Home-based video assessment of children's autism-related behaviours: Psychometric analysis and linkages with parental responsiveness and context.

OBJECTIVES: Assessment of autism-related behaviours (ARBs) in children has generally been limited to direct observations in clinical settings or informant-based reports. The widespread availability of video-streaming devices has made home observations of children's ARBs feasible. This approach could enable assessment of the generalization and durability of interventions and may be able to overcome methodological limitations of predominant current assessment approaches (response biases, limited sensitivity to treatment). DESIGN AND METHODS: Forty-four autistic children and their families participated in a repeated-measures study with a correlational design. Approximately 10 hr of unprompted behaviour at home were videorecorded over the course of a week (2 hr per day) for each participant. Gold standard measures of ARBs were also administered (ADOS-2 and ADI-R). Two home-based observational measures of ARBs utilizing streaming video were developed and evaluated: the ARCHER and the CHEERS. Trained independent evaluators made ratings on the ARCHER, CHEERS and an observational measure of parental responsiveness. RESULTS: Correlations with the ADOS-2 and ADI-R were .47 and .34 for ARCHER scores and .51 and .48 for CHEERS scores, respectively. In linear mixed models, more responsive parenting was associated with fewer ARBs on a daily basis. Children spent their afternoons engaged in many typical activities including electronics, homework and games with family members, and ARBs were more prominent in some of these contexts (e.g., electronics) than others (e.g., family games). CONCLUSIONS: Home-based observational assessment of ARBs may be useful for clinical and descriptive research.

Meta-analysis of Psychotherapy for Autistic Youth.

In order to provide more individualized support, it is imperative to further understand the effectiveness of different types of psychotherapy on the clinical areas of need common in autistic youth (Wood et al. in Behav Ther 46:83-95, 2015). Randomized controlled trials of psychotherapy for autistic youth were included if published in English, included random assignment to treatment or control group, required a previous diagnosis of autism, had a mean age of 6-17 years, and provided outcome measure data from both intervention and control groups. A total of 133 measures were coded across 29 studies and included 1464 participants with a mean age of 10.39 years (1.89). A small mean effect size (0.38,95% CI [0.26, 0.47]) was found overall, with the largest effects for cognitive behavioral therapies on autism-related clinical needs (0.81) and overall mental health (0.78). The results show the significant impact of psychotherapy interventions for autistic youth. Additional research should further assess the details of the most effective psychotherapies for each area of clinical need.

Empirically-identified subgroups of children with autism spectrum disorder and their response to two types of cognitive behavioral therapy.

Autism spectrum disorder (ASD) is heterogeneous and likely entails distinct phenotypes with varying etiologies. Identifying these subgroups may contribute to hypotheses about differential treatment responses. The present study aimed to discern subgroups among children with ASD and anxiety in context of the five-factor model of personality (FFM) and evaluate treatment response differences to two cognitive-behavioral therapy treatments. The present study is a secondary data analysis of children with ASD and anxiety (N=202; ages 7-13; 20.8% female) in a cognitive behavioral therapy (CBT) randomized controlled trial (Wood et al., 2020). Subgroups were identified via latent profile analysis of parent-reported FFM data. Treatment groups included standard-of-practice CBT (CC), designed for children with anxiety, and adapted CBT (BIACA), designed for children with ASD and comorbid anxiety. Five subgroups with distinct profiles were extracted. Analysis of covariance revealed CBT response was contingent on subgroup membership. Two subgroups responded better to BIACA on the primary outcome measure and a third responded better to BIACA on a peer-social adaptation measure, while a fourth subgroup responded better to CC on a school-related adaptation measure. These findings suggest that the FFM may be useful in empirically identifying subgroups of children with ASD, which could inform intervention selection decisions for children with ASD and anxiety.

Reward Sensitivity Predicts the Response to Cognitive Behavioral Therapy for Children with Autism and Anxiety.

