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Guideline Supplementary Paper
New Zealand Autism Spectrum Disorder Guideline supplementary paper on cognitive behaviour therapy for adults with ASD
With the support of the New Zealand Autism Spectrum Disorder
Living Guideline Group
7 March 2016
Ministry of Health 2016
Published by INSiGHT Research Ltd181 Blighs Rd, Strowan 8052, New Zealand
ISBN: 978-0-947515-65-2 (online)
Copyright
This work is licensed under the Creative Commons Attribution 4.0 International licence. In essence, you are free to: share ie, copy and redistribute the material in any medium or format; adapt ie, remix, transform and build upon the material. You must give appropriate credit, provide a link to the licence and indicate if changes were made.
Funding and independence
This work was funded by the New Zealand Ministry of Health and sponsored by the New Zealand Ministry of Education.
The work was researched and written by INSIGHT Research Ltd employees or contractors. Appraisal of the evidence, formulation of recommendations and reporting are independent of the Ministries of Health and Education.
Statement of intent
INSIGHT Research produces evidence-based best practice guidelines, health technology assessments and literature reviews to help health care practitioners, policy-makers and consumers make decisions about health care in specific clinical circumstances. The evidence is developed from systematic reviews of international literature and placed within the New Zealand context.
Guidelines, including supplementary papers, are not intended to replace the health practitioners judgment in each individual case.
Suggested citation
Marita Broadstock. New Zealand Autism Spectrum Disorder Guideline supplementary paper on cognitive behaviour therapy for adults with ASD. Christchurch: INSIGHT Research; 2016.
Currency review date: 2021
HP 6489
Contents
TOC \t "GL Heading 2,2,GL Heading 3,3,GL Heading 1,1" Contents PAGEREF _Toc309328727 \h iii
List of Tables PAGEREF _Toc309328728 \h v
About the evidence review PAGEREF _Toc309328729 \h vi
Purpose PAGEREF _Toc309328730 \h vi
Scope of the evidence review PAGEREF _Toc309328731 \h vi
Definitions PAGEREF _Toc309328732 \h vii
Target audience PAGEREF _Toc309328733 \h vii
Treaty of Waitangi PAGEREF _Toc309328734 \h viiii
Recommendation development process PAGEREF _Toc309328735 \h viii
Summary PAGEREF _Toc309328736 \h ix
Summary of new recommendations PAGEREF _Toc309328737 \h ix
1 Introduction PAGEREF _Toc309328738 \h 1
1.1 Cognitive behaviour therapy for adults with ASD PAGEREF _Toc309328739 \h 1
Cognitive behaviour therapy PAGEREF _Toc309328740 \h 1
Cognitive behaviour therapy for people with ASD PAGEREF _Toc309328741 \h 1
1.2 Recommendations relating to CBT in the NZ ASD Guideline PAGEREF _Toc309328742 \h 2
1.3 Objectives of the current review update 4
2 Cognitive behaviour therapy for adults with ASD 5
2.1 Scope and methods 5
Research question 5
Sample 5
Study designs 5
Intervention 5
Comparator 6
Outcomes 6
Publication type 6
Identification and selection of studies for inclusion 6
Critical appraisal of included studies 7
2.2 Body of evidence 7
Included studies 7
Systematic reviews 9
Primary studies 9
2.3 Quality of included studies 14
2.4 Narrative appraisal of studies 18
Systematic reviews 18
Primary studies 19
2.4 Synthesis of results 30
Effectiveness of CBT for adults with ASD 30
Adaptations to CBT for adults with ASD 33
2.5 Limitations and future research directions 37
Sample size 37
Sample characteristics and recruitment 37
Study design 38
Assessment and maintenance 38
Control groups 39
Outcome measures 40
Moderators and mediators of treatment response 41
2.6 Summary and conclusions 41
Overview 41
Key results 43
Conclusions 46
3 Recommendation development 49
Revision of existing recommendations 49
New recommendation 49
New good practice points 50
Appendix 1: Methods 53
A1.1 Contributors 53
Living Guideline Group members 53
Ex-officio LGG members 53
INSIGHT Research 53
Declarations of competing interest 54
Acknowledgements 54
A1.2 Review scope 54
A1.3 Research question 54
A1.4 Search strategy 55
Search databases 55
A1.5 Appraisal of studies 56
Assigning a level of evidence 56
Appraising the quality of included studies 56
A1.6 Preparing recommendations 58
Developing recommendations 58
A1.7 Consultation 59
Appendix 2: Abbreviations and glossary 60
A2.1 Abbreviations and acronyms 60
Miscellaneous Terms 60
Tests, scales and measures 61
Databases 61
A2.2 Glossary 62
Epidemiological and statistical terms 62
Appendix 3: Evidence Tables of relevant papers included in the NZ ASD Guideline 65
Appendix 4: Evidence Tables of included studies 67
References 82
List of Tables
TOC \t "GL Table heading,1" New recommendation relevant to CBT for adults with ASD PAGEREF _Toc307332067 \h ix
New good practice point relevant to CBT for adults with ASD PAGEREF _Toc307332068 \h ix
HYPERLINK \l "TableOriginalRecs" Table 1.1: Recommendations relevant to CBT in the NZ ASD Guideline 3
HYPERLINK \l "TableCBTAdaptions" Table 1.2: Adaptions to CBT in the ASD Guideline 4
HYPERLINK \l "TableSelectionCriteria" Table 2.1: Inclusion and exclusion criteria for selection of studies 8
HYPERLINK \l "TableCharacteristics" Table 2.2: Characteristics & results of primary studies by intervention 15
HYPERLINK \l "TableStudiesCBTAdaptions" Table 2.3: Primary studies using adaptations of CBT for adults with ASD 36
HYPERLINK \l "TableNewRecs" Table 3.1: New recommendations relevant to cognitive behaviour therapy. 50
HYPERLINK \l "TableGPPs" Table 3.2: New good practice points relevant to cognitive behaviour therapy. 52
HYPERLINK \l "NHMRChierarchy" Table A1.1: NHMRC levels of evidence 56
HYPERLINK \l "TableGrading" Table A1.2: Guide to grading recommendations 59
About the evidence review
Purpose
The New Zealand Autism Spectrum Disorder Guideline (the ASD Guideline) ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] was published in April 2008. As part of their commitment to the implementation of the guideline, New Zealands Ministry of Health and Ministry of Education agreed to establish a Living Guideline process in 2009. This process is where a guideline is regularly updated and refined to reflect new evidence and changing user needs.
Updates within the living guideline process are required when the recommendations in the guideline are no longer considered valid in view of research evidence that has emerged since the guidelines literature searches were conducted. A multidisciplinary team form the Living Guideline Group (LGG), an advisory group responsible for identification of areas for update, consideration of new evidence and reporting on any implications for guideline recommendations.
This supplementary report describes a systematic review which aims to provide an evidence-based synthesis of research published in or beyond 2004 relating to cognitive behaviour therapy for adults on the autism spectrum. This review updates the evidence considered in the ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1]. Also reported are revised and new recommendations pertinent to the topic developed by the Living Guideline Group following their consideration of the systematic review.
The systematic review was undertaken by INSIGHT Research to support the work of the ASD Guidelines Living Guideline Group. The methodology followed is consistent with that undertaken for previous supplementary reports of the LGG ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_2" \o "Broadstock, 2010 #1250" 2-7].
The systematic review and the entire living guideline process was funded by the New Zealand Ministry of Health, and sponsored by the New Zealand Ministry of Education.
Scope of the evidence review
The current review aims to systematically update evidence relating to the effectiveness of cognitive behaviour therapy (CBT) for improving social interaction, communication, emotional and mental health outcomes of adults (aged 18 years and over) with autism spectrum disorder. The Living Guideline Group identified this area as worthy of updating and one which could lead to revised or additional recommendations in the ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1].
This document needs to be read in the context of the original New Zealand ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1].
Definitions
Autism Spectrum Disorder (ASD) is a condition that affects communication, social interaction and adaptive behaviour functioning. In the current edition of the diagnostic manual of mental disorders, the DSM-5 ADDIN EN.CITE American Psychiatric Association20131249[8]124912496American Psychiatric Association,Diagnostic and statistical manual of mental disorders5th2013Washington, DCAPA Press[ HYPERLINK \l "_ENREF_8" \o "American Psychiatric Association, 2013 #1249" 8], four pervasive developmental disorder subcategories specified in the manuals predecessor, the DSM-IV ADDIN EN.CITE American Psychiatric Association20001248[9]124812486American Psychiatric Association,Diagnostic and statistical manual of mental disorders4th edition (Text revision)2000Washington, DCAPA Press[ HYPERLINK \l "_ENREF_9" \o "American Psychiatric Association, 2000 #1248" 9], are now subsumed into one broad category of autism spectrum disorder. These subtypes are autistic disorder, Asperger's disorder (Asperger syndrome), childhood disintegrative disorder (CDD), and pervasive developmental disorder not otherwise specified (PDD-NOS). The name pervasive developmental disorder (PDD) has now been changed to Autism Spectrum Disorder (ASD). The term ASD is used widely internationally and in the ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1], although some people prefer to refer to themselves as having autism, being on the spectrum, being autists, auties, Aspies, or having Aspergers, to reflect their identity rather than having a disorder. In the UK, the term Autism Spectrum Condition (ASC) is gaining favour as an official term instead of ASD.
The diverse range of disability and intellectual function expressed by people across the autism spectrum requires that a wide range of services and approaches be employed to reflect the heterogeneity of the condition.
It is understood that the terms high functioning and low functioning to describe groups of people with ASD are considered unhelpful and divisive by many on the autism spectum. In this report, the term high functioning (with quotations marks) is only used when quoting specific inclusion criteria for appraised studies. In such studies, the term refers to people with higher cognitive functioning either as established by intelligence tests (generally indicated by full IQ scores of 70 or above), or through the diagnosis of high-functioning autism or Asperger syndrome (under DSM-IV [9] criteria). It is acknowledged that these distinctions may no longer be used clinically in light of the removal of Asperger syndrome as a separate diagnostic classification in DSM-5 ADDIN EN.CITE American Psychiatric Association20131249[8]124912496American Psychiatric Association,Diagnostic and statistical manual of mental disorders5th2013Washington, DCAPA Press[ HYPERLINK \l "_ENREF_8" \o "American Psychiatric Association, 2013 #1249" 8].
Target audience
This evidence review and guidance update is intended primarily for the providers of professional health and education services for New Zealanders with ASD. It is also expected that the recommendations will be accessed by people with ASD and their families.Treaty of Waitangi
INSIGHT Research acknowledges the importance of the Treaty o f W a i t a n g i t o N e w Z e a l a n d , a n d c o n s i d e r s t h e T r e a t y p r i n c i p l e s o f p a r t n e r s h i p , p a r t i c i p a t i o n a n d p r o t e c t i o n a s c e n t r a l t o i m p r o v i n g M o r i h e a l t h .
I N S I G H T R e s e a r c h s c o m m i t m e n t t o i m p r o v i n g M o r i h e a l t h o u t c o m e s m e a n s w e a t t e m p t t o i d e n t i f y p o i n t s i n t h e g u i d e l i n e o r e v i d e n c e r e v i e w p r o c e s s w h e r e M o r i h e a l t h m u s t b e c o n s i d e r e d a n d a d d r e s s e d . I n a d d i t i o n , i t i s e x p e c t e d t h a t M o r i h e a l t h i s c o n s i d e r e d a t a l l p o i n t s i n t h e g u i d e l i n e o r e v i d e n c e r e v i e w i n a l e s s e x p l i c i t m a n n e r .
R e c o m m e n d a t i o n d e v e l o p m e n t p r o cess
The research questions were identified and prioritised by the Living Guideline Group and were used to inform the search of the published evidence. A one day, face-to-face meeting of the Living Guideline Group was held on 12 November 2015. At this meeting, evidence was reviewed and existing recommendations revised and/or new recommendations developed. These are described, accompanied by the LGGs rationale for changes, in HYPERLINK \l "RecDevelopment" Section 3.
INSIGHT Research follows specific structured processes for evidence synthesis. Full methodological details are provided in HYPERLINK \l "Appendix1" Appendix 1. This appendix also includes details of the Living Guideline Group membership and lists the organisations that provided feedback during the consultation period. Appendix 2 presents a HYPERLINK \l "Glossary" Glossary of key epidemiological and topic-specific terms, abbreviations and acronyms. HYPERLINK \l "Appendix3" Appendix 3 presents evidence tables developed for the original ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] for studies relevant to the use of CBT for adults with ASD. HYPERLINK \l "Appendix4" Appendix 4 presents full evidence tables of included studies for the current review update.
Summary
Summary of new recommendations
New recommendations relevant to cognitive behaviour therapy for adults with ASD
ReferenceNew recommendationGrade4.3.9aBroadly defined cognitive behaviour therapy, adapted for ASD, may assist adults with mental health conditions.CNew good practice point relevant to cognitive behaviour therapy for adults with ASD
ReferenceNew Good Practice PointsGrade4.3.9bCognitive behaviour therapy (CBT) has been designed and evaluated predominantly for people without ASD. More research is recommended to further develop and evaluate effective cognitive behaviour therapies and their necessary adaptations for people on the spectrum as well as appropriate and valid outcome measures for research in this field. As it seems likely that some individuals receiving CBT benefit and some do not, future research should also investigate what personal characteristics and aspects of therapy best predict treatment effectiveness.(4.3.10aThe following adaptations to cognitive behaviour therapy are recommended:
Use a structured approach and minimise anxiety about the therapeutic process by being explicit about roles, times, goals and techniques.
Extend the number of sessions and time provided to conduct tasks to accommodate slower information-processing and the mental demands of the therapeutic process. Be flexible about the length of each session and offer breaks to allow for cognitive and motivational deficits.
Provide psycho-education about autism, emotions, and mental health challenges relevant to the client.
Concentrate on well-defined and specific difficulties as the starting point for intervention, with less emphasis on changing clients cognitions.
Be more active and directive in therapy, where appropriate, including giving suggestions, information, and immediate and specific feedback on performance. Examine the rationale and evidence for inaccurate, automatic thoughts and collaboratively develop alternative interpretations, concrete strategies and courses of action.
Teach explicit rules and their appropriate context, including the use of verbal, nonverbal and paralinguistic cues to a social situation.
Incorporate specific behavioural techniques where appropriate, such as relaxation strategies, meditation, mindfulness, thought stopping or systematic desensitisation.
Communicate visually (e.g., using worksheets, images, diagrams, 'tool boxes', comic strip conversations, video-taped vignettes, peer-modelling, and working together on a computer).
Avoid ambiguity through minimising the use of colloquialisms, abstract concepts and metaphor. Use specific and concrete analogies relatable to the clients concerns.
Incorporate participants' interests in terms of content and modes of content delivery to enhance engagement.
Involve a support person, such as a family member, partner, carer or key worker (if the person with autism agrees) as a co-therapist to improve generalisation of skills learned within sessions.(1 Introduction
1.1 Cognitive behaviour therapy for adults with ASD
Cognitive behaviour therapy
Cognitive behaviour therapy (CBT), also known as cognitive behavioural therapy, is a structured, goal-directed form of psychotherapy directed toward solving current problems by modifying unrealistic and unhelpful thinking and behaviour. Derived from behavioural psychology, CBT aims to help individuals notice and understand the relationship between their thoughts, behaviours and emotions and to develop more helpful ways of thinking about, coping with, and responding to challenging situations ADDIN EN.CITE Beck19791271[10]127112716Beck, A. R.Rush, A. J.Shaw, B. F.et al,Cognitive Therapy of Depression1979New York, NYGuildford Press[ HYPERLINK \l "_ENREF_10" \o "Beck, 1979 #1271" 10]. The therapy tends to be short-term and time-limited (often fewer than 16 sessions) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_11" \o "Lerner, 2012 #102" 11].
CBT is commonly used to treat a diverse range of mental health disorders, and affective and behavioural problems including insomnia and stress ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_12" \o "Butler, 2006 #1274" 12-14]. Techniques include questioning and testing assumptions or habits of thought (schemas) that might be unhelpful and unrealistic, gradually facing activities which may have been avoided, and trying out new ways of behaving and reacting. Relaxation and distraction techniques are also commonly included.
Whilst traditionally CBT has been delivered individually on a one-to-one basis, CBT is also being delivered through other modalities including group-based formats, and more recently, guided self-help. Computerised online treatment courses such as Beating The Blues (www.beatingtheblues.org.nz) have shown promise in terms of efficacy and cost-effectiveness in primary care, although this is yet to be evaluated in populations with ASD ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_15" \o "Anderson, 2006 #229" 15].
In addition to traditional cognitive and behavioural techniques, so-called third wave CBT approaches incorporate mindfulness, meditation, metacognitive therapy, compassion focussed therapy, and acceptance and commitment (ACT) therapies ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13, HYPERLINK \l "_ENREF_16" \o "Hayes, 2004 #1243" 16, HYPERLINK \l "_ENREF_17" \o "Binnie, 2012 #1029" 17]. These place less focus on addressing unhelpful cognitions, and more on teaching people to accept phenomena (bodily sensations, thoughts, feelings, sounds) as they appear, to counter avoidance strategies, and reduce anxiety ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18].
Cognitive behaviour therapy for people with ASD
Adults with autism experience higher levels of psychiatric comorbidity compared with those without autism, including major depressive disorder, anxiety disorders, agoraphobia, obsessivecompulsive disorder and social phobia ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_19" \o "Bakken, 2010 #1244" 19-24]. Given the high effectiveness of cognitive behavioural therapy for these conditions in the general population [20], CBT has also been offered to people with ASD for the management of mental health difficulties including depression, anxiety, panic disorder, OCD, PTSD, and chronic stress ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_25" \o "Lang, 2011 #145" 25-28], as well as to ameliorate social-communication deficits.
As outlined in the ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1], CBT techniques used in ASD vary according to a persons developmental or cognitive level and the issue being treated. The main components have tended to include the following five areas ADDIN EN.CITE Connolly20071259[29]1259125917Connolly, S. D.Bernstein, G. A.Work Group on Quality I. Practice parameter for the assessment and treatment of children and adolescents with anxiety disordersJournal of the American Academy of Child & Adolescent PsychiatryJournal of the American Academy of Child & Adolescent Psychiatry267-2834622007[ HYPERLINK \l "_ENREF_29" \o "Connolly, 2007 #1259" 29]:
psycho-education about ASD and concurrent mental health symptoms/comorbidities, including exploring strengths
controlling physical symptoms through exercises in diaphragmatic breathing, muscle relaxation, visualisation techniques, and mindfulness exercises
cognitive restructuring through thought-listing and mood monitoring, linking thoughts and feelings, and examining evidence for beliefs, to change maladaptive cognitions into a more helpful form
learning and practice of new coping skills in situations where the problematic emotions/behaviours occur, sometimes through a graduated process, through direct instruction, role-play, performance and feedback
development of relapse prevention and action plans aimed at helping the person to identify and respond appropriately to early warning signs and triggers.
