Intolerance of Uncertainty in Autistic Children.

Intolerance of uncertainty (IU) is a multidimensional construct involving maladaptive responses to uncertainty. IU is strongly associated with autism and anxiety, yet no studies have examined its symptom profile in autistic children. This study compares IU symptom profiles in autistic and NT children and in autistic children with and without anxiety using the Intolerance of Uncertainty Scale for Children. Compared to NT peers, autistic children exhibited heightened IU symptoms in all domains, affective, behavioral, and cognitive; affective symptoms had the highest association with autism. Autistic children with anxiety also exhibited elevated IU symptoms in all domains compared to those without anxiety; behavioral IU symptoms had the highest association with anxiety. IU symptom profiles should be considered in assessment and treatment.

Dysregulation in Children and Adolescents Presenting to a Multidisciplinary Autism Clinic.

Research indicates that children with autism spectrum disorder (ASD) frequently exhibit dysregulation, which refers to poorly coordinated affective, behavioral, and cognitive responses to a given situation. We examined the characteristics of dysregulation in children presenting to a multidisciplinary ASD clinic for an ASD diagnostic evaluation. Sixty percent of children presenting for an ASD evaluation exhibited dysregulation. Dysregulation prevalence was higher in children without ASD versus with ASD (69% versus 56%). Severe dysregulation was higher in children without ASD (29% versus 16%). Both groups with severe dysregulation were equally likely to be taking psychiatric medications, however, children with ASD were less likely to be receiving therapy. These findings highlight the importance of implementing dysregulation screening and treatment protocols in ASD centers.

DINOSAUR: an integrated cognitive-behavioral treatment for anxiety in young children with ASD.

BACKGROUND: Anxiety disorders are highly prevalent in children and adolescents with autism spectrum disorder and often emerge before the age of 6 years. Yet, only a few studies have examined anxiety treatment for this group. Preliminary evidence from these studies suggests that utilizing cognitive behavioral therapy (CBT) as well as strategies to target intolerance of uncertainty (IU) and parental accommodation, known mechanistic and maintaining factors of anxiety may improve anxiety and optimize outcomes in this age group. MAIN BODY: To meet this need, we developed an integrated treatment called DINO Strategies for Anxiety and intolerance of Uncertainty Reduction (DINOSAUR), a 12-week group telehealth treatment for 4- to 6-year-old children with ASD. DINOSAUR works with young children and their parents to deliver CBT along with interventions targeting IU and parental accommodation. In this paper, we first discuss the rationale for developing this treatment and then describe a pilot study of its feasibility and preliminary efficacy. CONCLUSIONS: There is a great need to develop anxiety treatments for young children with ASD. We proposed a novel integrated treatment approach that aims to alter the way young children and parents respond to fear, which could potentially improve short- and long-term mental health outcomes for this age group. TRIAL REGISTRATION: ClinicalTrials.gov NCT04432077 on June 03, 2020.

Psychiatric problems during the COVID-19 pandemic in children with autism spectrum disorder.

Children with autism spectrum disorder (ASD) are at elevated risk for psychiatric problems in response to the COVID-19 pandemic. This risk is due to their high rates of pre-pandemic psychiatric comorbidities and the pandemic's disruption to routines and access to necessary supports. Prior research has indicated that children with ASD may experience a worsening of specific psychiatric symptoms in response to COVID-19, though this body of work is limited in scope. The present study expands this literature by examining specific types of psychiatric problems that emerged about 2 months after the onset of the pandemic, and risk factors predicting changes in these psychiatric symptoms. Parents of children with a confirmed ASD diagnosis (N = 257), who enrolled in a clinic registry at an outpatient specialty autism center, were included in this study. All data were gathered online via customized and standardized questionnaires. Results showed that 59% of children experienced either a worsening of their pre-pandemic psychiatric diagnoses and/or the development of new psychiatric symptoms during the pandemic. Multivariable regression models indicated that risk factors for increased psychiatric problems included child understanding of COVID-19, COVID-19 illness in the family, low family income, and elevated parental depression and anxiety symptoms (all p < 0.05). Findings from this study emphasize the urgent need to provide effective and accessible psychiatric services for children with ASD and their families during and after the pandemic. LAY SUMMARY: Children with ASD are at high risk for psychiatric problems during the COVID-19 pandemic. We found that 59% of children in our clinical sample are experiencing increased psychiatric problems. The child's understanding of COVID-19, COVID-19 illness in the family, low family income, and depression and anxiety symptoms in the parent increase the risk for poor mental health during the pandemic. These findings indicate the importance of helping children with ASD access mental health treatment during COVID-19.