OBJECTIVE: Cognitive-behavioral therapy (CBT) is an effective treatment for anxiety in youth with autism spectrum disorder (ASD). However, research has yet to examine what cognitive characteristics may influence treatment response. The current study investigated decision-making ability and social cognition as potential (a) predictors of differential treatment response to two versions of CBT and (b) moderators of the effect of treatment condition. METHOD: The study included 148 children (mean age = 9.8 years) with interfering anxiety and a diagnosis of ASD who were enrolled in a randomized clinical trial comparing two versions of CBT for anxiety (standard and adapted for ASD). Participants completed pretreatment measures of decision-making ability (adapted Iowa Gambling Task) and social cognition (Strange Stories) and analyses tested whether task performance predicted treatment response across and between (moderation) treatment conditions. RESULTS: Our findings indicate that decision-making ability moderated treatment outcomes in youth with ASD and anxiety, with a better decision-making performance being associated with higher post-treatment anxiety scores for those who received standard, not adapted, CBT. CONCLUSIONS: Children with ASD and anxiety who are more sensitive to reward contingencies and reinforcement may benefit more from adapted CBT approaches that work more explicitly with reward.

Treatment Fidelity and Outcome in CBT for Youth with Autism: The MEYA Fidelity Scale.

OBJECTIVE: Assessing treatment fidelity in effectiveness research is critical to interpreting study findings. This paper details the development and initial psychometric evaluation of the Modular Evidence-Based Practices for Youth with Autism Fidelity Scale (MEYA-FS) designed to support the assessment of cognitive-behavioral treatments for youth with autism in effectiveness research. METHOD: Recorded treatment sessions (N = 338) were randomly selected from 77 youth (M age = 9.65 years, SD = 1.87; 50.67% White; 85.33% male) who received the Schema, Emotion, and Behavior-Focused Therapy for Children (SEBASTIEN) (n = 51) or Coping Cat (n = 24) program. RESULTS: The MEYA-FS Adherence items displayed acceptable interrater reliability, but more than half of the MEYA-FS Competence items did not. The magnitude and pattern of correlations supported the score validity of the MEYA-FS Adherence and Competence items and subscales. However, some corresponding Adherence and Competence items displayed significant overlap. Scores on each Adherence subscale distinguished between the SEBASTIEN and Coping Cat programs, providing support for discriminant validity. Finally, higher Adherence and Competence subscales predicted significant improvements in youth clinical outcomes (adjustment problems in the school setting, social-communication difficulties, restrictive/repetitive behaviors, and externalizing problems), providing initial evidence for predictive validity. CONCLUSIONS: The psychometric properties of the MEYA-FS make it appropriate for supporting efforts to evaluate cognitive-behavioral interventions for youth with autism in effectiveness and implementation research.

Accommodation of Anxiety in Youth with Autism Spectrum Disorder: Results from the TAASD Study.

Objective: Accommodation, or the ways in which families modify their routines and expectations in response to a child's anxiety, is common and interferes with anxiety treatment outcomes. However, little research has examined family accommodation among youth with autism spectrum disorder and anxiety. The current study aimed to (a) identify pre-treatment correlates of accommodation, (b) examine changes in accommodation after treatment, and (c) assess relationships between accommodation and post-treatment anxiety severity.Method: The sample consisted of 167 youth (mean age = 9.90 years; 79.6% male; 18% Latinx) with clinically significant anxiety and a diagnosis of autism spectrum disorder who were enrolled in a randomized clinical trial comparing two cognitive behavioral therapy interventions for anxiety and treatment-as-usual. Participants were evaluated for symptom severity and family accommodation at pre- and post-treatment.Results: Results indicated that clinician-rated anxiety severity and parent-rated externalizing behaviors and autism spectrum disorder severity significantly predicted pre-treatment accommodation. Accommodation significantly decreased from pre- to post-treatment and non-responders showed significantly higher accommodation at post-treatment compared to responders. Finally, youth with higher pre-treatment accommodation had higher post-treatment anxiety.Conclusions: Findings indicate that accommodation for anxiety is common among youth with autism spectrum disorder and anxiety. Furthermore, accommodation is implicated in treatment outcomes and should be targeted in treatment for youth with autism spectrum disorder and anxiety.

Predictors of Suicidal Thoughts in Children with Autism Spectrum Disorder and Anxiety or Obsessive-Compulsive Disorder: The Unique Contribution of Externalizing Behaviors.