A recent systematic review of CBT for adults with ASD ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13] noted that some aspects of CBT may be particularly suited to people on the autism spectrum, such as the use of a highly structured approach with clear goals, and the flexibility around the tool-box of techniques available to the therapist. However the review also commented that the very structure, process and content of CBT techniques may bring particular challenges to those on the autism spectrum. For example, socio-communicative challenges core to autism may interfere with building rapport with the therapist and the therapy process.
Difficulty in describing and labeling emotions (alexithymia), which can be a particular challenge for people on the autism spectrum, may also make it difficult to recognise associations between feelings, thoughts and beliefs, and related behavioural responses, integral to the therapeutic process. Deficits in executive functioning, cognitive flexibility, and theory of mind, may also make it difficult for people on the spectrum to carry out cognitive restructuring tasks ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13]. Adaptations of CBT for people on the autism spectrum are therefore likely to be necessary ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_30" \o "Attwood, 2004 #1087" 30, HYPERLINK \l "_ENREF_31" \o "Gaus, 2011 #1089" 31].
1.2 Recommendations relating to cognitive behaviour therapy in the NZ ASD Guideline
The New Zealand ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] cites evidence ADDIN EN.CITE Hare20041260[32, 33]1260126017Hare, D. J.Developing cognitive behavioural work with people with ASDGood Autism PracticeGood Autism Practice18-22512004Howlin19971265126512656Howlin, PAutism: preparing for adulthood1997LondonRoutledge[ HYPERLINK \l "_ENREF_32" \o "Hare, 2004 #1260" 32, HYPERLINK \l "_ENREF_33" \o "Howlin, 1997 #1265" 33] suggesting that, because of the social and communicative aspects of ASD, psychodynamic approaches to therapy are unlikely to be successful as they rely on insight, introspection and the development of a therapeutic alliance. By contrast, it is argued that cognitive behaviour therapy may be more promising.
Cognitive behaviour therapy for treating behavioural, emotional and mental health difficulties in people on the autism spectrum is discussed in some depth in Part 4 (Treatment and Management of ASD) of the ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] under Section 4.3b (Cognitive behaviour therapy). It is noted that CBT is well supported across a range of problem types and populations ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_29" \o "Connolly, 2007 #1259" 29, HYPERLINK \l "_ENREF_33" \o "Howlin, 1997 #1265" 33-36].
CBT is specifically advocated in Recommendation 4.3.9 (see HYPERLINK \l "TableOriginalRecs" Table 1.1), with an evidence grade of C, which indicates being supported by international expert opinion (see HYPERLINK \l "TableGrading" Table A1.2). References include an expert opinion article relating to CBT use for adolescents with ASD ADDIN EN.CITE Attwood20031264[37]126412645Attwood, THolliday Willey, L.Cognitive Behaviour TherapyAsperger Syndrome in Adolescence: Living with the Ups, the Downs and Things in Between2003LondonJessica Kingsley Publishers Ltd[ HYPERLINK \l "_ENREF_37" \o "Attwood, 2003 #1264" 37], a case study of CBT used for an autistic child ADDIN EN.CITE Reaven20031258[38]1258125817Reaven, JHepburn, JCognitive-behavioral treatment of obsessive-compulsive disorder in a child with Asperger syndromeAutismAutism145-164722003[ HYPERLINK \l "_ENREF_38" \o "Reaven, 2003 #1258" 38], and an expert opinion overview on the subject ADDIN EN.CITE Hare20041260[32]1260126017Hare, D. J.Developing cognitive behavioural work with people with ASDGood Autism PracticeGood Autism Practice18-22512004[ HYPERLINK \l "_ENREF_32" \o "Hare, 2004 #1260" 32].
The ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] also emphasises the importance of cognitive behaviour therapists working with people on the spectrum understanding how characteristics of ASD may present in therapy. It suggests that therapists attend to the core deficits of ASD (communication, social skills, stereotypical and repetitive behaviour) and alter techniques accordingly. This advice is synthesised in Recommendation 4.3.10, and again given the evidence grade of C ( HYPERLINK \l "TableOriginalRecs" Table 1.1).
The ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1], citing narrative overviews of prominent experts working in the field ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_30" \o "Attwood, 2004 #1087" 30, HYPERLINK \l "_ENREF_32" \o "Hare, 2004 #1260" 32, HYPERLINK \l "_ENREF_37" \o "Attwood, 2003 #1264" 37, HYPERLINK \l "_ENREF_39" \o "Attwood, 2003 #1262" 39], offers advice on adaptations that can be made to CBT techniques to suit the characteristics of people with ASD more appropriately ( HYPERLINK \l "TableCBTAdaptions" Table 1.2). These include focusing on specific challenges, minimising anxiety through explicit processes, being flexible about duration of sessions, avoiding direct challenges to beliefs, using visual imagery and writing of thoughts, and including specific behavioural techniques such as relaxation strategies, thought stopping and systematic desensitisation.
Table 1.1: Recommendations relevant to CBT in the NZ ASD Guideline
Original ReferenceOriginal RecommendationGrade4.3.9Cognitive behaviour therapy should be considered as a suitable treatment for many behavioural, emotional and mental health difficulties.C4.3.10Cognitive behaviour therapists should adapt their techniques to take into account the characteristics of people with ASD.CTable 1.2: Adaptions to CBT in the ASD Guideline
Suggested adaptions to techniques used by cognitive behaviour therapists to take into account the characteristics of people with ASDconcentrate on well-defined and specific difficulties
minimise anxiety about the therapeutic process by being explicit about roles, times, goals and using techniques like repertory grid
be flexible about the length of sessions and leaving the treatment room
avoid direct challenges to personal beliefs, as these may be misinterpreted as a personal attack; instead, examine the rationale and evidence and collaboratively develop alternative interpretations and beliefs
use visual imagery
encourage clients to write down positive things, rather than relying on changing thoughts in their heads
incorporate specific behavioural techniques where appropriate, such as relaxation strategies, thought stopping or systematic desensitisationMost research relating to the usefulness of CBT for people on the autism spectrum has focused on the use of CBT in school-aged and adolescent populations ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_11" \o "Lerner, 2012 #102" 11], as did evidence cited in the original Guideline ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_29" \o "Connolly, 2007 #1259" 29, HYPERLINK \l "_ENREF_36" \o "Simpson, 2005 #1261" 36-38]. However, it is unclear whether this evidence applies to adults with autistic spectrum disorders.
An update of the evidence with respect to the use of CBT in adults with ASD is warranted. The current review aims to evaluate the evidence for the effectiveness of CBT for adults with ASD in relation to a broad range of outcome domains, and to describe adaptations to CBT recommended for adults with ASD.
Evidence tables prepared for the ASD Guideline which do describe studies considered relevant to CBT and adults ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_30" \o "Attwood, 2004 #1087" 30, HYPERLINK \l "_ENREF_32" \o "Hare, 2004 #1260" 32, HYPERLINK \l "_ENREF_37" \o "Attwood, 2003 #1264" 37] are presented in HYPERLINK \l "Appendix3" Appendix 3. These form part of the evidence base, alongside the updated evidence described in the current review, to be considered by the Living Guideline Group tasked with reconsidering the wording and evidence grade of the recommendations presented in HYPERLINK \l "TableOriginalRecs" Table 1.1, and the possibility of developing additional recommendations relevant to CBT (see HYPERLINK \l "RecDevelopment" Section 3).
1.3 Objectives of the current review update
The objectives of this review update were to:
systematically identify, select, appraise and synthesise research evidence published since January 2004 relating to the effectiveness of cognitive behaviour therapy for improving social interaction, communication, emotional and mental health outcomes of adults with autism spectrum disorder;
describe recommended adaptions to CBT that have been employed with adults on the autism spectrum; and to
consider this evidence as it supplements that of the original ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] to revise existing recommendations and/or develop new ones.2 Cognitive behaviour therapy for adults with ASD
This chapter describes the findings of a systematic review update relating to the effectiveness of cognitive behaviour therapy for adults with ASD. It also reports the development of new and revised recommendations by the Living Guideline Group to supplement the ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] on this topic.
2.1 Scope and methods
Research question
The review updates primary research question was:
What is the effectiveness of cognitive behavioural therapy for improving outcomes for adults with ASD?
A supplementary question was
What adaptations to CBT approaches are recommended when assisting adults with ASD?
Sample
Included were people aged 18 years or over (or for samples with a mean age of 18 years or over) diagnosed with Autism Spectrum Disorder (ASD) as classified by or consistent with DSM-IV ADDIN EN.CITE American Psychiatric Association20001248[9]124812486American Psychiatric Association,Diagnostic and statistical manual of mental disorders4th edition (Text revision)2000Washington, DCAPA Press[ HYPERLINK \l "_ENREF_9" \o "American Psychiatric Association, 2000 #1248" 9] or DSM-5 ADDIN EN.CITE American Psychiatric Association20131249[8]124912496American Psychiatric Association,Diagnostic and statistical manual of mental disorders5th2013Washington, DCAPA Press[ HYPERLINK \l "_ENREF_8" \o "American Psychiatric Association, 2013 #1249" 8].
Study designs
The review considered randomised controlled trials (RCTs), pseudo-experimental designs, single case experimental designs, case series, and case studies, where they reported at least one pre- and post-treatment relevant outcome measure.
In addition, recently published secondary studies (systematic reviews and/or meta-analyses) were included where they had a clear and relevant review question, used at least one electronic bibliographic database, included at least one study eligible for the current review, and were published in 2012 or more recently.
Intervention
Included studies evaluated cognitive behaviour therapy (CBT) as an intervention defined as including both cognitive and behavioural components, using any modality of treatment (including individually-delivered sessions, or group-based therapy). Therapy is typically given over a limited number of sessions over several weeks.
Comparator
Any comparison intervention was eligible, including no intervention, wait list control, receiving usual care, or an alternative intervention of similar intensity (contact time).
Outcomes
In order to broaden the scope of the review outcome types were not restricted.
Primary outcomes were published measures completed pre- and post-therapy as self-report, informant-report and/or clinician/therapist-report of any outcome relevant to social or communication functioning, mental health and well-being, including:
social interaction
communication skills
co-existing emotional and mental health conditions (including anxiety, depression, obsessive compulsive disorder, ADHD)
quality of life; global measures of daily life skills, functioning, adjustment and well being
Other measures were presented as secondary outcomes where a primary outcome was also reported.
Measures of satisfaction were reported only as measures of programme acceptability.
Publication type
English language publications from peer-reviewed Journals published in or beyond 2004 (or for systematic reviews, 2012). Non-systematic reviews, correspondence, editorials, commentaries, expert opinion articles, articles published in abstract form, conference proceedings, poster presentations, dissertations, book chapters, grey literature, animal studies were excluded. Unpublished data was excluded.
Identification and selection of studies for inclusion
Search strategies were limited to publications from January 1 2004 onwards to ensure capture of articles published since the search was conducted for the original ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1]. Studies already appraised in the ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] relevant to the topic (summarised in HYPERLINK \l "Appendix3" Appendix 3) were excluded from the current review regardless of date of publication.
Eight bibliographic, health technology assessment, and guideline databases were included in the systematic search. The search was conducted in May 2015 and following removal of duplicates identified 1149 articles. An updated search was conducted on August 2, 2015 bringing the total number of unique abstracts to 1158.
Selection criteria for included and excluded studies are described in HYPERLINK \l "TableSelectionCriteria" Table 2.1. Selection criteria were applied to abstracts to identify articles for retrieval, and then to retrieved full text articles, to identify included studies. References of retrieved articles were cross-checked to identify additional articles for consideration.
Critical appraisal of included studies
Included studies were assigned levels of evidence which correspond to an evidence hierarchy ADDIN EN.CITE National Health and Medical Research Council20081275[40]127512756National Health and Medical Research Council, NHMRC additional levels of evidence and grades for recommendtaitons for developers of guidelines: pilot program 2005-20072008Canberra, AustraliaNHMRC[ HYPERLINK \l "_ENREF_40" \o "National Health and Medical Research Council, 2008 #1275" 40]. This hierarchy (see HYPERLINK \l "NHMRChierarchy" Table A1.1) ranks the quality of research designs which are broadly associated with particular methodological strengths and limitations so as to rank them in terms of quality, from the most robust level of I (for systematic reviews of RCTs) to IV (case series). Systematic reviews of lower order evidence rank at the same level as that order of evidence.
Within each study design, studies can be conducted with varying degrees of rigour. This was reflected in assessment of methodological quality (including study validity, effect size, precision of results, applicability and generalisability) using design-specific validated instruments for the experimental studies. Quality was coded as either good (+), unclear (?), or poor (X).
Full details of review methods including search strategies, appraisal of study quality and data extraction are presented in HYPERLINK \l "Appendix1" Appendix 1.
2.2 Body of evidence
Included studies
Thirteen studies met selection criteria and were eligible for appraisal and inclusion, 10 primary studies, and 3 recently published systematic reviews. The Evidence Tables for included studies are presented in HYPERLINK \l "Appendix4" Appendix 4. Throughout tables and text, studies are ordered according to the following hierarchy: study type (systematic reviews then primary studies), level of evidence (as defined in HYPERLINK \l "NHMRChierarchy" Table A1.1) (lowest first), chronology of year of publication (oldest first), first authors surname (alphabetical order).
Table 2.1: Inclusion and exclusion criteria for selection of studies
CharacteristicInclusion criteriaPublication typeStudies published January 1 2004 or later.Participant characteristicsAdults aged 18 years or over (or a sample/sub-sample with mean age of 18 years or over) diagnosed with Autism Spectrum Disorder (ASD) as classified by or consistent with DSM-IV-TR ADDIN EN.CITE American Psychiatric Association20001248[9]124812486American Psychiatric Association,Diagnostic and statistical manual of mental disorders4th edition (Text revision)2000Washington, DCAPA Press[ HYPERLINK \l "_ENREF_9" \o "American Psychiatric Association, 2000 #1248" 9] or DSM-5 ADDIN EN.CITE American Psychiatric Association20131249[8]124912496American Psychiatric Association,Diagnostic and statistical manual of mental disorders5th2013Washington, DCAPA Press[ HYPERLINK \l "_ENREF_8" \o "American Psychiatric Association, 2013 #1249" 8]. Study DesignRandomised controlled trials, psuedo-experimental designs, single case experimental designs, case series, and case studies, with at least one pre- and post-treatment relevant outcome measure.
Recently published secondary studies (systematic reviews and/or meta-analyses) that had a clear and relevant review question, used at least one electronic bibliographic database, included at least one study eligible for the current review, and published in or since 2012.InterventionParticipation in cognitive behaviour analysis therapy (including both behavioural and cognitive components). ComparatorNo restriction: no intervention, wait list, usual treatment, alternative therapy.OutcomePrimary outcomes were published measures completed pre- and post- intervention by self-report, informant-report and/or clinician/assessor-report of any outcome relevant to social interaction, communication skills, emotional and mental health, general well-being, adjustment and/or quality of life. Other measures were presented as secondary outcomes where a primary outcome was also reported.CharacteristicExclusion criteriaPublication typeNon-systematic reviews, correspondence, editorials, commentaries, expert opinion articles, articles published in abstract form, conference proceedings, poster presentations, dissertations, book chapters, grey literature, animal studies.
Unpublished dataAttritionStudies with >50% attrition from either arm of a trial (unless adequate statistical methodology has been applied to account for missing data).Language Non-English language articlesScopeStudies that did not provide separate analyses/syntheses of results relevant to the scope of the review (e.g., with respect to age group and diagnosis).
Studies cited in the original ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1].Study DesignStudies where no pre- and post-intervention eligible outcomes were measured.Systematic reviews
Three recently published systematic reviews on the review topic were identified ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13, HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41].
A systematic review was conducted on the benefits and potential harms of CBT to inform the development of a Guideline for adults with autism in the UK ADDIN EN.CITE National Institute for Health and Clinical Excellence (NICE)20121267[22]126712676National Institute for Health and Clinical Excellence (NICE),Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. National Clinical Guideline No. 1422012London, EnglandThe British Psychological Society and The Royal College of Psychiatristshttp://www.nice.org.uk/guidance/cg142[ HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22]. Observational and experimental study designs including at least 10 people per treatment arm were eligible for inclusion in a comprehensive serach strategy of articles published to September 2011.
Another systematic review ADDIN EN.CITE Binnie20131157[41]1157115717Binnie, JamesBlainey, SarahBinnie, JamesThe use of cognitive behavioural therapy for adults with autism spectrum disorders: A review of the evidenceMental Health Review JournalMental Health Review Journal93-104182adultsautism spectrum disorderscognitive behavioural therapycomorbid psychiatric symptomsCognitive Behavior TherapyComorbidityPervasive Developmental DisordersPsychiatric Symptoms2013United KingdomEmerald Group Publishing Limited1361-9322
2042-87582013-27337-005http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-27337-005&site=ehost-livejamescbt@gmail.com10.1108/MHRJ-05-2013-0017psyhEBSCOhost[ HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41] considered the effectiveness of CBT for reducing comorbid psychiatric symptoms and increasing social and communication skills in adults with High Functioning Autism (HFA) or Asperger syndrome. Case studies and pseudo-experimental studies were identified from the search of research published between 1980 and 2009.
A more recent review ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13] evaluated investigations of CBT offered to people aged 18 years or over with ASD. A range of study designs were considered including case studies, case series, pseudo-experimental designs and RCTs published between 1993 and August 2013.
Primary studies
Ten primary studies were appraised ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42-50].
Study characteristics and outcomes for the included primary studies are summarised in HYPERLINK \l "TableCharacteristics" Table 2.2 organised by study design (observational studies, pseudo/non-randomised experimental studies, and randomised controlled trials), then by year of publication (oldest first), and alphabetically by first author.
Study location and setting
Three primary studies were conducted in the United States, three in the United Kingdom, and one each in Australia, Canada, Sweden, and The Netherlands. Whilst it was not generally stated where the interventions were provided, studies tended to be conducted in clinical settings delivered by staff within specialised research centres or university-based treatment clinics.
Study design
Four of the 10 primary studies appraised were before and after observational studies including 5 or fewer participants with ASD ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50]. Sometimes participants with autism were included as part of larger samples but results were available specific to those with ASD which enabled their inclusion in the current review.
The remaining 6 studies employed experimental designs comparing a group of participants receiving CBT to either a control group or to alternative interventions (see under HYPERLINK \l "Comparators" Comparators, below). One experimental study was non-randomised ADDIN EN.CITE Russell20091241[48]1241124117Russell, A. J.Mataix-Cols, D.Anson, M. A. W.Murphy, D. G. M.Russell, A. J., Department of Psychology, Institute of Psychiatry, Kings College London, PO Box 77, De Crespigny Park, Denmark Hill, London, United Kingdom, SE5 8AFPsychological treatment for obsessive-compulsive disorder in people with autism spectrum disordersA pilot studyPsychotherapy and PsychosomaticsPsychotherapy and psychosomatics59-61781obsessive compulsive disorderautism spectrum disorderspsychological treatmentComorbidityPervasive Developmental DisordersPsychotherapy2009SwitzerlandKarger0033-3190
1423-03482010-25760-010http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-25760-010&site=ehost-livea.russell@iop.kcl.ac.ukhttp://www.karger.com/Article/Abstract/17262210.1159/000172622psyhEBSCOhost[ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48], and two were pseudo-randomised ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45, HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]. A further three primary studies were fully randomised controlled trials (RCTs).