A Scoping Review of Anxiety in Young Children with Autism Spectrum Disorder.

Research on anxiety in children and adolescents with autism spectrum disorder (ASD) has burgeoned in the past 15 years. Most of the research has focused on school-age children, ages 6 to 18 years. Yet, recent studies suggest that anxiety can emerge in young children, under 6 years, with ASD. This scoping review synthesized the literature on anxiety in young children with ASD. Three domains of anxiety research were reviewed: (a) prevalence/severity, phenomenology, and course; (b) correlates; and (c) treatment. Four online databases were searched from the start of the database until March 2020. Keywords pertaining to anxiety, autism, and young children were entered. The search identified 44 articles for inclusion. These studies varied with respect to sample source, informants, and measures to assess anxiety. The overall prevalence of anxiety ranged from 1.6 to 62%. Sixteen of 17 studies found that young children with ASD had higher levels of anxiety compared to various control groups. A variety of DSM anxiety symptoms and disorders were present in young children with the most common symptoms being specific, social, and generalized fears. Correlates of anxiety included sensory over-responsivity, sleep disturbance, aggression/defiance, and attention deficit/hyperactivity disorder. Three cognitive behavioral treatment studies for anxiety and one developmental intervention targeting ASD symptoms showed promise in reducing anxiety. Findings indicate an early emergence of anxiety in some children with ASD. Further research on the measurement, pathophysiology, and treatment of anxiety in early childhood is critical to improving outcomes in children with ASD. LAY SUMMARY: This scoping review synthesizes the literature on anxiety in young children with autism spectrum disorder (ASD). Results indicate that children with ASD have higher levels of anxiety than children without ASD. Potential factors that could be contributing to anxiety include sensory, sleep, and behavioral problems. Preliminary studies show that anxiety can improve with cognitive behavioral treatment. These findings suggest that research on anxiety in young children with ASD should be prioritized to improve mental health outcomes.

Investigating the factor structure of the child behavior checklist dysregulation profile in children and adolescents with autism spectrum disorder.

Dysregulation has been identified as an important risk factor for the development of psychiatric disorders in individuals with autism spectrum disorder (ASD). Therefore, it is necessary to empirically characterize dysregulation and identify psychometrically sound and readily available assessment methods in the ASD population. We sought to evaluate the factor structure of the Child Behavior Checklist-Dysregulation Profile (CBCL-DP), an established dysregulation measure in neurotypical children that is derived from the CBCL, in a large, clinically referred sample of children, ages 6-18 years, with ASD (n = 727). Confirmatory factor analysis was used to characterize dysregulation and assess the validity of the CBCL-DP in children with ASD. Our findings support a bi-factor model of dysregulation in which dysregulation is a broad and distinct syndrome that is associated with the three subdomains of the CBCL-DP, anxiety/depression (AD), attention problems (AP), and aggressive behavior (AGG). Dysregulation was associated with most items in the AD and AGG domains and few items in the AP domain. This association with AD and AGG indicates that dysregulation in ASD may be conceptualized as the combined experience of internalized, negative mood states and externalized, reactive behaviors. These findings provide support as well as important caveats for the use of the CBCL-DP as a measure of dysregulation in the ASD population. Autism Res 2020, 13: 436-443. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Dysregulation is a risk factor for psychiatric disorders in ASD. This study examined if the CBCL-DP, an established measure of dysregulation in neurotypical children, can be used to assess dysregulation in children with ASD. Findings provide evidence that in ASD, dysregulation is a broad construct that exists alongside anxiety/depression, attention problems, and aggression. These findings indicate that the CBCL-DP can be considered a valid measure of dysregulation in the ASD population and could be used in clinical settings.

Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the US.