Children with autism spectrum disorder (ASD) are at elevated risk of suicidal ideation, particularly those with comorbid anxiety disorders and/or obsessive-compulsive disorder (OCD). We investigated the risk factors associated with suicidal ideation in 166 children with ASD and comorbid anxiety disorders/OCD, and the unique contribution of externalizing behaviors. Suicidal ideation was reported in the child sample by 13% of parents. Controlling for child age, sex, and IQ, perceived loneliness positively predicted the likelihood of suicidal ideation. In addition, externalizing behaviors positively predicted suicidal ideation, controlling for all other factors. Reliance on parental report to detect suicidal ideation in youth with ASD is a limitation of this study. Nonetheless, these findings highlight the importance of assessing and addressing suicidal ideation in children with ASD and comorbid anxiety disorders/OCD, and more importantly in those with elevated externalizing behaviors and perceptions of loneliness.

Anger Outbursts in Youth with ASD and Anxiety: Phenomenology and Relationship with Family Accommodation.

Anger outbursts (AO) are associated with severe symptoms, impairment and poorer treatment outcomes for anxious children, though limited research has examined AO in youth with co-occurring autism and anxiety disorders. This study examined AO in children with autism and anxiety by evaluating clinical characteristics, family accommodation, and changes in AO following anxiety-focused treatment. The sample comprised 167 youth with autism and anxiety enrolled in a multi-site randomized clinical trial comparing standard care CBT for anxiety, CBT adapted for youth with autism, and usual care. Most participants (60%) had AO, which contributed to impairment above and beyond anxiety and autism. AO impacted functional impairment indirectly through a pathway of parental accommodation. AO reduced with anxiety-focused treatment. Findings highlight that AO are common in this population and uniquely contribute to functional impairment, indicating a need for direct targeting in treatment.

The Pediatric Autism Spectrum Therapy Observation System: Development, Psychometric Properties, and Sensitivity to Treatment.

An observational coding system was developed to track clinical change in children with autism spectrum disorder (ASD) during psychotherapy. The Pediatric Autism Spectrum Therapy Observation System (PASTOS) consists of 23 items divided into 5 subscales and is used to rate child behaviors in individual psychotherapy sessions. Manual-based cognitive behavioral therapy session transcripts of 22 children diagnosed with ASD (IQ > 70) and a concurrent anxiety disorder (M = 9.41 years, SD = 1.56 years) enrolled in a randomized, controlled trial were coded. Results suggested that the PASTOS exhibited promising interrater reliability, internal consistency, convergent validity at post-treatment, and treatment sensitivity. The PASTOS may be a useful tool for studying process and outcome in psychotherapy research on children with ASD.

The Impact of Comorbidity on Cognitive-Behavioral Therapy Response in Youth with Anxiety and Autism Spectrum Disorder.

The impact of externalizing comorbidity on treatment outcome was examined in 104 youth ages 7-16 (M = 11.09 years) with autism spectrum disorder and primary anxiety/obsessive compulsive disorder who completed modular cognitive behavioral therapy (CBT) for anxiety/OCD. Three comorbidity profiles were utilized for group comparisons: participants with oppositional defiant or conduct disorder with attention-deficit hyperactivity disorder (ODD; CD; ADHD; group EXT, n = 25); those without ODD/CD and only ADHD (group ADHD, n = 46); and those without externalizing comorbidity (NO-EXT, n = 33). Post-treatment outcomes were measured continuously (Pediatric Anxiety Rating Scale, Clinical Global Impression-Severity) and categorically (treatment response, remission). The ADHD group was four times more likely of being a treatment responder compared to NO-EXT (OR 4.05). Comorbidity group did not impact remission. After controlling for pre-treatment scores, there was a significantly greater reduction of the CGI-S for ADHD versus NO-EXT and EXT versus NO-EXT, but results did not significantly differ for the PARS. Results suggest that a modular CBT approach yields positive impact for treatment outcomes in youth with comorbid externalizing problems, particularly among those with comorbid ADHD.

Open Trial of Modular Cognitive-Behavioral Therapy in the Treatment of Anxiety Among Late Adolescents with Autism Spectrum Disorder.