Included studies reported baseline assessments of outcomes, as well as repeated measures at post-test. This occurred immediately post intervention for the treatment group/s or after an equivalent time for the control group. Two studies also included weekly assessments throughout the intervention period ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50].
For 6 primary studies, further follow-up was reported for the intervention group to measure within-group maintenance of any observed treatment effects. Follow-up periods post treatment varied. Three uncontrolled studies reported on 2 month post-treatment follow-up ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50], one pseudo-controlled study reported 3 and 9 months follow-up ADDIN EN.CITE McGillivray2014244[45]24424417McGillivray, J. A.Evert, H. T.Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASDJournal of autism and developmental disordersJournal of autism and developmental disorders2041-51448AdolescentAdult*Anxiety/th [Therapy]Asperger Syndrome/px [Psychology]*Asperger Syndrome/th [Therapy]Autistic Disorder/px [Psychology]*Autistic Disorder/th [Therapy]*Cognitive Therapy*Depression/th [Therapy]FemaleHumansMale*Psychotherapy, GroupStress, Psychological/th [Therapy]Treatment OutcomeYoung Adult2014United StatesMcGillivray,J A. School of Psychology, Centre for Mental Health and Wellbeing Research, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia, jane.mcgillivray@deakin.edu.au.1573-3432http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=24634065http://link.springer.com/article/10.1007%2Fs10803-014-2087-9[ HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45], an RCT reported outcomes at 1, 3, 6, and 12 month followup ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47], and another RCT reported variable follow-up periods of between 8 and 57 months ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43].
Participants
Sample sizes for studies ranged from 1 to 68 (1 to 34 receiving the intervention), with 242 participants represented across the 10 included studies. The case studies reported on between 1 and 5 participants with ASD, and the controlled studies included between 11 and 68 participants.
Five of the 10 included studies included participants described as having High Functioning Autism (HFA) or Asperger syndrome (AS) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45, HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48-50]. A further two included people with ASD but specified a minimum IQ level of average ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46] or above 70 for verbal IQ ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]. The remaining 3 studies included people with ASD or autism ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44].
Three of the 10 primary studies specified a comorbidity or mental health symptom as an inclusion criteria. Having an obsessive-compulsive disorder (OCD) was required for inclusion in the two controlled studies led by Russell ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47, HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48], and symptoms of anxiety, depression, and/or rumination specified for included participants of an RCT conducted in The Netherlands ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18]. Outcomes for both studies included measures related to these symptoms. The participants in three small-sample case studies were reported as having either Social Anxiety Disorder (SAD) ADDIN EN.CITE Cardaciotto20041240[42]1240124017Cardaciotto, LeeAnnHerbert, James D.Cardaciotto, LeeAnn, Department of Psychology, Drexel University, M.S. 988, 245 N. 15th Street, Philadelphia, PA, US, 19102-1192Cognitive behavior therapy for social anxiety disorder in the context of Asperger's syndrome: A single-subject reportCognitive and Behavioral PracticeCognitive and Behavioral Practice75-81111Aspergers syndromecognitive behavior therapysocial anxiety disorderdevelopmental disordercomorbiditytreatmentAnxiety DisordersSocial Anxiety2004Win 2004USAssociation for Advancement of Behavior Therapy1077-72292004-15843-008http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2004-15843-008&site=ehost-livelc52@drexel.eduhttp://www.sciencedirect.com/science/article/pii/S107772290480009910.1016/S1077-7229(04)80009-9psyhEBSCOhost[ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42], various comorbidities ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50], or anxiety and a mild learning disability ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44].
Where provided, mean ages ranged from 21 to 42 years. All but two studies only considered adults aged 18 years or older. Exceptions were the Australian pseudo-experimental study ADDIN EN.CITE McGillivray2014244[45]24424417McGillivray, J. A.Evert, H. T.Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASDJournal of autism and developmental disordersJournal of autism and developmental disorders2041-51448AdolescentAdult*Anxiety/th [Therapy]Asperger Syndrome/px [Psychology]*Asperger Syndrome/th [Therapy]Autistic Disorder/px [Psychology]*Autistic Disorder/th [Therapy]*Cognitive Therapy*Depression/th [Therapy]FemaleHumansMale*Psychotherapy, GroupStress, Psychological/th [Therapy]Treatment OutcomeYoung Adult2014United StatesMcGillivray,J A. School of Psychology, Centre for Mental Health and Wellbeing Research, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia, jane.mcgillivray@deakin.edu.au.1573-3432http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=24634065http://link.springer.com/article/10.1007%2Fs10803-014-2087-9[ HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45] which considered young people aged 15-25 years, and an RCT ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47] which included people aged 14-65 years (with mean ages of over 18 years in both studies).
Samples were predominantly male, ranging from a mean of 60 to 91% in the 6 controlled studies.
Ethnicity was only reported for the three US-based studies, two case studies including only Caucasian participants ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46], and in a pseudo-experimental trial reporting on 9 Caucasian and 2 non-white participants ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49].
Interventions
The cognitive behaviour therapy (CBT) interventions evaluated were either group-based (7 studies) or provided as individually-delivered, one-to-one, therapy (3 studies).
The CBT-based intervention typically included some or all of the features outlined by Connolly et al ADDIN EN.CITE Connolly20071259[29]1259125917Connolly, S. D.Bernstein, G. A.Work Group on Quality I. Practice parameter for the assessment and treatment of children and adolescents with anxiety disordersJournal of the American Academy of Child & Adolescent PsychiatryJournal of the American Academy of Child & Adolescent Psychiatry267-2834622007[ HYPERLINK \l "_ENREF_29" \o "Connolly, 2007 #1259" 29] including psycho-education about ASD and problematic symptoms, controlling physical symptoms, cognitive restructuring, learning and practicing of new skills, and development of relapse prevention and action plans.
The degree to which all of the typical CBT features were represented varied between the studies. One RCT ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18] gave particular emphasis to mindfulness training rather than traditional thought restructuring techniques. The study also required participants to do 40-60 minutes of meditation at home 6 days per week during the 9-week treatment period.
Seven of studies placed particular emphasis on targeting specific mental health symptoms and behaviours in their intervention therapies. These included targeting anxiety and mood ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50], OCD-related beliefs ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47, HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48], problem solving ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46], and social skills training, emotion recognition and/or theory of mind training ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]. Exposure response prevention (ERP) was included in interventions targeting symptoms of OCD.
One intervention required a support person to be brought to treatment sessions ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44], and another included peer-tutors who assisted with role-playing exercises ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43].
The reported intensity of an intervention reflected how long each session was, how often, and over how many weeks. Where reported, sessions, occured weekly and were typically one hour long, ranging from 50 minutes to 3 hours across studies. Intervention intensity ranged from 6 to 108 hours across the 10 studies. Intensity appeared to increase for the more robust comparative studies such that the range was between 6 and 14 hours for the 4 case studies, 10 and 50 hours for the 3 pseudo-experimental studies, and between 20 and 108 hours for the three RCTs. In addition to session time, homework tasks were commonly set to be completed between sessions.
Six CBT interventions were reported as being manualised, five of which were group-based ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50] and one individualised therapy ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]. Only two studies monitored programme fidelity to the curriculum with a sample of audio- or video-taped sessions independently rated to ensure treatment integrity ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47].
Comparators
Four experimental studies compared participants receiving CBT to either a control group receiving usual care ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48, HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49], or a waitlist control group (i.e., receiving usual care during the study phase of the trial, but offered CBT at the studys conclusion) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45].
Two randomised controlled trials included alternative active interventions matched for programme intensity with the CBT intervention. One trial ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43] considered recreational activities as a comparison intervention. Each week a therapist leader would take the group of adults, all on the autism spectrum, to a different activity (museum, board-games, cooking, boating, cinema, walks, etc.) as chosen and prioritised by participants. This approach considered whether CBT adds additional benefits over and above those of regular, structured contact with other people on the autism spectrum.
The other RCT ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47] compared the treatment intervention of individually-delivered CBT with an individually-delivered Anxiety Management (AM) intervention. The AM therapy included psycho-education about anxiety, mood, healthy habits and problem solving, as well as teaching and practice of diaphragmatic breathing and muscle relaxation techniques. The Anxiety Management therapy was offered as a plausible control group to ensure treatment effects were solely due to the adapted CBT therapy and not therapist contact, psycho-education about anxiety, and anxiety reduction techniques common to both interventions.
Outcomes assessed
Outcomes varied widely with respect to domain measured, assessment method (rating scales, observations, and performance measures), and informant used (self-report, spouse/parent/caregiver, assessor).
Areas assessed as primary outcomes considered:
social communication functioning
emotional and mental health outcomes (anxiety, depression, obsessive-compulsive disorder, ADHD)
general well-being
An overview of the outcome measures used is provided below. Measurement tools are presented in HYPERLINK \l "TableCharacteristics" Table 2.2, as well as in the individual studys Evidence Table ( HYPERLINK \l "Appendix4" Appendix 4).
Social interaction and communication
Two studies included social skill measures. The single case study of a man with ASD and Social Anxiety Disorder ADDIN EN.CITE Cardaciotto20041240[42]1240124017Cardaciotto, LeeAnnHerbert, James D.Cardaciotto, LeeAnn, Department of Psychology, Drexel University, M.S. 988, 245 N. 15th Street, Philadelphia, PA, US, 19102-1192Cognitive behavior therapy for social anxiety disorder in the context of Asperger's syndrome: A single-subject reportCognitive and Behavioral PracticeCognitive and Behavioral Practice75-81111Aspergers syndromecognitive behavior therapysocial anxiety disorderdevelopmental disordercomorbiditytreatmentAnxiety DisordersSocial Anxiety2004Win 2004USAssociation for Advancement of Behavior Therapy1077-72292004-15843-008http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2004-15843-008&site=ehost-livelc52@drexel.eduhttp://www.sciencedirect.com/science/article/pii/S107772290480009910.1016/S1077-7229(04)80009-9psyhEBSCOhost[ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42] included a behavioural assessment of him engaging in a conversation exercise and giving a speech. Assessors rated videotapes for verbal content, nonverbal behaviour, paralinguistic behaviour, and overall social skills. Direct observational data was also collected in a pseudo-randomised trial assessing Social Cognitive Interaction Training ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]. Social skills exhibited in a performance-based role play exercise (SSPA) were independently assessed by two raters blinded to treatment group allocation. The same study also assessed perceived social skills through a self-reported index (SCSQ).
Emotional and mental health outcomes
Symptoms relating to psychological distress were assessed in all but one of the studies, as indicated in HYPERLINK \l "TableCharacteristics" Table 2.2. Measures of the following outcomes were included:
anxiety or self statements indicating anxiety (7 studies) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44, HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47, HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50]
social anxiety, social phobia, fear, avoidance (2 studies) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]
rumination tendencies (1 study) ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18]
depression, self statements indicating depression (7 studies) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47, HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50]
general psychological distress, stress (3 studies) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46]
dimensions of obsessive compulsive disorder (2 studies) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47, HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48]
ADHD (1 study) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43].
General well-being
Broad indices of global improvement and general well-being were included in 5 studies, including:
global symptom severity (3 studies) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]
global functioning/symptom improvement (4 studies) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42-44, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]
quality of life (2 studies) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44]
positive general affect (1 study) ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18]
social/work adjustment (1 study) ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47].
Miscellaneous secondary outcomes
In addition to primary outcomes, other miscellaneous secondary outcomes were reported:
emotion recognition ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]
theory of mind skills ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]
problem solving ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46]
sense of coherence ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43]
self esteem ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43]
autism symptoms ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43]
family accommodations ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47].
Most assessment tools were self-report. Apart from some social skills measures used in two studies as noted earlier ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46], clinician ratings were only used for clinical global symptom severity and improvement (CGI-S, CGI-I) scales in two studies: a single case study ADDIN EN.CITE Cardaciotto20041240[42]1240124017Cardaciotto, LeeAnnHerbert, James D.Cardaciotto, LeeAnn, Department of Psychology, Drexel University, M.S. 988, 245 N. 15th Street, Philadelphia, PA, US, 19102-1192Cognitive behavior therapy for social anxiety disorder in the context of Asperger's syndrome: A single-subject reportCognitive and Behavioral PracticeCognitive and Behavioral Practice75-81111Aspergers syndromecognitive behavior therapysocial anxiety disorderdevelopmental disordercomorbiditytreatmentAnxiety DisordersSocial Anxiety2004Win 2004USAssociation for Advancement of Behavior Therapy1077-72292004-15843-008http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2004-15843-008&site=ehost-livelc52@drexel.eduhttp://www.sciencedirect.com/science/article/pii/S107772290480009910.1016/S1077-7229(04)80009-9psyhEBSCOhost[ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42], and a randomised controlled trial ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]. The RCT also included clinician assessed dimensions of OCD, family/carer assessed dimensions of OCD, and family/carer assessed family accommodations (provision of reassurance and modification of home routines).
Blinding
Due to the nature of the study designs, the adult receiving the intervention, their family/caregiver, and the therapist providing the intervention, were unable to be blinded to group allocation. Outcomes were therefore open to detection and performance biases (see HYPERLINK \l "Glossary" Glossary, Appendix 2) such that the way outcomes were reported, and/or the way the individual was treated, may have varied in ways not strictly related to the intervention.
Blinded, independent assessment was rarely employed, and was evident in only two studies: for rating a social skills behavioural task in a pseudo-experimental trial ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49], and for assessing OCD (using the YBOCS) and global symptom severity and improvement (CGI-S/I) in an RCT ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47].
2.3 Quality of included studies
Studies were assigned levels of evidence (described in HYPERLINK \l "NHMRChierarchy" Table A1.1) and quality codes according to methods described elsewhere (see HYPERLINK \l "ScopeMethods" Section 2.1, and HYPERLINK \l "Appraisal" Section A1.5, Appendix 1).
Three systematic reviews were appraised. One review was conducted to inform the NICE Guideline relating to adults with autism ADDIN EN.CITE National Institute for Health and Clinical Excellence (NICE)20121267[22]126712676National Institute for Health and Clinical Excellence (NICE),Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. National Clinical Guideline No. 1422012London, EnglandThe British Psychological Society and The Royal College of Psychiatristshttp://www.nice.org.uk/guidance/cg142[ HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22]. Following a comprehensive and robust methodology , which was rated as being of good (+) quality, the review identified one eligible study using a pseudo-experimental design. This led to its ranking of III-2 in the NHMRC hierarchy of evidence ADDIN EN.CITE National Health and Medical Research Council20081275[40]127512756National Health and Medical Research Council, NHMRC additional levels of evidence and grades for recommendtaitons for developers of guidelines: pilot program 2005-20072008Canberra, AustraliaNHMRC[ HYPERLINK \l "_ENREF_40" \o "National Health and Medical Research Council, 2008 #1275" 40] due to its inclusion of lower order evidence. Another systematic review ADDIN EN.CITE Binnie20131157[41]1157115717Binnie, JamesBlainey, SarahBinnie, JamesThe use of cognitive behavioural therapy for adults with autism spectrum disorders: A review of the evidenceMental Health Review JournalMental Health Review Journal93-104182adultsautism spectrum disorderscognitive behavioural therapycomorbid psychiatric symptomsCognitive Behavior TherapyComorbidityPervasive Developmental DisordersPsychiatric Symptoms2013United KingdomEmerald Group Publishing Limited1361-9322
2042-87582013-27337-005http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-27337-005&site=ehost-livejamescbt@gmail.com10.1108/MHRJ-05-2013-0017psyhEBSCOhost[ HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41] was graded as being of uncertain (?) quality and was also ranked at level III-2. The most recent systematic review ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13] gave a detailed synthesis of features of the 6 included studies, and was coded as being of good quality (+). It included 2 RCTs and was therefore ranked at level I in the evidence hierarchy.
Meta-analysis was not possible in any of the reviews due to the heterogeneity of the interventions and outcomes, and the small samples of the appraised literature.
Of the 10 primary studies appraised, the 4 uncontrolled case studies (evidence level IV) were ungraded for study quality ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50]. A non-randomised pseudo-experimental study had an evidence grade of III-2 ADDIN EN.CITE Russell20091241[48]1241124117Russell, A. J.Mataix-Cols, D.Anson, M. A. W.Murphy, D. G. M.Russell, A. J., Department of Psychology, Institute of Psychiatry, Kings College London, PO Box 77, De Crespigny Park, Denmark Hill, London, United Kingdom, SE5 8AFPsychological treatment for obsessive-compulsive disorder in people with autism spectrum disordersA pilot studyPsychotherapy and PsychosomaticsPsychotherapy and psychosomatics59-61781obsessive compulsive disorderautism spectrum disorderspsychological treatmentComorbidityPervasive Developmental DisordersPsychotherapy2009SwitzerlandKarger0033-3190
1423-03482010-25760-010http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-25760-010&site=ehost-livea.russell@iop.kcl.ac.ukhttp://www.karger.com/Article/Abstract/17262210.1159/000172622psyhEBSCOhost[ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48], with study quality assessed as being poor (X). Two pseudo-randomised studies were graded evidence level III-1, with one ADDIN EN.CITE McGillivray2014244[45]24424417McGillivray, J. A.Evert, H. T.Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASDJournal of autism and developmental disordersJournal of autism and developmental disorders2041-51448AdolescentAdult*Anxiety/th [Therapy]Asperger Syndrome/px [Psychology]*Asperger Syndrome/th [Therapy]Autistic Disorder/px [Psychology]*Autistic Disorder/th [Therapy]*Cognitive Therapy*Depression/th [Therapy]FemaleHumansMale*Psychotherapy, GroupStress, Psychological/th [Therapy]Treatment OutcomeYoung Adult2014United StatesMcGillivray,J A. School of Psychology, Centre for Mental Health and Wellbeing Research, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia, jane.mcgillivray@deakin.edu.au.1573-3432http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=24634065http://link.springer.com/article/10.1007%2Fs10803-014-2087-9[ HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45] rated as being of poor quality (X) and the other ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49] assessed as being of uncertain (?) quality.
The three fully randomised controlled trials (RCTs) are ranked at level II of the NHMRC hierarchy of evidence. Two RCTs ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47] were coded as being of good quality (+) and the third ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43] was rated as being of uncertain quality (?). No RCTs were assessed as being of poor (X) quality.