BACKGROUND: Visits to the emergency department (ED) for psychiatric purposes are an indicator of chronic and acute unmet mental health needs. In the current study, we examined if psychiatric ED visits among individuals 6 to 24 years of age are increasing nationwide. METHODS: ED data came from the 2011-2015 National Hospital Ambulatory Medical Care Survey, a national survey of ED visits across the United States. Psychiatric ED visits were identified by using the International Classification of Diseases, Ninth Revision and reason-for-visit codes. Survey-weighted logistic regression analyses were employed to examine trends in as well as correlates of psychiatric ED visits. Data from the US Census Bureau were used to examine population rates. RESULTS: Between 2011 and 2015, there was a 28% overall increase (from 31.3 to 40.2) in psychiatric ED visits per 1000 youth in the United States. The largest increases in psychiatric ED visits per 1000 US youth were observed among adolescents (54%) and African American (53%) and Hispanic patients (91%). A large increase in suicide-related visits (by 2.5-fold) was observed among adolescents (4.6-11.7 visits per 1000 US youth). Although psychiatric ED visits were long (51% were ≥3 hours in length), few (16%) patients were seen by a mental health professional during their visit. CONCLUSIONS: Visits to the ED for psychiatric purposes among youth are rising across the United States. Psychiatric expertise and effective mental health treatment options, particular those used to address the rising suicide epidemic among adolescents, are needed in the ED.

Exploring Relationships Between Negative Cognitions and Anxiety Symptoms in Youth With Autism Spectrum Disorder.

Although cognitions are central to the conceptualization and treatment of anxiety in typically developing (TD) youth, there is scant research investigating automatic thoughts and their relationship with anxiety in youth with autism spectrum disorder (ASD). We sought to examine the types of automatic thoughts experienced by youth with ASD and co-occurring anxiety as well as the predictive relationship of anxiety to different types of automatic thoughts in 97 children, ages 8-14 years. We also explored the relationship of automatic thoughts and intolerance of uncertainty. Consistent with prior data, there was a strong relationship between anxiety and automatic thoughts pertaining to social and physical threat. Anxiety and IU were independently associated with thoughts pertaining to personal failure which raises the hypothesis that personal failure may serve as a common pathway between anxiety, IU, and depression in ASD youth. These findings highlight the importance of assessing and treating negative cognitions in youth with ASD and anxiety.

Training clinicians to deliver group CBT to manage anxiety in youth with ASD: Results of a multisite trial.

OBJECTIVE: Few guidelines are available regarding optimal training models for practitioners delivering cognitive-behavioral therapy (CBT) for anxiety in youth with autism spectrum disorder (ASD). The present study systematically compared 3 instructional conditions for delivering the Facing Your Fears program (FYF) to children with ASD and anxiety. METHOD: Thirty-four clinicians (Mage = 34 years; 94% women, 88% Caucasian) and an intent-to-treat sample of 91 children with ASD and anxiety (Mage = 11; 84% male 53% Caucasian) met eligibility criteria across 4 sites. A 3-group parallel design via a Latin square procedure was used to randomize 9 teams of clinicians to 1 of 3 training conditions: Manual, Workshop, Workshop-Plus. The effectiveness of instructional condition was assessed via implementation (CBT knowledge, treatment fidelity) and treatment outcomes (reductions in anxiety as measured by the Anxiety Disorders Interview Schedule-Parent (ADIS-P). RESULTS: Clinicians in both Workshop conditions significantly increased CBT knowledge postworkshop, F(1, 18) = 19.8, p < .001. Excellent treatment fidelity was obtained across conditions (above 89%), although clinicians in the Workshop conditions obtained significantly higher fidelity ratings and delivered FYF with greater quality than the Manual condition. Children with ASD demonstrated significant reductions in anxiety symptoms for three of the four anxiety diagnoses, with no differences noted across instructional condition. Rates of improvement were lower than those obtained in a previous controlled trial. CONCLUSIONS: Results suggest that although there may be some advantage to participating in a Workshop, clinicians in all conditions could deliver FYF with excellent fidelity and yield positive treatment outcomes. Lack of a no-treatment comparison group limits interpretation of findings. (PsycINFO Database Record

Psychosocial interventions for internalizing disorders in youth and adults with ASD.