Given the high rates of comorbid anxiety and autism spectrum disorder (ASD) in the adolescent and young adult population, effective treatment protocols to address anxiety symptoms are of importance to help promote greater independence across settings. While research supports the use of cognitive-behavioral therapy (CBT) across younger age groups with ASD, the literature is limited on interventions benefitting adolescents and young adults with comorbid anxiety disorders and ASD. Therefore, this open trial utilized a modified CBT manual for seven participants between the ages of 16 and 20 years, consisting of a 16-week modularized CBT treatment, including psychoeducation, cognitive therapy, and exposure therapy. Measures of anxiety and depression were completed at baseline and post-treatment. Findings demonstrated significant reductions on clinician-rated measures of anxiety. While findings are encouraging, additional studies examining the efficacy of CBT for this population with ASD and clinical anxiety are necessary to further identify beneficial treatment components.

Anxiety Disorders Interview Schedule-Autism Addendum: Reliability and Validity in Children With Autism Spectrum Disorder.

Assessing anxiety in autism spectrum disorder (ASD) is inherently challenging due to overlapping (e.g., social avoidance) and ambiguous symptoms (e.g., fears of change). An ASD addendum to the Anxiety Disorders Interview Schedule-Child/Parent, Parent Version (ADIS/ASA) was developed to provide a systematic approach for differentiating traditional anxiety disorders from symptoms of ASD and more ambiguous, ASD-related anxiety symptoms. Interrater reliability and convergent and discriminant validity were examined in a sample of 69 youth with ASD (8-13 years, 75% male, IQ = 68-143) seeking treatment for anxiety. The parents of participants completed the ADIS/ASA and a battery of behavioral measures. A second rater independently observed and scored recordings of the original interviews. Findings suggest reliable measurement of comorbid (intraclass correlation = 0.85-0.98, κ = 0.67-0.91) as well as ambiguous anxiety-like symptoms (intraclass correlation = 0.87-95, κ = 0.77-0.90) in children with ASD. Convergent and discriminant validity were supported for the traditional anxiety symptoms on the ADIS/ASA, whereas convergent and discriminant validity were partially supported for the ambiguous anxiety-like symptoms. Results provide evidence for the reliability and validity of the ADIS/ASA as a measure of traditional anxiety categories in youth with ASD, with partial support for the validity of the ambiguous anxiety-like categories. Unlike other measures, the ADIS/ASA differentiates comorbid anxiety disorders from overlapping and ambiguous anxiety-like symptoms in ASD, allowing for more precise measurement and clinical conceptualization. Ambiguous anxiety-like symptoms appear phenomenologically distinct from comorbid anxiety disorders and may reflect either symptoms of ASD or a novel variant of anxiety in ASD.

Trait self-control predicts adolescents' exposure and reactivity to daily stressful events.

The current study used an influence model of personality and stress processes to examine the association between individual differences in trait self-control and daily stress exposure and reactivity in adolescent youth. A total of 129 adolescents (Mage = 14.7 years, 59% female) completed individual difference measures of self-control, neuroticism, and measures of responses to stress. Participants then reported on daily stressful events, stress severity, mood, coping, and mindlessness (a predictor of acting on impulse) for 14 consecutive days. Self-control predicted less exposure to daily stress, less reactivity to daily stress, and more adaptive responses to stress. Specifically, adolescents with higher self-control experienced fewer daily stressors and reported lower stress severity, particularly when daily mindlessness was high. Second, adolescents with higher self-control reported less mindlessness in response to daily stress relative to those with lower self-control, but they did not show differences in emotional reactivity to stress. Finally, results also offered evidence for an indirect effect of problem-focused coping strategies between self-control and emotional reactivity to stress. The current investigation illustrates the importance of trait self-control in daily stress processes among adolescents and suggests possible mechanisms through which self-control confers these positive effects.

The relationship between alliance and client involvement in CBT for child anxiety disorders.