Table 2.2: Characteristics and results of primary studies by intervention
ReferenceQuality, country Intensity Sample Outcomes (measure) (informant) with significant improvements for CBT groupOutcomes (measure) (informant) with no significant improvements for CBT groupObservational studiesCardaciotto & Herbert (2004) ADDIN EN.CITE Cardaciotto20041240[42]1240124017Cardaciotto, LeeAnnHerbert, James D.Cardaciotto, LeeAnn, Department of Psychology, Drexel University, M.S. 988, 245 N. 15th Street, Philadelphia, PA, US, 19102-1192Cognitive behavior therapy for social anxiety disorder in the context of Asperger's syndrome: A single-subject reportCognitive and Behavioral PracticeCognitive and Behavioral Practice75-81111Aspergers syndromecognitive behavior therapysocial anxiety disorderdevelopmental disordercomorbiditytreatmentAnxiety DisordersSocial Anxiety2004Win 2004USAssociation for Advancement of Behavior Therapy1077-72292004-15843-008http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2004-15843-008&site=ehost-livelc52@drexel.eduhttp://www.sciencedirect.com/science/article/pii/S107772290480009910.1016/S1077-7229(04)80009-9psyhEBSCOhost[ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42]Evidence: IV
Quality: NA
US14 weekly sessions
=14 hours*N=1
23 years
male
AS, comorbid for SAD
Individual CBTglobal symptom severity (CGI-S) (assessor)
global symptom improvement (CGI-I) (assessor)
social phobia (SPAI) (self)
avoidance (LSAS) (self)
depression (BDI-II) (self)
anxiety impairment (ADIS-R) (self)fear (LSAS) (self)
social skills (Behavioural assessments) (assessor)Weiss & Lunsky (2010) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50] Evidence: IV
Quality: NA
Canada12 weekly
1-hour sessions
=12 hoursN=3
late 30s-late 50s
67% male
AS, & various comorbidities
Group CBTMixed results, 1 dropped out
anxiety (BAI) (self) (in 1 of 2 participants)Mixed results, 1 dropped out
depression (BDI-II) (self) (worsened for 2/2)
anxiety (BAI) (self) (worsened for 1/2)Marwood & Hewitt 2012 ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44] Evidence: IV
Quality: NA
UK6 weekly
1-hour sessions
=6 hoursN=1
26 years
male
Autism, mild learning disability, anxiety,
Group CBT- quality of life (QLS) (self)- anxiety (GAS) (self)
- global functioning (HNOS-LDV) (self) Pugliese & White 2014 ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46]Evidence: IV
Quality: NA
US
9 weekly
1-hour sessions
=9 hoursN=5
M=21 years
100% male
ASD, > average IQ
Group CBTMixed results, reliable improvement for 2/5
- problem solving (SPSI-R:L) (self) (2/5)
- general distress (OQ) (self) (2/5)Mixed results, no significant improvement for 3/5
- problem solving (SPSI-R:L) (self) (3/5)
- general distress (OQ) (self) (3/5)Table 2.2: Characteristics and results of included primary studies grouped by type of intervention (continued)
ReferenceQuality, country Intensity Sample, comparatorsOutcomes (measure) (informant) with significant improvements for CBT vs CGOutcomes (measure) (informant) with no significant improvements for CBT vs CGPseudo-randomised or non-randomised experimental studiesTurner-Brown et al (2008) ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]Evidence: III.1
Quality: ?
US18 weekly
50-minute sessions
=15 hoursN=11
25-55 years
91% male
AS, HFA
Group CBT=6;
CG (usual care)=5- emotion recognition of faces (FEIT) (self)
- Theory of Mind skills (Hinting Task) (self)- perceived social communication (SCSQ) (self)
- social skills (SSPA, rated performance) (assessor)Russell et al (2009) ADDIN EN.CITE Russell20091241[48]1241124117Russell, A. J.Mataix-Cols, D.Anson, M. A. W.Murphy, D. G. M.Russell, A. J., Department of Psychology, Institute of Psychiatry, Kings College London, PO Box 77, De Crespigny Park, Denmark Hill, London, United Kingdom, SE5 8AFPsychological treatment for obsessive-compulsive disorder in people with autism spectrum disordersA pilot studyPsychotherapy and PsychosomaticsPsychotherapy and psychosomatics59-61781obsessive compulsive disorderautism spectrum disorderspsychological treatmentComorbidityPervasive Developmental DisordersPsychotherapy2009SwitzerlandKarger0033-3190
1423-03482010-25760-010http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-25760-010&site=ehost-livea.russell@iop.kcl.ac.ukhttp://www.karger.com/Article/Abstract/17262210.1159/000172622psyhEBSCOhost[ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48]Evidence: III.2
Quality: X
UK10-50 sessions, M=27.5 hours*N=24
M=23 years
88% male
HFA, comorbid for OCD
Individual CBT=12; CG (usual care)=12- obsessive-compulsive scale (YBOCS) (varied informants)- depression (BDI) (self)
- anxiety (BAI) (self)McGillivray et al (2014) ADDIN EN.CITE McGillivray2014244[45]24424417McGillivray, J. A.Evert, H. T.Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASDJournal of autism and developmental disordersJournal of autism and developmental disorders2041-51448AdolescentAdult*Anxiety/th [Therapy]Asperger Syndrome/px [Psychology]*Asperger Syndrome/th [Therapy]Autistic Disorder/px [Psychology]*Autistic Disorder/th [Therapy]*Cognitive Therapy*Depression/th [Therapy]FemaleHumansMale*Psychotherapy, GroupStress, Psychological/th [Therapy]Treatment OutcomeYoung Adult2014United StatesMcGillivray,J A. School of Psychology, Centre for Mental Health and Wellbeing Research, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia, jane.mcgillivray@deakin.edu.au.1573-3432http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=24634065http://link.springer.com/article/10.1007%2Fs10803-014-2087-9[ HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45] Evidence: III.1
Quality: X
Australia9 weekly
2-hour sessions
=18 hoursN=42
M=21 years
76% male
AS, HFA
Group CBT=26;
CG (waitlist)=16Some improvements in depression, and stress (subscales of self-reported DASS) for sub-group of participants who were symptomatic at baseline- depression (DASS subscale) (self)
- stress (DASS subscale) (self)
- anxiety (DASS subscale) (self)
- depressed self-statements (ATQ) (self)
- anxious self-statements (ASSQ) (self)Table 2.2: Characteristics and results of included primary studies grouped by type of intervention (continued)
ReferenceQuality, country Intensity Sample, comparatorsOutcomes (measure) (informant) with significant improvements for CBT vs CGOutcomes (measure) (informant) with no significant improvements for CBT vs CGRandomised Controlled TrialsHesselmark et al (2013) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43] Evidence: II
Quality: ?
Sweden36
3-hour sessions
=108 hoursN=68
M=42 years
60% male
ASD
Group CBT=34;
CG (Recreational Activities)=34- global symptoms improvement (CGI-I) (self)- quality of life satisfaction (QOLI) (self)
- psychological distress (SCL-90-R) (self)
- sense of coherence (SoC) (self)
- self esteem (RSES) (self)
- Autism Quotient (AQ) (self)
- depression (BDI) (self)
- ADHD (ASRS) (self)
- global symptoms severity (CGI-S) (self)Russell et al (2013) ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]Evidence: II
Quality: +
UK20 1 hour sessions
=20 hoursN=46
M=27 years
76% male
ASD, verbal IQ>70, OCD
Individual CBT=23;
CG (Anxiety Management)=23- global symptom improvement (CGI-I) (assessor)- global symptom impression severity (CGI-S) (assessor)
- dimensions of OCD (D-YBOCS) (assessor)
- OCD (OCI-R) (self) (improved for CG only)
- depression (BDI) (self)
- anxiety (BAI) (self)
- social anxiety (LSAS) (self)
- social/work adjustment (WSAS) (self)
- anxiety (SCAS) (self)
- obsessive-compulsive (PR-CHOCI-R) (family)
- family accommodation (FSAS-PR) (family)Spek et al (2013) ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18] Evidence: II
Quality: +
The Nether-lands9 weekly
2.5-hour sessions
=22.5 hours + meditation 6 days p/wkN=41
M=42 years
66% male
ASD; anxiety, depression, rumination
Group CBT=20;
CG (waitlist)=21- anxiety (SCL-90-R subscale) (self)
- depression (SCL-90-R subscale) (self)
- rumination tendencies (RRQ) (self)
- positive general affect (GMS) (self)Key: * approximately, session length not reported; ? rated as uncertain quality; + rated as good quality; X rated as poor quality; AS=Asperger sydrome; ASD=Autism Spectrum Disorder; CBT=cognitive behaviour therapy; CG=Control Group; IQ=Intelligence Quotient; OCD=Obsessive Compulsive Disorder; HFA=High Functioning Autism; M=mean; NA=Not Applicable; p/wk=per week; SAD=Social Anxiety Disorder; UK=United Kingdom; US=United States of America.
Note: See HYPERLINK \l "Glossary" Glossary (Appendix 2) for full titles of assessment tools
2.4 Narrative appraisal of studies
A narrative critique of included studies individual strengths and limitations is provided in this section. Full details are presented in the appendicised Evidence Tables ( HYPERLINK \l "Appendix4" Appendix 4). Results are summarised across the primary studies in HYPERLINK \l "TableCharacteristics" Table 2.2. Throughout this section and in the Table, the acronyms only are given for the measures, scales and indexes used to assess outcomes. The full titles are provided in the table of HYPERLINK \l "ScaleAcronyms" acronyms in Appendix 2.
Systematic reviews
Three systematic reviews were included ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13, HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22, HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41].
NICE (2012)
A high quality systematic review was conducted in the UK on the effectiveness of CBT for managing coexisting mental disorders of adults with autism. The review informed the development of a broader NICE Guideline ADDIN EN.CITE National Institute for Health and Clinical Excellence (NICE)20121267[22]126712676National Institute for Health and Clinical Excellence (NICE),Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. National Clinical Guideline No. 1422012London, EnglandThe British Psychological Society and The Royal College of Psychiatristshttp://www.nice.org.uk/guidance/cg142[ HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22]. A broad and extensive search strategy of electronic databases identified studies published up to September 2011. Included were studies of adults aged over 18 years, with a minimum of 10 people per study arm, employing observational and experimental study designs. Robust data extraction and analysis tools were used including GRADE checklists and Review Manager.
Only one study was eligible for inclusion, a low-quality, pseudo-experimental controlled trial including adults with ASD and OCD ADDIN EN.CITE Russell20091241[48]1241124117Russell, A. J.Mataix-Cols, D.Anson, M. A. W.Murphy, D. G. M.Russell, A. J., Department of Psychology, Institute of Psychiatry, Kings College London, PO Box 77, De Crespigny Park, Denmark Hill, London, United Kingdom, SE5 8AFPsychological treatment for obsessive-compulsive disorder in people with autism spectrum disordersA pilot studyPsychotherapy and PsychosomaticsPsychotherapy and psychosomatics59-61781obsessive compulsive disorderautism spectrum disorderspsychological treatmentComorbidityPervasive Developmental DisordersPsychotherapy2009SwitzerlandKarger0033-3190
1423-03482010-25760-010http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-25760-010&site=ehost-livea.russell@iop.kcl.ac.ukhttp://www.karger.com/Article/Abstract/17262210.1159/000172622psyhEBSCOhost[ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48]. It found no significant treatment effects and failed to describe any adaptions made to the CBT approach for the ASD population. The Guideline Development Group (GDG) interpreting the evidence suggested that the lack of adaptations could, in part, account for the lack of efficacy found. The GDG recommended that for adults with autism and coexisting mental disorders, the existing NICE guidance on the specific disorder be used, which includes the use of CBT (Recommendation 7.6.7.5), that staff should understand core symptoms of autism (Recommendation 7.6.7.6), and that staff should make adaptations to the delivery of CBT to suit people with ASD (Recommendation 7.6.7.7).
Specific adaptations to the method of delivery of CBT interventions for people with autism were recommended based on the Guideline Development Groups knowledge and expertise. These are included in a summary of recommended HYPERLINK \l "AdaptationsSynthesis" adaptations to CBT (Section 2.4, Synthesis of Results).
Binnie and Blainey (2013)
The systematic review by Binnie and Blainey (2013) ADDIN EN.CITE Binnie20131157[41]1157115717Binnie, JamesBlainey, SarahBinnie, JamesThe use of cognitive behavioural therapy for adults with autism spectrum disorders: A review of the evidenceMental Health Review JournalMental Health Review Journal93-104182adultsautism spectrum disorderscognitive behavioural therapycomorbid psychiatric symptomsCognitive Behavior TherapyComorbidityPervasive Developmental DisordersPsychiatric Symptoms2013United KingdomEmerald Group Publishing Limited1361-9322
2042-87582013-27337-005http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-27337-005&site=ehost-livejamescbt@gmail.com10.1108/MHRJ-05-2013-0017psyhEBSCOhost[ HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41] considered studies evaluating the effectiveness of CBT for reducing comorbid psychiatric symptoms and increasing social and communication skills in high-functioning adults with ASD. The review was well conducted, employing a broad search of English-language original research published to 2009, explicit selection criteria, and critical appraisal using published checklists. The scope was limited to studies of adults aged 18 years or over diagnosed with High Functioning Autism (HFA) or Asperger syndrome (AS), and excluded those with a learning disability.
Of the 7 eligible studies identified: 5 used a case study methodology, and 2 used pseudo-experimental designs, leading the review to be graded as evidence level III-2. Three of the studies are included in the current review ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48, HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]. As the authors acknowledge, the precision of their conclusions was limited by the heterogeneity of the studies, their small number, and a lack of RCT. The review was graded as being of uncertain quality. Following narrative synthesis, the reviewers tentatively concluded that individually-delivered CBT shows promise in decreasing comorbid psychiatric symptomatology such as anxiety and depression but was unlikely to be effective in changing core cognitive and social deficits associated with ASD. There was insufficient research (from the one included study) to make conclusions about group-based CBT.
Spain et al (2015)
A recent systematic review ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13] by reviewers also based in the UK considered the effectiveness of CBT for assisting adults with ASD and psychiatric co-morbidity where studies employed at least one pre- and post-treatment outcome measure relevant to mental health or functioning. Interventions targeting social skills training or social cognition were excluded.
A robust search strategy considered English language Journal publications to August 2013 and identified 6 eligible studies: two RCTs, one pseudo-experimental study, one case series, and two case studies. Five of these studies are included in the current review ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47, HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50]. All included studies revealed a decrease in co-morbid mental health symptoms. The two appraised RCTs (targeting OCD; and using mindfulness to target low mood and rumination) reported a proportion of participants showing global improvements including reduced co-morbid mental health problems, improved functioning, and increased positive affect. The lower order studies found that several participants benefitted clinically in terms of reduced self-reported symptom severity, and in one study, a clinician-administered measure of OCD symptoms.
The authors concluded that whilst CBT interventions were moderately effective treatments for co-morbid anxiety and depression symptoms, adaptations are likely to be needed to augment the acceptability and effectiveness of interventions for adults on the autism spectrum. Modifications to CBT for people on the autism spectrum are included in a summary of recommended HYPERLINK \l "AdaptationsSynthesis" adaptations to CBT (Section 2.4, Synthesis of Results).
Primary studies
HYPERLINK \l "TableCharacteristics" Table 2.2 summarises key study characteristics and findings for the 10 primary studies appraised relevant to the effectiveness of cognitive behaviour therapy for adults with ASD ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42-50]. Studies in this table, and for the narrative summaries provided below, are organised broadly by study design in the following order: observational studies (4 studies), pseudo- or non-randomised experimental studies (3 studies), and randomised controlled trials (3 studies), and then within each group, by year of publication (oldest first), and alphabetically by first author.
Observational studies
Cardaciotto & Herbert (2004)
Cardaciotto & Herbert (2004) ADDIN EN.CITE Cardaciotto20041240[42]1240124017Cardaciotto, LeeAnnHerbert, James D.Cardaciotto, LeeAnn, Department of Psychology, Drexel University, M.S. 988, 245 N. 15th Street, Philadelphia, PA, US, 19102-1192Cognitive behavior therapy for social anxiety disorder in the context of Asperger's syndrome: A single-subject reportCognitive and Behavioral PracticeCognitive and Behavioral Practice75-81111Aspergers syndromecognitive behavior therapysocial anxiety disorderdevelopmental disordercomorbiditytreatmentAnxiety DisordersSocial Anxiety2004Win 2004USAssociation for Advancement of Behavior Therapy1077-72292004-15843-008http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2004-15843-008&site=ehost-livelc52@drexel.eduhttp://www.sciencedirect.com/science/article/pii/S107772290480009910.1016/S1077-7229(04)80009-9psyhEBSCOhost[ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42] report a careful case study of a young man (aged 23 years) with Asperger syndrome (AS) and co-morbid Social Anxiety Disorder (SAD) who participated in 14 weeks of individually-delivered CBT. Therapy involved cognitive restructuring, role-play, thought-listing, and homework, with an emphasis on social skills training. A battery of published psychological and behavioural measures were assessed at several intervals, commencing prior to therapy (at 6 months, 2 weeks, and immediately prior), during treatment, and immediately post-treatment, with maintenance of affect assessed at 2 months follow-up.
Between pre- and post-therapy assessments, improvements were evident in: CGI ratings of social anxiety (from severely ill to mildly ill), described as very much improved; and in ADIS-R rated anxiety impairment (from very severe to moderate). Measures of fear (LSAS) increased initially during treatment, and decreased to baseline at followup, whereas the score on avoidance (LSAS) steadlily decreased to below baseline. At 2 months follow-up, the client did not meet criteria for social anxiety disorder, and ratings of social phobia (SPAI), and depression (BDI-II) both decreased to normal range. Ratings of social skills observed from video-taped speech and conversation exercises revealed minimal changes over time.
Thorough assessment is a strength of this early case study of an adult on the autism spectrum. The authors concluded that CBT was successful in reducing symptoms of social anxiety, and comorbid depression, in an individual with comorbid Asperger syndrome and social anxiety disorder. However, improvements in social skills were limited.
Weiss & Lunsky (2010) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50]
A small Canadian study reported on three adults with ASD and various comorbidities (including Major Depressive Disorder, PTSD, Panic Disorder) who participated together in group-based CBT (using the manualised Mind Over Mood programme) run over 12 weekly sessions. Anxiety (BAI) and depression (BDI-II) were monitored pre-therapy, weekly throughout therapy, and at 8 weeks followup.
Results were variable across the participants. Franks depression scores increased during therapy, as his anger was reportedly identified, and remained elevated at followup, whilst his anxiety scores decreased somewhat.
Shellis depression and anxiety ratings were reduced throughout therapy. However Shelli became very upset by a thought record that triggered previous trauma during session 9 and was voluntarily hospitalised. Whilst continuing with therapy, she did not participate in assessment at follow-up.
Jakes depression sharply decreased until session 10 which coincided with the anniversary of his mothers death, and remained high at follow-up, with anxiety increasing throughout therapy and was also elevated at followup.
The detailed descriptive reporting of these three peoples experiences, all diagnosed with ASD as adults and with significant and different psychological comorbidities, assisted in interpreting the variable symptomatology ratings exhibited throughout the 12 weeks of therapy. For some, therapy was associated with some short-term improvements in depression and/or anxiety, whilst for others, the therapy appeared to heighten depression and/or anxiety. The experience of coming to therapy and examining unsettling emotions may in itself be challenging for some people. Despite the variable findings, the authors reported that participants were motivated to attend, reported appreciating the socialising function of the group, and liked the predictability and structure of the sessions.