Internalizing disorders are common in individuals with ASD. Psychosocial interventions targeting these disorders in the ASD population have burgeoned in the last decade. Cognitive-behavioural therapy, modified for ASD, is the most frequently investigated model, although other interventions, including behaviour therapy, third-wave interventions, models targeting transdiagnostic constructs, and alternative interventions and treatment delivery methods are now emerging. This review provides a summary of the efficacy of these interventions in treating internalizing disorders in youth and adults with ASD. The barriers to accessing these treatments, which are experienced by many individuals with ASD and their families, as well as future research directions, are also discussed.

Relationships between autism spectrum disorder and intolerance of uncertainty.

Intolerance of uncertainty (IU) is a dispositional risk factor involving maladaptive responding under conditions of uncertainty. Recent data indicate that IU is likely elevated in youth with autism spectrum disorder (ASD) and is positively correlated with anxiety. This study examined whether IU may be associated with ASD independent of anxiety. Relationships between anxiety, ASD, and IU were examined in 57 children with ASD without co-occurring intellectual disability and 32 control participants, ages 7-16 years. Hierarchal linear regressions were run to examine whether ASD variables, including emotion dysregulation, were predictive of IU when controlling for anxiety. Severity of social communication deficits, repetitive behaviors, and emotion dysregulation were each related to IU when controlling for the effects of anxiety. When these variables were entered into the regression model together, emotion dysregulation was the only significant predictor of IU. These findings suggest that IU is directly related to features of ASD possibly due to shared genetic, neurological, or psychological underpinnings. Autism Res 2018, 11: 636-644. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Youth with ASD without co-occurring intellectual disability experience high levels of intolerance of uncertainty (IU), which is related to anxiety. This study found that IU may also have a relationship with certain aspects of ASD, particularly emotion dysregulation.

Priorities for Advancing Research on Youth with Autism Spectrum Disorder and Co-occurring Anxiety.

Research on anxiety disorders in youth with autism spectrum disorder (ASD) has burgeoned in the past two decades. Yet, critical gaps exist with respect to measuring and treating anxiety in this population. This study used the nominal group technique to identify the most important research priorities on co-occurring anxiety in ASD. An international group of researchers and clinicians with experience in ASD and anxiety participated in the process. Topics ranked as most important focused on understanding how ASD symptoms affect treatment response, implementing treatments in real world settings, developing methods to disentangle overlapping symptoms between anxiety and ASD, and developing objective measures to assess anxiety. Collectively, these priorities can lead to collaborative studies to accelerate research in the field.

Intolerance of Uncertainty Predicts Anxiety Outcomes Following CBT in Youth with ASD.

Modified cognitive-behavioral therapy (MCBT) has been demonstrated to reduce anxiety in youth with autism spectrum disorder (ASD). However, non-response rates are fairly high. Few studies have investigated factors associated with response. Intolerance of uncertainty (IU) is a treatment target for anxiety and worry in neurotypical populations and has been linked to anxiety and ASD. We sought to examine whether IU affects outcomes following MCBT in 43 children, ages 8-14 years, with ASD without intellectual disability. Consistent with prior data, there was a significant reduction in parent reported anxiety following MCBT. Higher levels of pre-intervention IU predicted higher anxiety and worry pre- and post-intervention. These findings suggest that targeting IU may improve outcomes following MCBT in youth with ASD and anxiety.

Anxiety, sensory over-responsivity, and gastrointestinal problems in children with autism spectrum disorders.

Children with autism spectrum disorders (ASD) experience high rates of anxiety, sensory processing problems, and gastrointestinal (GI) problems; however, the associations among these symptoms in children with ASD have not been previously examined. The current study examined bivariate and multivariate relations among anxiety, sensory over-responsivity, and chronic GI problems in a sample of 2,973 children with ASD enrolled in the Autism Treatment Network (ages 2-17 years, 81.6 % male). Twenty-four percent of the sample experienced at least one type of chronic GI problem (constipation, abdominal pain, bloating, diarrhea, and/or nausea lasting three or more months). Children with each type of GI problem had significantly higher rates of both anxiety and sensory over-responsivity. Sensory over-responsivity and anxiety were highly associated, and each provided unique contributions to the prediction of chronic GI problems in logistic regression analyses. The results indicate that anxiety, sensory over-responsivity and GI problems are possibly interrelated phenomenon for children with ASD, and may have common underlying mechanisms.