Little is known about the nature of the relationship between the alliance and client involvement in child psychotherapy. To address this gap, we examined the relationship between these therapy processes over the course of cognitive-behavioral therapy (CBT) for child anxiety disorders. The sample was 31 child participants (M age = 9.58 years, SD = 2.17, range = 6-13 years, 67.7% boys; 67.7% Caucasian, 6.5% Latino, 3.2% Asian/Pacific Islander, and 22.6% mixed/other) diagnosed with a primary anxiety disorder. The participants received a manual-based individual CBT program for child anxiety or a manual-based family CBT program for child anxiety. Ratings of alliance and client involvement were collected on early (Session 2) and late (Session 8) treatment phases. Two independent coding teams rated alliance and client involvement. Change in alliance positively predicted late client involvement after controlling for initial levels of client involvement. In addition, change in client involvement positively predicted late alliance after controlling for initial levels of the alliance. The findings were robust after controlling for potentially confounding variables. In CBT for child anxiety disorders, change in the alliance appears to predict client involvement; however, client involvement also appears to predict the quality of the alliance. Our findings suggest that the nature of the relationship between alliance and client involvement may be more complex than previously hypothesized. In clinical practice, tracking alliance and level of client involvement could help optimize the impact and delivery of CBT for child anxiety.

Gender Differences: Confirmatory Factor Analysis of the ADOS-II.

PURPOSE: Recent research has suggested that autism may present differently in girls compared to boys, encouraging the exploration of a sex-differential diagnostic criteria. Gender differences in diagnostic assessments have been shown on the ADOS-II, such that, on average, females score significantly lower than males on all scales and are less likely to show atypicality on most items related to social communicative difficulties. Yet, gender differences in the latent structure of instruments like the ADOS-II have not been examined systematically. METHODS: As such, this secondary data analysis examined 4,100 youth diagnosed with autism (Mage = 9.9, 813 female & 3287 male) examined item response trends by gender on the ADOS-II Module 3. RESULTS: Multi-Group Confirmatory Factor Analysis results show that the factor loadings of four ADOS-II items differ across the genders. One SCD item and one RRB item are strongly related to the latent factor in the female group, while two RRB items have larger factor loadings in the male group. CONCLUSION: The assumption of an identical latent factor structure for the ADOS-II Module 3 for males and females might not be justifiable. Possible diagnostic implications are discussed.

Practitioner Adherence and Competence in MEYA, a Free Online Self-Instruction Program in Modular Psychotherapy and Counseling for Children's Autism-Related Clinical Needs.

The quality of care in public schools and other community settings for school-aged youths on the autism spectrum is variable and often not evidence-based. Training practitioners in these settings to deliver evidence-based practices (EBPs) may improve the quality of care. We developed a free internet-based training and clinical guidance system synthesizing multiple EBPs for youth on the autism spectrum addressing a range of mental health needs and autism-related behaviors, entitled Modular EBPs for Youth on the Autism Spectrum (MEYA; meya.ucla.edu). A multiple baseline study was conducted with seven practitioners recruited from mental health practice settings across the United States who were providing services to children on the autism spectrum (aged 6 to 17 years). Practitioners were randomly assigned to undergo baseline conditions of 2 to 8 weeks. Once online training in MEYA commenced, practitioners engaged in algorithm-guided self-instruction in EBPs for autism. Participants video-recorded sessions. Independent coders used the MEYA Fidelity Scale (MEYA-FS) to rate adherence and competence in EBPs for autism. Practitioners also completed measures pertaining to implementation outcomes and parents rated youth outcomes on personalized target behaviors. Five of seven practitioners increased their adherence to MEYA practices (i.e., MEYA-FS scores) following MEYA training. Findings for competence were similar, though somewhat less robust. Practitioners generally viewed MEYA as feasible, understandable, and acceptable. Most youth outcomes improved during MEYA. A randomized, controlled trial of MEYA would be helpful in characterizing its effectiveness for supporting practitioner EBP implementation and youth outcomes in school and community service settings.

Cognitive behavioral therapy age effects in child and adolescent anxiety: an individual patient data metaanalysis.