Marwood & Hewitt (2013)
A UK clinic-based case series study offered group-based CBT targeting anxiety to 8 adults with learning disabilities ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44]. Only one of the group had autism (according to health records), 42 year old Nigel, and his results are reported here. Potential participants were screened for their suitability for the intervention, assessing their understanding of the problem, and communication skills. Group therapy involved 6, 1-hour weekly sessions using a CBT approach, including exercises in breathing/relaxation and distraction. Diaries and worksheets were employed, and participants brought support partners to each session.
For Nigel, pre- and post-intervention self-report assessments revealed a non significant decrease in anxiety (GAS), a significant increase in quality of life (QLS) (from dissatisfied to very satisfied), and a slight nominal improvement in global functioning (HoNOS-LDV) that may not have been clinically significant. Semi-structured interviews were conducted for 4 of the 8 participants, with the remaining 4, including Nigel, refusing or being lost to follow-up.
The results were variable across the small group, and for the participant with autism, limited to a single item self-report of improved quality of life. No direct observational data or reports from the support partner were collected, and no longer-term follow-up was undertaken.
Pugliese and White (2014)
Most recently, a small case series study ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46] considered group-based CBT for college (university) students recruited through the student disabilities office. Participants were 5 Caucasian males aged 18-23 years (M=21.3) with independently verified (by ADOS) ASD (4 previously diagnosed with AS and one with Autistic Disorder), all with above average IQ. The students participated in 9, weekly 1-hour sessions of group-based manualised CBT targeting problem solving. The Problem Solving Therapy included psycho-education about autism, feedback on performance, modelling of new skills, direct instruction, and homework assignments.
Ratings from 3 assessments were averaged to produce stable measures for each time-point: baseline, post-intervention, and 2-month follow-up. Programme fidelity was high according to independently rated videotapes of treatment integrity. Students exhibited high attendance and homework completion rates, and reported moderately high satisfaction with the intervention.
Of the 5 participants, 2 demonstrated reliable improvements from baseline to immediately post-intervention in total scores for problem solving (SPSI-R:L) and for subjective general distress (OQ), 2 demonstrated trends toward improvement, and 1 experienced sub-threshold (non-significant) worsening in both outcomes. At 2-month follow-up, improvements for 2 participants were maintained for only one (of 3) subscales of problem solving, and no subscales of subjective distress.
Whilst most participants experienced positive change at either a clinical or subthreshold level, the authors acknowledge that the impact of the CBT intervention on problem solving and general distress outcomes was inconclusive in this preliminary study. They observed that the participants who exhibited the least improvements in outcome both had co-occuring symptoms of anxiety and depression.
Pseudo-randomised or non-randomised experimental studies
Turner-Brown et al (2008)
A US study ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49] investigated the effectiveness of 18, 50-minute weekly sessions of Social Cognitive Interaction Training (SGIT) in a sample of adults with autism and average intellectual ability. The group therapy targetted emotion recognition, theory of mind, and social interaction skills, and included showing videotaped examples of socially challenging situations. Of 13 people recruited, 2 were lost to follow-up. Whilst initially designed as a randomised controlled study, two of the remaining 11 participants opted out of their allocated treatment group and joined the control group (usual care), introducing the potential for allocation biases. Unfortunately no analyses were reported on whether those who dropped out or moved groups differed at baseline from the rest of the sample.
The 11 included participants were aged 25-55 years, were predominantly male (10/11) and Caucasian (9/11). The 6 in the SGIT group were not significantly different to the 5 receiving usual care with respect to IQ, gender, or outcome measures at baseline. However the SGIT group were significantly older than controls (M 42 years cf 29 years, respectively) and included more Caucasian versus non white participants (6/6 cf 3/5). Whilst age and ethnicity were not found to be related to outcomes, some residual confounding may exist in this small pseudo-experimental study.
Treatment integrity was not reported in the study, although the group therapy was manualised. Attendance was high (92%) and satisfaction reported as primarily positive based on self-report questionnaire data. Repeated measures 2 (Group) X 2 (Time) ANOVAs were conducted. Emotion recognition (assessing photographs of faces) (FEIT) was improved over time in the therapy group compared with controls, with a large treatment effect found. Significant main effects for Time, and Group X Time interaction, suggested that the treatment group improved on Theory of Mind skills (Hinting Task) more than control group participants, again with a large treatment effect observed. No significant main effects or interactions were found for the social skills performance task (SSPA, blind-rated from taped role-plays), and only a non-significant trend toward improved self-reported perceived communication skills (SCSQ) was observed in the therapy group.
The CBT-based Social Cognitive Interaction Training demonstrated treatment feasibility and improvements in social cognition tasks relating to judging facial emotions and Theory of Mind vignettes. However robust social functioning improvements were not observed in either the study participants perceived social communication skills, or their directly observed social skills during role-plays. The study was limited by its small, mainly white, male sample, lack of strict randomisation, and no monitoring of treatment fidelity or longer term follow-up.
Russell et al (2009)
A non-randomised, experimental study in the UK ADDIN EN.CITE Russell20091241[48]1241124117Russell, A. J.Mataix-Cols, D.Anson, M. A. W.Murphy, D. G. M.Russell, A. J., Department of Psychology, Institute of Psychiatry, Kings College London, PO Box 77, De Crespigny Park, Denmark Hill, London, United Kingdom, SE5 8AFPsychological treatment for obsessive-compulsive disorder in people with autism spectrum disordersA pilot studyPsychotherapy and PsychosomaticsPsychotherapy and psychosomatics59-61781obsessive compulsive disorderautism spectrum disorderspsychological treatmentComorbidityPervasive Developmental DisordersPsychotherapy2009SwitzerlandKarger0033-3190
1423-03482010-25760-010http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-25760-010&site=ehost-livea.russell@iop.kcl.ac.ukhttp://www.karger.com/Article/Abstract/17262210.1159/000172622psyhEBSCOhost[ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48] considered 24 adult participants with high functioning (i.e., IQ in the average range), clinician-validated autism (ADI, ADOS) who were comorbid with Obsessive-Compulsive Disorder (OCD). Age and ethnicity were not reported for the participants, who were recruited from a specialist ASD clinic, but the sample were predominantly male (88%). Around half of the sample spent some time as inpatients during the study, half had an additional comorbidity (usually depression or anxiety), and between half and two-thirds were on medication at baseline at a stable dose for 6 weeks prior to study commencement. Whether any people were excluded from the study, refused to participate, or dropped out during the study was not reported.
Half of the sample (n=12) received non-manualised individually-delivered CBT from one of three therapists for between 10 and 50 sessions (M=27.5). The length of the sessions was not reported. Therapy was CBT-based and included exposure and response prevention (ERP), and cognitive appraisal of OCD-related beliefs. The other half of the sample (n=12) received treatment as usual, although what this may have included was not discussed. How participants were allocated to treatment or control groups was not reported and was not randomised.
Outcomes including OCD symptoms (YBOCS severity, obsessions and compulsions subscales), anxiety (BAI) and depression (BDI) were measured at baseline and followup, which was immediately after treatment ended for the CBT group (mean=15.9 months), and a similar interval for the control group, although how this was controlled given that the session length varied widely between participants was not reported.
At baseline, there were no significant differences between groups in gender, IQ, proportion with additional psychopathology, time to follow-up, time as inpatients during study period, or whether receiving medication. The CBT group were significantly younger than those receiving usual care (23.8 cf 32.1, p<0.017), and had significantly more severe OCD (YBOCS) at baseline than the control group.
A 2 (Group) X 2 (Time) mixed model ANOVA found significant main effects for Group, Time, and a Group X Time interaction such that the CBT group improved on obsessive compulsive severity scores (YBOCS Total score) compared with control participants, with a large treatment effect evident for those receiving the individualised therapy (Cohens d=1.01). Repeated measures t-tests found significant improvement in OCD symptoms for the CBT group, but not for the usual care group, in overall severity and obsession subscale scores, with a non-significant trend in improved compulsion subscale scores in the CBT group (p=0.09), but not the control group. Clinically significant improvement (defined as >25% reduction on the total YBOCS) was found for more people in the CBT group (n=7) than in the usual care group (n= 2; p<0.05). No difference was evident between groups in the secondary outcomes of anxiety or depression.
Whilst improvements in OCD symptoms were more evident for those receiving CBT that those in the usual care group, the methodological limitations of the study make it difficult to be confident that the therapy alone was responsible. In particular, group allocation was not randomised, and may have been influenced by suitability for therapy, motivation to improve, and/or severity of OCD. The treatment group had higher OCD symptoms and were younger at baseline than the control group, and the lower OCD symptoms at followup may reflect a regression to the mean in their scores. For half of the therapy group, assessment was completed by therapists who were not blind to group allocation. Treatment and therefore followup time varied substantially within the treatment group, and whilst the mean followup time for the control group was said to not differ, it is not clear how this was orchestrated practically given that session times were variable. The small sample size also limits the studys ability to explore potential confounding effects of participant characteristics including age, ethnicity, medication use, dose changes, inpatient time, and additional psychopathology.
Notably, 40% of the CBT group did not respond to treatment. Exploring sample characteristics in a larger, randomly allocated sample would assist in predicting what sort of participants may be most likely to benefit from a programme of intensive individually-delivered therapy targeting OCD symptoms.
McGillivray et al (2014)
An Australian pseudo-experimental study ADDIN EN.CITE McGillivray2014244[45]24424417McGillivray, J. A.Evert, H. T.Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASDJournal of autism and developmental disordersJournal of autism and developmental disorders2041-51448AdolescentAdult*Anxiety/th [Therapy]Asperger Syndrome/px [Psychology]*Asperger Syndrome/th [Therapy]Autistic Disorder/px [Psychology]*Autistic Disorder/th [Therapy]*Cognitive Therapy*Depression/th [Therapy]FemaleHumansMale*Psychotherapy, GroupStress, Psychological/th [Therapy]Treatment OutcomeYoung Adult2014United StatesMcGillivray,J A. School of Psychology, Centre for Mental Health and Wellbeing Research, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia, jane.mcgillivray@deakin.edu.au.1573-3432http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=24634065http://link.springer.com/article/10.1007%2Fs10803-014-2087-9[ HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45] considered changes to psychological distress in young people diagnosed with high functioning autism who received either group CBT or were in a waitlist control group. The sample were 42, mostly male (76%) young people aged 15-25 years (M age=20.6 years) with previous diagnoses of Asperger syndrome (AS) or High Functioning Autism (HFA) (not independently verified). Inclusion criteria required being above the normal range for any of the three outcome measures assessing depression, anxiety, and stress (DASS subscales), and automatic self-statements associated with depressed mood (ATQ) and anxiety (ASSQ). Eligible participants were pseudo-randomised by alternating allocation to treatment or control groups, however randomisation was compromised as evident by the uneven group sizes: CBT group: n=26; control group: n=16.
The treatment group received a group-run CBT-based programme for 9, weekly 2-hour sessions, which included thought restructuring, muscle relaxation and visualisation techniques. Treatment integrity was not reported. Wait-list controls were offered CBT following post-test assessment. Measures were assessed at pre-test, and post-test, with long-term followup assessing maintenance of affect after a further 3, and 9 months (n=27).
At baseline, there were no significant differences between groups in sample characteristics, receipt of treatment, or outcome measures, suggesting that despite inadequate randomisation, the groups were broadly similar at pre-test. A 2 (Group) X 2 (Time) repeated measures ANOVA found a significant main effect for DASS for time but no Group X Time interaction, indicating that there were equal improvements in CBT and control groups over time for psychological distress. The same pattern of findings was observed for the DASS subscales of depression, anxiety, & stress, ATQ, and ASSQ.
Whilst there appeared to be no treatment effect from these initial analyses, post hoc analyses were conducted on the sub-groups of those above normal range (i.e., symptomatic) for each outcome at baseline. Significant Group X Time effects were found for the depression subscale, and for the stress subscale, of the DASS, indicating improvements over time for those receiving CBT more than controls who were symptomatic at baseline in these outcomes, respectively. Increases for these outcomes were maintained in the treatment group at 3 and 9 month followup. However there were no treatment effects for those symptomatic at baseline found for the DASS anxiety subscale, or for automatic self-statements associated with depressed mood (ATQ), or anxiety (ASSQ).
This study had several limitations. Although there were no significant differences detected at baseline in characteristics or outcome measures, randomisation was not adequately performed and systematic biases may have crept into allocation to groups. The sample itself broadly selected people for being above the normal range for one or more of the outcome measures, and therefore included people in the normal range for each outcome with little room for improvement. The self-report outcome measures chosen were atypical for studies of people with ASD, and the authors suggested that they may have been less sensitive to change, as they required attention to symptoms such as autonomous arousal, or reflected real-life concerns that CBT didnt target. Finally, the sample size was reduced for the post hoc sub-group analyses, as well as for assessment of maintenance effects in the control group due to drop-outs, which would reduce the studys statistical power to identify differences over time or between groups.
Hesselmark et al (2014)
A recent randomised controlled trial ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43] compared outcomes following intensive CBT group therapy with those for a group receiving recreational activity (RA) of the same duration. The study was set in an outpatient tertiary psychiatric clinic in Sweden for difficult-to-treat psychiatric patients. The sample were 68 adults with verified ASD and intelligence in the normal range who were aged over 18 years (mean of 32 years), 60% of whom were male. Ethnicity was not reported. The majority presented with psychiatric comorbidity (75%), and use of psychotropic medication (79%). Nearly a third had been a psychiatric inpatient (31%), and over a third had made a previous suicide attempt (35%).
The sample were stratified by gender and randomised through a paper-based lottery to either the CBT or RA groups over the extended study period, although 2 participants were added directly to the RA group after randomisation in an attempt to address a higher initial dropout rate in that group. Both groups (n=34) received 36, weekly 3-hour sessions in groups of 6-8 participants. The manualised group-based CBT programme offered psycho-education, mindfulness and relaxation exercises, social skills training, goal setting, role-playing (with peer-tutors), exposure exercises, and behaviour analysis. The programme was manualised but treatment integrity was not assessed. By contrast, the recreational activities group suggested and voted on activities which therapist leaders took the group to each week, including museum visits, board-games, cooking, boating, cinema, and walks.
Drop out rates were marginally higher for the RA group than the CBT group (15 cf 6, respectively), most occuring at commencement of the trial, which the authors surmised may have been related to practical concerns for inpatient participants or for those who might find public outings challenging. Participants who dropped out showed lower sense of coherence scale scores (which aim to measure the comprehensibility, manageability, and meaningfulness of life) at baseline than completers. There was significant missing data, and the last observation carried forward method was used, alongside intention-to-treat methods, in analyses.
Outcomes were all self-report measures (and thus unblinded) and were measured at pre-test (after randomisation and unblinded to group allocation), and post-test (during the last session). Longer term follow-up occurred for only two measures (quality of life and clinical global improvement) assessed between 8 and 57 months after therapy was completed.
At baseline, there were no significant differences between groups in sample characteristics, diagnostic or outcome measures with the notable exception that the CBT group were more likely to have current diagnoses of anxiety, and depression, than the RA group. A 2 (Group) X 2 (Time) repeated measures ANOVA found a significant increase in quality of life (QOLI) scores at post-test cf baseline for both CBT and RA groups, indicating a medium effect size. This significant increase was maintained at extended followup. However there were no significant differences between the groups in quality of life, indicating that both were equally effective at increasing scores from a general dissatisfaction with life at baseline to the satisfied range by the last group session. Participants did self-rate an improvement in their global functioning (CGI-I) at post-test, with a between group difference favouring CBT, although there was significant missing data (n=29 missing). However there was no improvement observed at longer term follow-up (n=20 missing).
There were no significant changes between pre- and post-test assessments for sense of cohesion (SoC) or self esteem (RSES) scores, nor for a range of exploratory secondary outcomes measuring psychiatric health including psychological distress, autistic symptoms, depression, or ADHD.
The authors conclude that intensive 3-hour sessions offering either CBT, or recreational activities, over up to 36 weeks appear to both be promising treatment options for adults with ASD. Further, they suggest that the two interventions similar efficacy in terms of significantly improving quality of life may be due to their common elements, including structure and group setting. It is possible that the CBT may have been particularly helpful (or unhelpful) for participants with specific concerns or comorbidities. The sample size did not permit exploration of such mediating factors.
Some caution is needed in interpreting these results. The relatively severe level of psychiatric morbidity represented in the sample may limit generalisability to the broader ASD population. The authors suggest that is possible that the sample were at a point of crisis when the intervention began and improvement over time may have occurred without any treatment. A wait-list, no-treatment control could have investigated this possibility. The lack of improvement over time for several other measures suggests that the improvement is either specific to satisfaction with areas of ones life, or is a chance effect. Randomisation was not fully adequate, and the CBT group had higher psychological distress at baseline than the recreation group, although these measures did not change at post-test in either group. There was significant missing data, particularly at longer term follow-up, the duration of which was widely variable and problematic. A particular limitation of the study was that all outcomes were self-reported, with no direct observational data collected by clinicians blind to condition, or informants such as family members.
Russell et al (2013)
After Russell et als (2009) [48] small non-randomised investigation of CBT for treatment of OCD symptoms appraised above, a broadened research team ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47] conducted a larger, fully randomised trial. Drawing on 58 eligible referrals from diverse clinical and community sources, the UK study included 46 young people and adults aged 14-65 years (M=26.9 years), most of whom were male (76%), with a clinically verified diagnosis of ASD, comorbid with Obsessive-Compulsive Disorder (OCD), and meeting a threshold for verbal ability (IQ>70).
The sample were randomised (by masked, random number table) to receive either CBT (n=23) or Anxiety Management (AM) (n=23). The individually-delivered CBT was given in up to 20 (M=17.4) 1-hour sessions. It followed a manualised therapeutic approach adapted for ASD which targeted OCD beliefs involving exposure response prevention, cognitive appraisal, and regular homework. The therapy was adapted for ASD through the use of additional sessions, visual tools and concrete/special interest analogies.
The Anxiety Management therapy included psycho-education about anxiety, mood, healthy habits and problem solving, and teaching techniques in diaphragmatic breathing and muscle relaxation. As these features were common to both interventions, the AM aimed to act as a plausible control group to identify treatment effects related solely to the CBT. The therapy involved marginally fewer (M=14.4) 1-hour sessions. A sample of 20% of sessions were audio-taped and independently rated and established that no cross-contamination of CBT methods occured. Attendance, and homework compliance was good (79%), and satisfaction was reportedly good for both approaches.
Outcome assessments were made at baseline (within 4 weeks of treatment commencement) and at 1 week post-treatment (mean follow-up=25 weeks, matched between groups), with maintenance effects assessed (YBOCS only) after 1, 3, 6, and 12 months post treatment. Six of the initial 46 participants dropped out, and the number of participants completing 1-month followup was reduced to 17 (of 20) in the CBT group and 11 (of 20) in the AM group due to people crossing over to receive the alternative therapy, a condition of ethical approval for the study. The primary outcome was OCD symptom severity (YBOCS) completed by psychologists blind to therapy condition. Secondary outcomes included clinician-rated global symptom improvements (also blinded to group), and a sleuth of other self-report and informant (parent, carer, spouse) outcomes measuring symptoms of anxiety, depression, work/social adjustment, OCD, and family adjustments.
At baseline there were no significant differences between groups in gender, verbal IQ, ADOS, age, or OCD symptoms. Using intention to treat analyses, a 2 (Group) X 2 (Time) ANCOVA controlling for baseline YBOCS found no significant differences between treatment groups in OCD symptoms at the end of treatment.
Considering within group improvement, univariate ANOVAs indicated significant decreases in OCD symptom severity (YBOCS) over time for the CBT group, and also for the Anxiety Management (AM) group. Medium to large effect sizes were observed, and were slightly higher for the CBT group. Improvements were maintained at follow-up intervals for the CBT group (not reported for the AM group). Clinician global impression (CGI) ratings also increased post therapy, equally for both CBT and AM groups. There was a marginal effect such that a higher proportion of participants very much or much improved compared with minimally improved, unchanged or worse (CGI-I) in CBT versus AM groups.
Notably, no improvement over time was observed for any of the self-report measures for either CBT or AM group. Informant interviews revealed improvement over time in OCD symptoms for the AM group only.
The significant reductions in OCD severity were maintained at each follow-up point to 12 months for the CBT group, although half the group were lost to follow-up by this point. (Maintenance was not reported for the AM group, 9 of whom withdrew from follow-up to receive CBT therapy). Moderating factors for treatment effects were investigated. Age, verbal ability or ADOS scores did not moderate outcomes in OCD symptom severity. Treatment responders (>25% reduction on the OCD symptoms) in the AM group (but not CBT group) had lower initial OCD severity ratings at baseline than non-responders.
The researchers conclude that both Anxiety Management and CBT were effective in treating comorbid OCD in young people and adults with ASD as assessed by clinicians blind to treatment allocation. This effect appeared to be maintained for up to a year, however a 50% drop-out rate at that point could have biased assessments toward the positive of those retained. Against predictions, CBT had no advantage over AM in the reduction of OCD symptoms.
The study was generally well conducted, although there was no adjustment made for the many outcomes assessed to allow for chance effects, leading some borderline significant results to be questionable. A larger sample is needed to understand moderating factors better, in particular features of the small but significant number of participants who worsened in Clinical Global Improvement ratings after CBT (10%) and AM (15%) therapies, in addition to the 6 (13%) who dropped out altogether.
Spek et al (2013)
A randomised controlled trial conducted in an adult autism centre in The Netherlands ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18] investigated the effectiveness of group-based Mindfulness Therapy for adults with high functioning ASD, high verbal ability and clinician-identified symptoms of depression, anxiety and/or rumination. People who were institutionalised, used drugs, or changed their medication during the study were ineligible. Two-thirds of the sample of 41 eligible participants (excluding one drop out) were male, and the group mean age was 42 years, with no ethnicity data reported. The sample were randomised (by computer-generated, masked allocation) to either the treatment group (n=20) or a wait-list control group (N=21).
Treatment was a group-based mindfulness behaviour therapy given in weekly 2.5 hour sessions for 9 weeks in groups of 10 or 11 participants. Sessions, which were modified for ASD, included mindfulness exercises relating to breathing, eating, sitting, movement (yoga), and listening; and psycho-education about ruminative thoughts and their relationship with autism. There was also regular planning and review of home mindfulness practice, which participants were instructed to practice at home for 40-60 minutes, 6 days per week. A protocol for sessions was followed by the two therapists although treatment fidelity was not reported.
No significant differences were evident between groups in gender, age, diagnosis, verbal ability (WAIS-III), or outcome measures at baseline. Intention-to-treat analysis was performed. A 2 (Group) X 2 (Time) MANOVA found significant main effects for Time, & Time and Group interactions such that, compared with the wait list control group, those receiving the Mindfulness therapy decreased more on depressive symptoms (SCL-90-R), anxiety (SCL-90-R) and rumination symptoms (RRQ), and increased more on positive affect (GMS). Medium to large effect sizes (Cohens d) were observed for all outcomes. Additional analyses suggested an indirect mediating effect of rumination for: anxiety symptoms, a trend for depressive symptoms and no effect on positive affect. The researchers conclude that rumination may be a potentially important mediating factor in reducing comorbid anxiety and depression.
This well conducted, small study found that adults with ASD and high verbal abilities can acquire meditation skills and transfer these to regular home use. Data suggest that these skills may be associated with reduced psychological distress and and improved wellbeing immediately following 9 weeks of therapy. However, these findings are based on participant self-report with no independently observed improvements, and no followup to determine whether any benefits, or mindfulness practices, were maintained. The suggestion that mindfulness may reduce distress through the reduction of rumination is worth further investigation.
2.4 Synthesis of results
The current systematic review identified 10 primary studies evaluating cognitive behaviour therapy interventions for adults with ASD which have been published since 2004, and 3 recently published systematic reviews with overlapping scope to the current review. As apparent from HYPERLINK \l "TableCharacteristics" Table 2.2, the studies employed different study designs, of varying quality, and investigated a range of outcomes using various assessment tools completed by different types of informants.
Results are synthesised relevant to the two research questions separately: clinical effectiveness of CBT, and recommended adaptations of CBT, for adults with ASD.
Effectiveness of CBT for adults with ASD
Systematic reviews
Three recently published systematic reviews on the topic were appraised as providing background to the current review.
A systematic review of the effectiveness of CBT for managing mental disorders comorbid with ASD in adults was conducted to inform a UK Guideline relating to adults with autism ADDIN EN.CITE National Institute for Health and Clinical Excellence (NICE)20121267[22]126712676National Institute for Health and Clinical Excellence (NICE),Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. National Clinical Guideline No. 1422012London, EnglandThe British Psychological Society and The Royal College of Psychiatristshttp://www.nice.org.uk/guidance/cg142[ HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22]. Only one study, also included in the current review, met restrictive inclusion criteria ADDIN EN.CITE Russell20091241[48]1241124117Russell, A. J.Mataix-Cols, D.Anson, M. A. W.Murphy, D. G. M.Russell, A. J., Department of Psychology, Institute of Psychiatry, Kings College London, PO Box 77, De Crespigny Park, Denmark Hill, London, United Kingdom, SE5 8AFPsychological treatment for obsessive-compulsive disorder in people with autism spectrum disordersA pilot studyPsychotherapy and PsychosomaticsPsychotherapy and psychosomatics59-61781obsessive compulsive disorderautism spectrum disorderspsychological treatmentComorbidityPervasive Developmental DisordersPsychotherapy2009SwitzerlandKarger0033-3190
1423-03482010-25760-010http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-25760-010&site=ehost-livea.russell@iop.kcl.ac.ukhttp://www.karger.com/Article/Abstract/17262210.1159/000172622psyhEBSCOhost[ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48]. The Guideline Development Group recommended that the existing NICE guidance on a specific disorder be used to identify psychological interventions, predominantly CBT, for managing a specific comorbidity with ASD.
The review by Binnie and Blainey (2013) ADDIN EN.CITE Binnie20131157[41]1157115717Binnie, JamesBlainey, SarahBinnie, JamesThe use of cognitive behavioural therapy for adults with autism spectrum disorders: A review of the evidenceMental Health Review JournalMental Health Review Journal93-104182adultsautism spectrum disorderscognitive behavioural therapycomorbid psychiatric symptomsCognitive Behavior TherapyComorbidityPervasive Developmental DisordersPsychiatric Symptoms2013United KingdomEmerald Group Publishing Limited1361-9322
2042-87582013-27337-005http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-27337-005&site=ehost-livejamescbt@gmail.com10.1108/MHRJ-05-2013-0017psyhEBSCOhost[ HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41] considered studies evaluating the effectiveness of CBT for reducing comorbid psychiatric symptoms and increasing social and communication skills in adults with High Functioning Autism or Asperger syndrome. Following narrative synthesis of 7 studies, the reviewers tentatively concluded that individually-delivered CBT shows promise in decreasing comorbid psychiatric symptomatology such as anxiety and depression but was unlikely to be effective in changing core cognitive and social deficits associated with ASD.
These conclusions were consistent with Spain et als (2015) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13] more recent systematic review of CBT for adults with ASD and psychiatric comorbidity. The 6 eligible studies included two recent RCTs allowing the somewhat firmer conclusion that cognitive behaviour therapy was moderately effective in treating co-morbid anxiety and depression symptoms in adults on the autism spectrum.
All three reviews emphasised the need for clinicians to be familiar with the characteristics and breadth of ASD and the need for adaptations to be incorporated into the therapy process for those on the autism spectrum.
Social interaction and communication
Only two studies included social skill measures; a case study ADDIN EN.CITE Cardaciotto20041240[42]1240124017Cardaciotto, LeeAnnHerbert, James D.Cardaciotto, LeeAnn, Department of Psychology, Drexel University, M.S. 988, 245 N. 15th Street, Philadelphia, PA, US, 19102-1192Cognitive behavior therapy for social anxiety disorder in the context of Asperger's syndrome: A single-subject reportCognitive and Behavioral PracticeCognitive and Behavioral Practice75-81111Aspergers syndromecognitive behavior therapysocial anxiety disorderdevelopmental disordercomorbiditytreatmentAnxiety DisordersSocial Anxiety2004Win 2004USAssociation for Advancement of Behavior Therapy1077-72292004-15843-008http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2004-15843-008&site=ehost-livelc52@drexel.eduhttp://www.sciencedirect.com/science/article/pii/S107772290480009910.1016/S1077-7229(04)80009-9psyhEBSCOhost[ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42] and a small pseudo-randomised trial of uncertain quality ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]. Both included behavioural assessments of social performance tasks, and the latter study also included a self-rating of social communication skills. There were no significant treatment effects found for either study (see HYPERLINK \l "TableCharacteristics" Table 2.2).
Emotional and mental health outcomes
The most commonly targeted outcome domain assessed, which was included in all but one primary study, was of emotional and mental health. Some 30 outcome comparisons were measured ranging in symptom dimensions targeted (anxiety, social anxiety, social phobia, fear, avoidance, rumination, depression, psychological distress, OCD, and ADHD), assessment tool used, and informant. Some studies included multiple assessments, sometimes of the same outcome using different tools or informants ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]. It was difficult to discern a clear pattern across the 9 studies including emotional and mental health measures. No treatment effect was found for 20 outcomes, improvement was apparent (in the treatment group, and for two controlled studies, greater relative to the comparison group) for 8 outcomes, and there were mixed results across participants for 2 outcomes in 2 small case studies ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50].
When considering only the controlled studies, 5 included assessments of emotional and mental health outcomes. The two pseudo-randomised studies, both assessed as being of poor quality, found no treatment effects for 7 separate repeated assessments of self-reported depression, stress, anxiety, depressed self-statements, and anxious self-statements. The only positive treatment effect observed was for a measure of OCD symptoms reported by varying informants in one of these studies ADDIN EN.CITE Russell20091241[48]1241124117Russell, A. J.Mataix-Cols, D.Anson, M. A. W.Murphy, D. G. M.Russell, A. J., Department of Psychology, Institute of Psychiatry, Kings College London, PO Box 77, De Crespigny Park, Denmark Hill, London, United Kingdom, SE5 8AFPsychological treatment for obsessive-compulsive disorder in people with autism spectrum disordersA pilot studyPsychotherapy and PsychosomaticsPsychotherapy and psychosomatics59-61781obsessive compulsive disorderautism spectrum disorderspsychological treatmentComorbidityPervasive Developmental DisordersPsychotherapy2009SwitzerlandKarger0033-3190
1423-03482010-25760-010http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-25760-010&site=ehost-livea.russell@iop.kcl.ac.ukhttp://www.karger.com/Article/Abstract/17262210.1159/000172622psyhEBSCOhost[ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48]. In post-hoc sub-group analyses for the other pseudo-randomised study [45], there were some improvements in depression and stress subscales (of self-reported DASS) observed for a sub-group of participants who were symptomatic for these respective outcomes at baseline.
Considering emotional and mental health outcomes assessed in the 3 appraised RCTs, two found no treatment effects for any of 10 outcomes assessed. These included a trial of uncertain quality ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43] which found no greater improvement in self-reported psychological distress, depression, or ADHD symptoms in the CBT group compared with the group receiving a programme of recreational activities matched for (the high, 108 hour) intensity. The other trial ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47], rated as being of good quality, found no greater improvement in those receiving individually delivered CBT compared with those receiving anxiety management therapy, in a host of outcomes including self, assessor or informant assessments of comorbid OCD symptoms, or of self-reported depression, anxiety, social anxiety, and (another index of) anxiety.
Only one of the 3 appraised RCTs found treatment effects for all of its outcomes, including self-reported anxiety, depression, and rumination tendencies. This trial ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18], conducted in The Netherlands and rated as being of good quality, compared outcomes for a group receiving meditation-based therapy of 22.5 hours, in addition to encouraging 6 meditation sessions at home per week, to those for a waitlist control group.
General well being
Eleven general indices of global improvement and well-being were included in 5 of the 10 appraised primary studies. These are likely to correlate with some indices of emotion and mental health symptom improvement described above. Treatment effects were evident for 6 of the outcomes in all the 5 studies including measures relevant to this domain.
Considering the four observational studies, post-CBT improvements in global symptom severity and global symptom improvement were reported for an individual with ASD comorbid with Social Anxiety Disorder (SAD) ADDIN EN.CITE Cardaciotto20041240[42]1240124017Cardaciotto, LeeAnnHerbert, James D.Cardaciotto, LeeAnn, Department of Psychology, Drexel University, M.S. 988, 245 N. 15th Street, Philadelphia, PA, US, 19102-1192Cognitive behavior therapy for social anxiety disorder in the context of Asperger's syndrome: A single-subject reportCognitive and Behavioral PracticeCognitive and Behavioral Practice75-81111Aspergers syndromecognitive behavior therapysocial anxiety disorderdevelopmental disordercomorbiditytreatmentAnxiety DisordersSocial Anxiety2004Win 2004USAssociation for Advancement of Behavior Therapy1077-72292004-15843-008http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2004-15843-008&site=ehost-livelc52@drexel.eduhttp://www.sciencedirect.com/science/article/pii/S107772290480009910.1016/S1077-7229(04)80009-9psyhEBSCOhost[ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42]. Another case study of people with mild learning disabilities included one male with ASD and anxiety who self-reported improvements in quality of life, but not in global functioning.
General well being outcomes were also assessed in all three appraised RCTs. A trial of uncertain quality ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43] found greater improvements in self-reported global symptom improvement for the intensive CBT group than for the matched intensity programme of recreational activities. However there was no treatment advantage for the CBT group for the severity of global symptoms, or for self reported quality of life satisfaction. Similarly mixed results were evident for a good quality trial ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47] comparing individually delivered CBT with anxiety management therapy. This time considering independently assessed and blinded CGI outcomes, there was a CBT treatment advantage for global symptom improvement, but not for improvement in global symptom severity. Nor was there a treatment effect for self-reported adjustment found in this trial.
A more recent, high quality RCT ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18] evaluating meditation-based CBT therapy in The Netherlands, reported findings similar to those found for emotional and mental health outcomes in the same study, such that a treatment effect was observed for self-reported positive general affect.
Miscellaneous secondary outcomes
A number of miscellaneous secondary outcomes were reported alongside primary outcomes.
The small pseudo-randomised trial (of uncertain quality) evaluating group-based Social Cognitive Interaction Training (SCIT) ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49] found significant treatment effects for the targeted outcomes of self-reported emotion recognition, and theory of mind skills.
A small case series study ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46] found that following 9 sessions of group-based Problem Solving Therapy there were mixed results; an improvement was evident for self-reported problem solving skills for only 2 of the 5 participants.
The RCT (of uncertain quality) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43] comparing group-based CBT with a group receiving Recreational Activities found no difference in improvement for self-reported ratings of a sense of coherence, or self-esteem.
Finally, a good quality RCT ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47] comparing individually delivered CBT with an anxiety management programme found no difference in self-reported characteristics of autism, or for family assessed family accommodations made for the family member/spouse with ASD.
Maintenance
Follow-up beyond post-test to measure maintenance of any observed treatment effects was included for 6 of the primary studies for periods of 2 months ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50], 3 and 9 months ADDIN EN.CITE McGillivray2014244[45]24424417McGillivray, J. A.Evert, H. T.Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASDJournal of autism and developmental disordersJournal of autism and developmental disorders2041-51448AdolescentAdult*Anxiety/th [Therapy]Asperger Syndrome/px [Psychology]*Asperger Syndrome/th [Therapy]Autistic Disorder/px [Psychology]*Autistic Disorder/th [Therapy]*Cognitive Therapy*Depression/th [Therapy]FemaleHumansMale*Psychotherapy, GroupStress, Psychological/th [Therapy]Treatment OutcomeYoung Adult2014United StatesMcGillivray,J A. School of Psychology, Centre for Mental Health and Wellbeing Research, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia, jane.mcgillivray@deakin.edu.au.1573-3432http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=24634065http://link.springer.com/article/10.1007%2Fs10803-014-2087-9[ HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45], at 1, 3, 6, and 12 months ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47], and at variable follow-up periods of between 8 and 57 months ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43].
For three studies, no outcomes exhibiting treatment benefits post CBT were maintained at extended followup ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50] and for another case series ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46], only improved problem solving for 2 of 5 participants was maintained at 2 months followup.
For an RCT comparing CBT with Anxiety Management ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47], a post-treatment improvement for the CBT group in OCD symptoms (YBOCS) was maintained at 1, 3, 6 and 12 months followup, but whether the post-test improvement also observed in the Anxiety Management group was maintained at extended followup was not reported.
The only study reporting consistently maintained improvements at followup was for the case study of one adult [42]. For this study, self-reported social phobia and anxiety impairment remained improved compared to baseline, as did clinically assessed global symptom improvement and severity. Further, the clients depression and avoidance fell to within a normal range, and the participant no longer met criteria for Social Anxiety Disorder 2 months after CBT was completed.
Adaptations to CBT for adults with ASD
This reviews second and supplementary research question was to describe adaptations that have been developed for CBT to make it more suitable and potentially efficacious for adults on the autism spectrum.
The recent systematic review of Spain et al ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13] described the common adaptations to CBT-based interventions that have been employed for managing mental disorders co-occuring with ASD in adults. These included:
Adopting a more structured approach, and being more directive in therapy
Modifying the means through which information is delivered to include more visual cues and written materials, avoid colloquialisms, and to identify specific and concrete examples
Incorporating participants' interests to enhance engagement and facilitate learning of new techniques
Greater emphasis on enhancing participant understanding of their emotions and mood
Extending the number of sessions and time provided to conduct experiential tasks to overcome potential cognitive processing deficits and to permit more time for additional components.