BACKGROUND: Investigations of age effects on youth anxiety outcomes in randomized trials (RCTs) of cognitive behavior therapy (CBT) have failed to yield a clear result due to inadequate statistical power and methodologic weaknesses. We conducted an individual patient data metaanalysis to address this gap. QUESTION: Does age moderate CBT effect size, measured by a clinically and statistically significant interaction between age and CBT exposure? METHODS: All English language RCTs of CBT for anxiety in 6-19 year olds were identified using systematic review methods. Investigators of eligible trials were invited to submit their individual patient data. The anxiety disorder interview schedule (ADIS) primary diagnosis severity score was the primary outcome. Age effects were investigated using multilevel modeling to account for study level data clustering and random effects. RESULTS: Data from 17 of 23 eligible trials were obtained (74%); 16 studies and 1,171 (78%) cases were available for the analysis. No interaction between age and CBT exposure was found in a model containing age, sex, ADIS baseline severity score, and comorbid depression diagnosis (power ≥ 80%). Sensitivity analyses, including modeling age as both a categorical and continuous variable, revealed this result was robust. CONCLUSIONS: Adolescents who receive CBT in efficacy research studies show benefits comparable to younger children. However, CBT protocol modifications routinely carried out by expert trial therapists may explain these findings. Adolescent CBT protocols are needed to facilitate the transportability of efficacy research effects to usual care settings where therapists may have less opportunity for CBT training and expertise development.

Daily living skills in school-age children with and without anxiety disorders.

OBJECTIVE: Anxiety may interfere with school-age children's independent behaviour and hence, their daily living skills (DLS). Nonetheless, this has not been tested in previous studies of children with clinical anxiety. METHOD: This study compared two groups of age-, gender-, and ethnicity-matched children with and without anxiety disorders (N = 60), testing the association of anxiety disorders with a lack of independence in DLS. RESULTS: Anxiety disorders are significantly associated with less mastery of DLS. Age moderated this effect for children with anxiety disorders; older children were more negatively impacted by anxiety disorders than younger children. CONCLUSIONS: Anxiety disorders may negatively impact children's independence in DLS. As children transition from mid- to late childhood - a period normally marked by increasing independence - this effect may grow in magnitude.

Examining Diagnostic Trends and Gender Differences in the ADOS-II.

Approximately 3-4 boys for every girl meet the clinical criteria for autism in studies of community diagnostic patterns and studies of autism using samples of convenience. However, girls with autism have been hypothesized to be underdiagnosed, possibly because they may present with differing symptom profiles as compared to boys. This secondary data analysis used the National Database of Autism Research (NDAR) to examine how gender and symptom profiles are associated with one another in a gold standard assessment of autism symptoms, the Autism Diagnostic Observation Schedule II (ADOS-II; Lord, C., Luyster, R., Guthrie, W., & Pickles A. (2012a). Patterns of developmental trajectories in toddlers with autism spectrum disorder. Journal of Consulting and Clinical Psychology, 80(3):477-489. https://doi.org/10.1037/a0027214 . Epub 2012 Apr 16. PMID: 22506796, PMCID: PMC3365612). ADOS-II scores from 6183 children ages 6-14 years from 78 different studies in the NDAR indicated that gender was a significant predictor of total algorithm, restrictive and repetitive behavioral, and social communicative difficulties composite severity scores. These findings suggest that gender differences in ADOS scores are common in many samples and may reflect on current diagnostic practices.

Idiographic Coping Outcomes in Youth with Autism Spectrum Disorder and Co-Occurring Anxiety: Results from the TAASD Study.

Versions of cognitive behavioral therapy (Coping Cat, CC; Behavioral Interventions for Anxiety in Children with Autism, BIACA) have shown efficacy in treating anxiety among youth with autism spectrum disorder. Measures of efficacy have been primarily nomothetic symptom severity assessments. The current study examined idiographic coping outcomes in the Treatment of Anxiety in Autism Spectrum Disorder study (N = 167). Longitudinal changes in coping with situations individualized to youth fears (Coping Questionnaire) were examined across CC, BIACA and treatment as usual (TAU) in a series of multilevel models. CC and BIACA produced significantly greater improvements than TAU in caregiver-reported coping. Youth report did not reflect significant differences. Results show the efficacy of CC and BIACA in improving idiographic caregiver-, but not youth-, reported youth coping.