The NICE Guideline for adults with ASD ADDIN EN.CITE National Institute for Health and Clinical Excellence (NICE)20121267[22]126712676National Institute for Health and Clinical Excellence (NICE),Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. National Clinical Guideline No. 1422012London, EnglandThe British Psychological Society and The Royal College of Psychiatristshttp://www.nice.org.uk/guidance/cg142[ HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22] developed a list of recommended adaptations to the method of delivery of CBT based on the Guideline Development Groups (GDG) expertise and knowledge of the literature. Similar to Spain et als ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13] list, the GDG recommended:
a more concrete and structured approach,
a greater use of written and visual information (which may include worksheets, thought bubbles, images and 'tool boxes'),
using plain English and avoiding excessive use of metaphor, ambiguity and hypothetical situations, and
maintaining the person's attention by offering regular breaks and incorporating their special interests into therapy if possible (such as using computers to present information).
Further, the GDG suggested additional modifications:
placing a greater emphasis on changing behaviour, rather than cognitions, and using the (problem) behaviour as the starting point for intervention,
making rules explicit and explaining their context,
involving a family member, partner, carer or professional (if the person with autism agrees) to support the implementation of an intervention.
With respect to the primary studies appraised in the current review, adaptations made to therapies to suit adults with autism were not specified in three of the 10 included primary studies ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44, HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50]. However, adaptations specified in the other 7 primary studies are presented in HYPERLINK \l "TableStudiesCBTAdaptions" Table 2.3. Although which adaptations were used varied between the studies, all of the themes already identified above were evident, as detailed below.
The listed adaptations mentioned above in appraised secondary studies ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13, HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22] included using a more structured approach with explicit roles, times, goals and techniques aimed to increase the predictability of the programme and to allow for deficits in executive function and planning. This advice was consistent with that of two studies ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47] advising the therapist to use a more directive approach. For example, through providing immediate, direct and specific feedback on performance, and direct instruction to teach skills.
Also in common with the aforementioned reviews, adapting the modes of delivery of therapy was undertaken in several of the primary studies ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47, HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]. Suggested modifications included using more visual material, such as diaries and diagrams, writing communication, tape recording sessions, showing videotaped vignettes, and peer-modelling. The use of concrete analogies has been advised in favour of the use of metaphors and ambiguous terms. Attempts were also made to incorporate examples of problems familiar to programme participants as well special-interest related analogies and tools.
Consistent with Spain et als review ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13], an emphasis on affective education was identified as a useful adaptation, evident in a few of the studies included in the current review ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47, HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]. Specific modifications included an emphasis on how to read emotional responses in others, understanding and differentiating emotions, and linking emotions to non-verbal behaviours. Related to this adaptation, several primary studies mentioned including psycho-education about autism, and/or mental health symptoms such as anxiety, as explicit adaptations ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47].
The NICE Guideline ADDIN EN.CITE National Institute for Health and Clinical Excellence (NICE)20121267[22]126712676National Institute for Health and Clinical Excellence (NICE),Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. National Clinical Guideline No. 1422012London, EnglandThe British Psychological Society and The Royal College of Psychiatristshttp://www.nice.org.uk/guidance/cg142[ HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22] suggested that CBT for people on the autism spectrum place a greater emphasis on changing behaviour, rather than changing cognitions. A number of primary studies also made adaptations of this kind ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46], such as placing a focus on the social interaction, organisation and time management problems brought to the sessions by participants, and in one study ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18], leaving out exercises requiring the restructuring of cognitions altogether.
A related adaptation recommended by NICE ADDIN EN.CITE National Institute for Health and Clinical Excellence (NICE)20121267[22]126712676National Institute for Health and Clinical Excellence (NICE),Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. National Clinical Guideline No. 1422012London, EnglandThe British Psychological Society and The Royal College of Psychiatristshttp://www.nice.org.uk/guidance/cg142[ HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22] was to make rules explicit. Examples evident in two primary studies ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49] include teaching the recognition and understanding of verbal, nonverbal and paralinguistic social cues, grasping the general picture of a social situation, and distinguishing relevant from irrelevant social facts. Practising new skills in live interactions was also employed, which was facilitated by the use of peer tutors in role-plays ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43].
Although not mentioned as an adaptation, one of the studies ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44] encouraged participants to bring a support person to therapy, as recommended by the NICE Guideliness GDG. A family member or key support worker people can act as a co-therapist in an attempt to improve generalisation of skills ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_15" \o "Anderson, 2006 #229" 15].
One appraised review ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13] identified adaptations to increase the length of particular exercises, and the number of sessions. This was undertaken by one included primary study ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18], however was likely to have been applied to others, particularly where very intensive programmes were developed ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43]. Extending the time provided in therapy overall can accommodate slower information processing and also the mental strain of the therapeutic process on clients with ASD, whilst giving breaks and varying the length of sessions can allow for cognitive and motivational deficits ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_15" \o "Anderson, 2006 #229" 15].
In conclusion, the suggested adaptations identified in appraised primary and secondary literature in the current review update those presented in the NZ ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1]. A synthesis of this evidence is presented in HYPERLINK \l "SummaryConclusions" Section 2.6 (Summary and conclusions).
Table 2.3: Primary studies using adaptations of CBT for adults with ASD
ReferenceDesign, country CBT Sample Adaptations of CBT for autism populationCardaciotto & Herbert (2004) ADDIN EN.CITE Cardaciotto20041240[42]1240124017Cardaciotto, LeeAnnHerbert, James D.Cardaciotto, LeeAnn, Department of Psychology, Drexel University, M.S. 988, 245 N. 15th Street, Philadelphia, PA, US, 19102-1192Cognitive behavior therapy for social anxiety disorder in the context of Asperger's syndrome: A single-subject reportCognitive and Behavioral PracticeCognitive and Behavioral Practice75-81111Aspergers syndromecognitive behavior therapysocial anxiety disorderdevelopmental disordercomorbiditytreatmentAnxiety DisordersSocial Anxiety2004Win 2004USAssociation for Advancement of Behavior Therapy1077-72292004-15843-008http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2004-15843-008&site=ehost-livelc52@drexel.eduhttp://www.sciencedirect.com/science/article/pii/S107772290480009910.1016/S1077-7229(04)80009-9psyhEBSCOhost[ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42]Case study
USIndividual CBT
14 hours*N=1
AS, comorbid for SAD
- emphasis on social skills training to attend to deficits in verbal, nonverbal and paralinguistic social skillsPugliese & White (2014) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46]Case series
US
Group CBT
9 hoursN=5
ASD, > average IQ
- increasing structure and predictability of programme
- immediate, direct and specific feedback on performance
- direct instruction and use of shaping to teach skills
- used visual aids
- intensive modelling of new skills by leaders
- included psycho-education about ASD
- focussed on one individualised problem
- emphasis on social interaction, organisation and time management as common problems Turner-Brown et al (2008) ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]Pseudo-randomised study
USGroup CBT
15 hoursN=11
AS, HFA
- created videotaped vignettes of social problems familiar to people with autism
- linked non-verbal behaviours to emotions
- distinguished relevant from irrelevant social facts
- taught how to recognise where they missed the general picture of a social situation
- practiced identifying relevant social cues in social interactionsMcGillivray et al (2014) ADDIN EN.CITE McGillivray2014244[45]24424417McGillivray, J. A.Evert, H. T.Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASDJournal of autism and developmental disordersJournal of autism and developmental disorders2041-51448AdolescentAdult*Anxiety/th [Therapy]Asperger Syndrome/px [Psychology]*Asperger Syndrome/th [Therapy]Autistic Disorder/px [Psychology]*Autistic Disorder/th [Therapy]*Cognitive Therapy*Depression/th [Therapy]FemaleHumansMale*Psychotherapy, GroupStress, Psychological/th [Therapy]Treatment OutcomeYoung Adult2014United StatesMcGillivray,J A. School of Psychology, Centre for Mental Health and Wellbeing Research, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia, jane.mcgillivray@deakin.edu.au.1573-3432http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=24634065http://link.springer.com/article/10.1007%2Fs10803-014-2087-9[ HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45] Pseudo-randomised study
AustraliaGroup CBT
18 hoursN=42
AS, HFA
- focused on social difficulties
- taught how to read emotional responses in othersHesselmark et al (2013) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43] RCT
SwedenGroup CBT
108 hoursN=68
ASD
- psycho-education included ASD, self esteem and psychiatric symptoms
- minimised use of metaphors
- discussed social training and social contacts
- included peer tutors in social training role playsRussell et al (2013) ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]RCT
UKIndividual CBT
20 hoursN=46
ASD, verbal IQ>70, comorbid for OCD
- used structured and therapist-directed approach
- used visual tools and concrete/special interest-related analogies
- emphasis on understanding and differentiating emotions
- included psycho-education sessions about understanding and rating anxiety Spek et al (2013) ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18] RCT
The NetherlandsGroup CBT
22.5 hoursN=41
ASD; symptoms of anxiety, depression, rumination- avoided use of metaphors, and ambiguous terms.
- included psycho-education about rumination and autism
- omitted cognitive elements such as exercises examining thoughts
- extended length of breathing exercises, and of programmeKey: AS=Asperger sydrome; ASD=Autism Spectrum Disorder; CBT=cognitive behaviour therapy; CG=Control Group; IQ=Intelligence Quotient; OCD=Obsessive Compulsive Disorder; HFA=High Functioning Autism; RCT=randomised controlled trial; UK=United Kingdom.2.5 Limitations and future research directions
Key methodological issues will be outlined below with suggestions on directions for future research.
Sample size
The 10 primary studies appraised in this review considered 242 participants with ASD. Included studies were relatively small, ranging from 1-68, particularly once randomised such that between 10 and 34 received CBT in any one study. Small samples limit statistical power to detect small treatment effects. Randomised experimental designs with larger samples are needed to provide adequate power to detect clinically significant effects and to conduct robust sensitivity analyses.
Sample characteristics and recruitment
The majority of studies included in the current review concerned so-called higher functioning, verbally fluent adults with ASD. Inclusion criteria for 7 of the 10 appraised studies specifyied that participants demonstrated cognitive and/or language functioning above specified thresholds (typically, full IQ scores of above 70) according to standardised scales. More research is needed into the feasibility and effectiveness of CBT-based approaches for individuals with learning disabilities and lacking verbal fluency.
Whilst co-occuring mental health conditions or symptomatology were common in the study samples, only 3 specified a comorbidity as an inclusion criteria. Having an obsessive-compulsive disorder (OCD) was required for inclusion in 2 controlled studies, and symptoms of psychological distress required in one RCT. It is possible that outcomes targeting emotional and mental health may have had less chance of achieving change for participants with sub-clinical symptoms of psychological distress (i.e., due to a floor effect).
Where reported, mean ages ranged from 21 to 42 years, with some studies focusing on younger College students ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46], and others on older people, often diagnosed later in life ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50]. Programme content and adaptations are likely to vary between such populations based on age, presenting problems, and life experience with a diagnosis of ASD.
Samples were predominantly male (range: 60 to 91%), broadly reflecting the 4:1 male to female gender distribution observed in the condition generally. Larger samples of female participants would be useful to consider whether effectiveness of different approaches varies by gender. It may also be important to develop different assessment tools for females compared with males, given that mental health symptoms, and indeed autism, may present differently based on gender ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_27" \o "Scattone, 2013 #1081" 27].
Most studies reported ASD as clinically diagnosed, although it was not always clear whether diagnoses were independently verified ADDIN EN.CITE Binnie20131157[41]1157115717Binnie, JamesBlainey, SarahBinnie, JamesThe use of cognitive behavioural therapy for adults with autism spectrum disorders: A review of the evidenceMental Health Review JournalMental Health Review Journal93-104182adultsautism spectrum disorderscognitive behavioural therapycomorbid psychiatric symptomsCognitive Behavior TherapyComorbidityPervasive Developmental DisordersPsychiatric Symptoms2013United KingdomEmerald Group Publishing Limited1361-9322
2042-87582013-27337-005http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-27337-005&site=ehost-livejamescbt@gmail.com10.1108/MHRJ-05-2013-0017psyhEBSCOhost[ HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41]. In one study the diagnosis was based on previous assessments as noted in a clients records ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46]. Historic reporting of diagnoses may be inaccurate or no longer current.
The research tended to be conducted in Western, developed nations of North America, northern Europe and Australia. Ethnicity was rarely reported in the appraised research, and in the 3 US-based studies where it was, a high majority of Caucasian participants were represented in the samples. No studies were undertaken in New Zealand. As such, care should be taken in generalising findings to different cultural and ethnic populations. A lack of information regarding recruitment strategies is common in this field and there is a likelihood of drawing participants from opportunistic samples which further reduce the ability to generalise to broader populations ADDIN EN.CITE Binnie20131157[41]1157115717Binnie, JamesBlainey, SarahBinnie, JamesThe use of cognitive behavioural therapy for adults with autism spectrum disorders: A review of the evidenceMental Health Review JournalMental Health Review Journal93-104182adultsautism spectrum disorderscognitive behavioural therapycomorbid psychiatric symptomsCognitive Behavior TherapyComorbidityPervasive Developmental DisordersPsychiatric Symptoms2013United KingdomEmerald Group Publishing Limited1361-9322
2042-87582013-27337-005http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-27337-005&site=ehost-livejamescbt@gmail.com10.1108/MHRJ-05-2013-0017psyhEBSCOhost[ HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41].
Future research should include people with intellectual disability and people from different cultures and socio-economic groups to permit understanding of the generalisability of the findings to a broader range of populations.
Study design
Studies investigated whether outcome measures changed between baseline and post-test after receiving a cognitive behaviour therapy intervention, either in a group-based setting (7 studies) or as individually-delivered sessions with a therapist (3 studies).
Four small case studies each including between 1 and 5 people with ASD (sometimes as part of a broader clinical group) were included. Case series studies can be invaluable in the development, fine-tuning, adaption, and improvement of an intervention, crucial to exploring why an intervention works (and doesnt), who it works best for, and what components are necessary.
The other 6 studies were experimental studies comparing treatment effects with those of a control group: usual-care, wait-list controls, or alternative treatment. Three of these studies employed no or only pseudo randomisation in group allocation, and three were fully randomised controlled trials. Large sampled RCTs have the potential to provide stronger evidence of causal clarity whilst allowing scope to investigate mediating and moderating variables associated with treatment success, such as participant characteristics ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46].
For future research, more large-scale, high-quality trials have been suggested using manualised CBT and checks on therapist adherence to inform what adaptions may be necessary to therapy for people with ASD ADDIN EN.CITE Binnie20131157[41]1157115717Binnie, JamesBlainey, SarahBinnie, JamesThe use of cognitive behavioural therapy for adults with autism spectrum disorders: A review of the evidenceMental Health Review JournalMental Health Review Journal93-104182adultsautism spectrum disorderscognitive behavioural therapycomorbid psychiatric symptomsCognitive Behavior TherapyComorbidityPervasive Developmental DisordersPsychiatric Symptoms2013United KingdomEmerald Group Publishing Limited1361-9322
2042-87582013-27337-005http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-27337-005&site=ehost-livejamescbt@gmail.com10.1108/MHRJ-05-2013-0017psyhEBSCOhost[ HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41].
Assessment and maintenance
Outcome assessments were measured at baseline (pre-test), and at post-test, either upon/just after completion of the last CBT session, or for the control group, at an equivalent time post baseline. However this schedule is likely to pick up short-term effects of the intervention and may exaggerate some indicators due to recency effects.
Whether any improvements at post-test are maintained for the treatment group was investigated in 6 studies for periods ranging from 2 to 57 months post intervention. Such assessments were commonly limited by smaller sample sizes and intrinsic biases related to study attrition.
Control groups
Of the 6 experimental studies comparing treatment effects with a control group, 2 were treatment as usual (TAU) controls ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48, HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49], 2 were wait-list controls ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45], and two studies employed alternative active treatments ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]. There are benefits and limitations for all of these comparators.
Control groups where everyone completes similarly spaced repeated assessments control for maturation or time-relevant effects (including improvement over time, and regression to the mean), and practice and therapeutic effects of completing measures. For wait list controls, treatment is deferred, providing the ethical benefit of not depriving the control group of the potential benefit of the intervention, and an incentive to stay enrolled in the study and complete the assessment measures.
However inactive control groups do not receive expectency effects; that is, the possible effect of expecting a benefit from receiving any active treatment, no matter what the content. That is, they do not act as genuine placebo controls.
It is also not possible to determine whether indirect aspects of the intervention, such as gathering together in a group of people affected by similar challenges on a regular basis, may be contributing to improvements apart from the programme content itself. Such gathering may be effective at reducing psychological distress, in providing informal support, exchanging experiences, and normalising feelings ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]. The UKs NICE Guideline recommends a group-based structured leisure activity programme for adults with ASD (who have no or only mild learning disability) who are socially isolated or have restricted social contact ADDIN EN.CITE National Institute for Health and Clinical Excellence (NICE)20121267[22]126712676National Institute for Health and Clinical Excellence (NICE),Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. National Clinical Guideline No. 1422012London, EnglandThe British Psychological Society and The Royal College of Psychiatristshttp://www.nice.org.uk/guidance/cg142[ HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22].
Studies which provide alternative active interventions where groups meet for a similar amount of time but do not receive CBT attempt to control for such confounders and determine whether CBT specific features have an added benefit. Two RCTs provided comparison groups which offered potentially active treatments of anxiety management ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47], and recreational activities ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43], for the same duration as the CBT group received therapy.
Future studies could consider non-directive counseling as comparators to individually-directed counseling to identify any additional benefits of goal-directed, planned cognitive-behavioural therapy ADDIN EN.CITE Binnie20131157[41]1157115717Binnie, JamesBlainey, SarahBinnie, JamesThe use of cognitive behavioural therapy for adults with autism spectrum disorders: A review of the evidenceMental Health Review JournalMental Health Review Journal93-104182adultsautism spectrum disorderscognitive behavioural therapycomorbid psychiatric symptomsCognitive Behavior TherapyComorbidityPervasive Developmental DisordersPsychiatric Symptoms2013United KingdomEmerald Group Publishing Limited1361-9322
2042-87582013-27337-005http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-27337-005&site=ehost-livejamescbt@gmail.com10.1108/MHRJ-05-2013-0017psyhEBSCOhost[ HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41].
Outcome measures
There was a broad range of outcomes reported in the appraised primary studies in the current review, varying with respect to domain measured, assessment method (rating scales, observations, and performance measures), and informant.
The sheer number of tools used for similar outcomes is of concern and restricts the ability to compare results across studies. A standard set battery of assessment tools is needed to permit comparisons between studies.
Whilst assessment tools used frequently had good psychometric properties, often their reliability and validity is yet to be established in ASD populations ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13] or with adults (rather than children) on the autism spectrum, which may reduce their ability to reliably measure change. Future research needs to evaluate the utility of existing rating scales for this population and/or develop scales specifically for adults with ASD ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_27" \o "Scattone, 2013 #1081" 27].
Most assessment tools were self-report. It has been suggested that future studies should incorporate measures other than self-reports for people on the spectrum ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18], particularly for judging emotional states which can be controversial. Ratings from informants such as the participants spouse/family-member, and independent clinicians/assessors, were rarely undertaken and few were blinded to group assignment.
Broadening of outcomes is recommended to rely less on self-appraisal of affect and emotions ADDIN EN.CITE Binnie20131157[41]1157115717Binnie, JamesBlainey, SarahBinnie, JamesThe use of cognitive behavioural therapy for adults with autism spectrum disorders: A review of the evidenceMental Health Review JournalMental Health Review Journal93-104182adultsautism spectrum disorderscognitive behavioural therapycomorbid psychiatric symptomsCognitive Behavior TherapyComorbidityPervasive Developmental DisordersPsychiatric Symptoms2013United KingdomEmerald Group Publishing Limited1361-9322
2042-87582013-27337-005http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-27337-005&site=ehost-livejamescbt@gmail.com10.1108/MHRJ-05-2013-0017psyhEBSCOhost[ HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41], and to target transdiagnostic characteristics commonly associated with psychiatric morbidity (anger, eating problems and sleep difficulties) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13].
Programme components
Intervention programmes were led by trained instructors/therapists, and followed a schedule of content, techniques and strategies employed in each session. Future research requires a component analysis to attempt to isolate and analyse features of effective CBT programmes to determine necessary and specific contributions to overall efficacy. Potential variable components could include involvement of a support person, use of peer tutors, varying the media for delivering content (e.g., computers, performances, written vignettes), and replacing traditional thought restructuring techniques with mindfulness training.
Programme standardisation and fidelity
Fully manualised programmes attempt to standardise the programme format and content which allows for more consistent transfer of the intervention into a new setting and/or population. Six of the 10 primary studies appraised were reported as being manualised, five of which were group-based ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50] and one individually directed ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]. There was a lack of reporting of treatment integrity, with only two manualised studies assessing fidelity of programmes to providing scheduled content through independent ratings of a selection of taped sessions ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47].
Standardisation of broad content does not require uniformity. Programmes can be multi-component, and vary in aspects such as choice of scenarios that are modelled, and problem behaviours attended to, to suit the needs of the participant/s. Some programmes evaluated in this review were adapted for use with an ASD population from exisiting programmes developed for people with other needs.
Programme intensity
The intensity of an intervention may be associated with treatment effects indicating a dose-response relationship. In the current review, intensity varied from 6 to 108 hours across the 10 studies. Intensity appeared to increase for the more robust study designs, ranging from 6 - 14 hours for the 4 case studies, 10 - 50 hours for the 3 pseudo-experimental studies, and 20 - 108 hours for the three RCTs. As the intensity of these interventions also varied characteristics of their content and approach, it is difficult to disentangle the impact of intensity from content in treatment response.
Moderators and mediators of treatment response
Formally developing the evidence-base for the mediating and moderating mechanisms of CBT for adults with ASD is an important next step for clinicians and researchers ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13]. There are a number of factors that may moderate or mediate a treatment response that should be measured and reported, and ideally, experimentally manipulated in a controlled manner to determine its potential influence.
A programme of research has been proposed in the UKs NICE Guideline on supporting adults with autism ADDIN EN.CITE National Institute for Health and Clinical Excellence (NICE)20121267[22]126712676National Institute for Health and Clinical Excellence (NICE),Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. National Clinical Guideline No. 1422012London, EnglandThe British Psychological Society and The Royal College of Psychiatristshttp://www.nice.org.uk/guidance/cg142[ HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22]. It aims to develop methods of delivery of CBT to take into account the impact of autism and nature and duration of the intervention, test treatment feasibility in pilot studies, and formally evaluate the outcomes in a large-scale randomised controlled trial/s.
In addition to investigating programme components, socio-demographic, diagnostic, and other attributes of participants at baseline may relate to treatment outcomes in predictable ways, characterising treatment responders and non-responders. Identifying characteristics of individuals for whom the intervention is most likely to work will assist in the tailoring and targeting of interventions.
2.6 Summary and conclusions
Overview
This systematic review updates evidence for the New Zealand Autism Spectrum Disorder Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] with respect to the effectiveness of cognitive behaviour therapy for adults with ASD. Following a comprehensive database search and reference checking of primary studies and systematic reviews published since 2004, 13 studies met selection criteria for inclusion: 3 systematic reviews and 10 primary studies.
Participants
The research tended to be conducted in clinical or research settings based in Western, developed nations. Three studies each came from the United States and UK, with single studies represented from Australia, Sweden, The Netherlands, and Canada. Ethnicity was only reported in the 3 US-based studies, where they included a high majority of Caucasian participants.
Samples were predominantly male, and broadly consistent with the higher proportion of males diagnosed with ASD in the general population. Selection criteria specified a minimum age of 18 years for inclusion in all but two studies, which were also open to youth. Mean ages ranged from 21 to 42 years across the 10 primary studies. Most studies included higher functioning participants with ASD; that is; with Asperger syndrome, High Functioning Autism (HFA) and/or of moderate or higher intelligence according to standardised tests.
Whilst co-occuring mental health conditions or symptomatology were common in the study samples, only 3 specified a comorbidity as an inclusion criteria. Having an obsessive-compulsive disorder (OCD) was required for inclusion in 2 controlled studies, and symptoms of psychological distress required in one RCT.
Design
The 10 primary studies represented 242 adults with ASD, ranging from 1 to 68 participants in individual studies, with between 10 and 34 receiving the intervention in comparative studies. Studies investigated whether outcome measures changed between baseline and post-test assessments after receiving a cognitive behaviour therapy (or comparison) intervention.
Four case studies of 1-5 people with ASD (sometimes as part of a broader clinical group) were included. The other 6 were experimental studies compared treatment effects with those of a control group: usual-care, wait-list controls, or for two studies, alternative treatment (a recreation programme, and an anxiety management programme, respectively). Three of these studies employed no or only pseudo-randomisation in group allocation, and three were fully randomised controlled trials. Whether any improvements at post-test were maintained for the treatment group were investigated in 6 studies for periods ranging from 2 to 57 months.
Intervention
Cognitive behaviour therapy was offered either in a group-based setting (7 studies) or in individually-delivered one-to-one sessions with a therapist (3 studies). The CBT intervention targeted specific mental health symptoms and behaviours in 7 of the 10 included studies, including anxiety and mood, OCD-related beliefs, problem solving, social skills training, emotion recognition and theory of mind training. One study encouraged participants to bring a support person, and another included peer-mentors. An RCT from the Netherlands ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18] employed a third-wave CBT approach which emphasises mindfulness training rather than traditional thought restructuring techniques in an intensive programme of 3-hour weekly sessions held over 36 weeks.
The assessed therapy was typically provided in one-hour, weekly sessions, however intensity was extremely variable. Sessions ranged from 50 minutes to 3 hours long and extended over 6 to 50 weeks, with a total of between 6 and 108 hours across the 10 studies. In addition, many therapists set homework, including one study requiring 40-60 minutes of home-based meditation 6 days per week for 9 weeks.
Outcome assessment and study quality
A broad number of outcomes and assessment tools were used in the included studies. Most common were assessments of mental health and well-being, including measures of specific symptoms of psychological distress, global symptom improvement, quality of life, and adjustment. Two studies assessed social skills, and included direct behavioural ratings of participants engaged in role-plays or performance. Cognitive outcomes were assessed in one study including emotion recognition, Theory of Mind skills and problem solving skills. Miscellaneous outcomes included family accommodations, self esteem, sense of coherence, and autism symptoms. Nearly all outcomes were measured through self-report assessment tools, with the exception of global symptoms, dimensions of OCD, and some of the behavioural ratings of social skills completed by clinical assessors. Family members/carers were informants in only one study, where they assessed dimensions of OCD, and family accommodations.
In the current systematic review, quality was assessed using validated checklists. For the 6 comparative studies, 2 were assessed as being of poor quality, 2 of uncertain quality, and 2 (both RCTs) were rated as being of good quality. Blinded, independent assessment was evident in only two studies; for rating a social skills behavioural task in a pseudo-experimental trial, and for assessing OCD and global symptoms in an RCT.
Key results
Systematic reviews
Three recently published systematic reviews were appraised as providing background to the current review.
In the UK, a systematic review of the effectiveness of CBT for managing mental disorders in adults with ASD ADDIN EN.CITE National Institute for Health and Clinical Excellence (NICE)20121267[22]126712676National Institute for Health and Clinical Excellence (NICE),Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. National Clinical Guideline No. 1422012London, EnglandThe British Psychological Society and The Royal College of Psychiatristshttp://www.nice.org.uk/guidance/cg142[ HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22] led to a Guideline Recommendation that that usual practice be followed, including CBT, for a specific mental health condition. Another included systematic review ADDIN EN.CITE Binnie20131157[41]1157115717Binnie, JamesBlainey, SarahBinnie, JamesThe use of cognitive behavioural therapy for adults with autism spectrum disorders: A review of the evidenceMental Health Review JournalMental Health Review Journal93-104182adultsautism spectrum disorderscognitive behavioural therapycomorbid psychiatric symptomsCognitive Behavior TherapyComorbidityPervasive Developmental DisordersPsychiatric Symptoms2013United KingdomEmerald Group Publishing Limited1361-9322
2042-87582013-27337-005http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-27337-005&site=ehost-livejamescbt@gmail.com10.1108/MHRJ-05-2013-0017psyhEBSCOhost[ HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41] tentatively concluded that individually-delivered CBT shows promise in decreasing comorbid psychiatric symptomatology such as anxiety and depression but was unlikely to be effective in changing core cognitive and social deficits associated with ASD. The most recent systematic review ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13] concluded that cognitive behaviour therapy was moderately effective in treating co-morbid anxiety and depression symptoms in adults on the autism spectrum.
All three reviews were based on a small evidence base. They emphasised the need for clinicians to be familiar with the core characteristics of ASD and recommended that adaptations be made to CBT for those on the autism spectrum.
Social interaction and communication
Only two studies assessed outcomes relating to social and communication skills. There were no treatment effects found for CBT on behavioural assessments of social performance tasks, or social communication skills, in either study.
Emotional and mental health outcomes
Emotional and mental health outcome measures were the most common target for CBT interventions with adults on the autism spectrum, being assessed in all but one included primary study. Measures assessed areas including anxiety, social anxiety, social phobia, fear, avoidance, rumination, depression, psychological distress, OCD, and ADHD symptoms.
No treatment effects were evident for the greater majority of emotional and mental health outcome measures assessed. Improvement following CBT was only evident for 8 of 30 outcomes, assessed in three studies, two of which were controlled. One of the two controlled trials was a pseudo-randomised study of poor quality assessing individually-directed CBT which found an improvement in OCD symptoms reported by varying informants ADDIN EN.CITE Russell20091241[48]1241124117Russell, A. J.Mataix-Cols, D.Anson, M. A. W.Murphy, D. G. M.Russell, A. J., Department of Psychology, Institute of Psychiatry, Kings College London, PO Box 77, De Crespigny Park, Denmark Hill, London, United Kingdom, SE5 8AFPsychological treatment for obsessive-compulsive disorder in people with autism spectrum disordersA pilot studyPsychotherapy and PsychosomaticsPsychotherapy and psychosomatics59-61781obsessive compulsive disorderautism spectrum disorderspsychological treatmentComorbidityPervasive Developmental DisordersPsychotherapy2009SwitzerlandKarger0033-3190
1423-03482010-25760-010http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-25760-010&site=ehost-livea.russell@iop.kcl.ac.ukhttp://www.karger.com/Article/Abstract/17262210.1159/000172622psyhEBSCOhost[ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48], but no treatment effects for self-reported depression, stress, anxiety, depressed self-statements, and anxious self-statements. The other trial finding an improvement was an RCT ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18] conducted in The Netherlands and rated as being of good quality. Significant improvements were evident for those receiving meditation-based group therapy (accompanied by home meditation) compared with waitlist controls for all outcomes including self-reported anxiety, depression, and rumination tendencies.
General well being
Treatment effects were evident for 6 of 11 outcomes measured relating to general indices of global improvement and well-being. These were included in all of the 5 primary studies containing outcomes of this domain, including two case studies and all three of the appraised RCTs.
Of the three RCTs, 3 of 7 general well-being outcomes measured showed improvements between baseline and post CBT compared with the comparator group. A study of uncertain quality assessing intensive group-based CBT compared with recreational activities ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43] found a treatment effect in self-reported global symptom improvement, but not in severity of global symptoms, or self reported quality of life satisfaction. Mixed results were also evident for the good quality trial comparing individually-delivered CBT with anxiety management therapy ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]. There was greater improvement for the CBT group in blinded, independently-rated global symptom improvement, but not for global symptom severity, or for self-reported adjustment. Finally, in the high quality RCT evaluating meditation-based group CBT therapy compared with a waitlist control ADDIN EN.CITE Spek20131239[18]1239123917Spek, Avan Ham, NNyklicek, IMindfullness-based therapy in adults with an autism spectrum disorder: A randomized controlled trialResearch in Developmental DisabilitiesResearch in Developmental Disabilities246-253342013[ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18], a treatment effect was observed for self-reported positive general affect.
Miscellaneous secondary outcomes
Miscellaneous secondary outcomes were reported alongside primary outcomes in four studies. One small pseudo-randomised trial (of uncertain quality) evaluating group-based Social Cognitive Interaction Training (SCIT) ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49] found significant treatment effects for the targeted outcomes of self-reported emotion recognition, and theory of mind skills. In a small case series study ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46], mixed results were observed between individuals for self-rated problem solving skills.
Finally, two RCTs revealed no significant treatment effects for self-rated sense of coherence and self-esteem ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43], or for autism characteristics and family assessed family accommodations outcomes ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47].
Maintenance
In 6 of the 10 primary studies, most outcomes were followed up between 2 and 57 months post intervention. Where treatment effects were observed, improvements were maintained in only some measures of 2 studies: a single case study ADDIN EN.CITE Cardaciotto20041240[42]1240124017Cardaciotto, LeeAnnHerbert, James D.Cardaciotto, LeeAnn, Department of Psychology, Drexel University, M.S. 988, 245 N. 15th Street, Philadelphia, PA, US, 19102-1192Cognitive behavior therapy for social anxiety disorder in the context of Asperger's syndrome: A single-subject reportCognitive and Behavioral PracticeCognitive and Behavioral Practice75-81111Aspergers syndromecognitive behavior therapysocial anxiety disorderdevelopmental disordercomorbiditytreatmentAnxiety DisordersSocial Anxiety2004Win 2004USAssociation for Advancement of Behavior Therapy1077-72292004-15843-008http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2004-15843-008&site=ehost-livelc52@drexel.eduhttp://www.sciencedirect.com/science/article/pii/S107772290480009910.1016/S1077-7229(04)80009-9psyhEBSCOhost[ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42], and in an RCT where reduced OCD symptoms were observed up to 12 months post treatment ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47]. However, significant treatment effects were not maintained at post intervention follow-up for 4 studies ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43, HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45, HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50].
In sum, there is no reliable or consistent evidence of longer term maintenance of improvements to relevant outcomes following participation in cognitive behaviour therapy. Conclusions were also limited by significant drop-out rates of participants available for follow-up, and a lack of controlled assessment of maintenance effects.
Adaptations to CBT for adults with autism
The following adaptations to traditional CBT components/procedures are suggested for assisting adults on the autism spectrum, incorporating evidence included in the current update of secondary and primary research with those presented in the original New Zealand ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1]:
Use a structured approach and minimise anxiety about the therapeutic process by being explicit about roles, times, goals and techniques.
Extend the number of sessions and time provided to conduct tasks to accommodate slower information-processing and the mental demands of the therapeutic process. Be flexible about the length of each session and offer breaks to allow for cognitive and motivational deficits.
Provide psycho-education about autism, emotions, and mental health challenges relevant to the client.
Concentrate on well-defined and specific difficulties as the starting point for intervention, with less emphasis on changing clients cognitions.
Be more active and directive in therapy, where appropriate, including giving suggestions, information, and immediate and specific feedback on performance. Examine the rationale and evidence for inaccurate, automatic thoughts and collaboratively develop alternative interpretations, concrete strategies and courses of action.
Teach explicit rules and their appropriate context, including the use of verbal, nonverbal and paralinguistic cues to a social situation.
Incorporate specific behavioural techniques where appropriate, such as relaxation strategies, meditation, mindfulness, thought stopping or systematic desensitisation.
Communicate visually (e.g., using worksheets, images, diagrams, 'tool boxes', comic strip conversations, video-taped vignettes, peer-modelling, and working together on a computer).
Avoid ambiguity through minimising the use of colloquialisms, abstract concepts and metaphor. Use specific and concrete analogies relatable to the clients concerns.
Incorporate participants' interests in terms of content and modes of content delivery to enhance engagement.
Involve a support person, such as a family member, partner, carer or key worker (if the person with autism agrees) as a co-therapist to improve generalisation of skills learned within sessions.
Conclusions
Researchers evaluating the effectiveness of CBT as a suitable treatment for behavioural, emotional and mental health difficuties have tended to focus on interventions with school-aged participants. The current systematic review considered studies evaluating the use of CBT for adults with ASD published in or since 2004. It included 10 primary studies: 4 case studies, 3 pseudo-randomised experimental studies, and 3 fully randomised controlled trials. The review also considered three recently published systematic reviews, one of which informed a clinical guideline, as providing background to the current review.
Key findings were:
Emotional and mental health outcomes were commonly targetted by CBT interventions. However results were inconsistent with a lack of treatment effect evident in 22 of 30 outcomes measured in this domain and in 6 of 9 studies including relevant measures. Of the 3 studies reporting treatment effects, 2 employed controlled designs. From these single trials, there was weak evidence that CBT focussed on reducing obsessive compulsive symptoms can be effective, and there was evidence for consistent and significant improvements in self-reported anxiety, depression, and rumination tendencies for a meditation-based group therapy compared with waitlist controls.
Assessment of the impact of CBT on general indices of global improvement and well-being also led to mixed results, with treatment effects found for 6 of 11 relevant measures across five studies including this domain. From 3 RCTs, improvements were evident in global symptom improvement in two trials (one self-report and another by blind independent rating) and in self-reported positive general affect in the third trial. However treatment effects were lacking in four other outcomes across these studies, including severity of global symptoms, quality of life satisfaction, and adjustment. It was notable that in one trial, a small but significant proportion of participants receiving CBT (and the anxiety management group) worsened post therapy.
From a small evidence base, there appeared to be no evidence that social interaction or communication could be improved by therapy based in cognitive behaviour theory. No improvements following CBT were observed in two studies, including behavioural assessments of social performance tasks, or social communication skills.
Considering miscellaneous secondary outcomes, findings varied. There was weak evidence from single studies that CBT may improve self-reported problem solving skills, emotion recognition, and theory of mind skills, and there appeared to be no improvement post CBT in self-rated sense of coherence, self-esteem, autism characteristics and family assessed family accommodations outcomes.
There was poor evidence of longer term maintenance of improvements following participation in cognitive behaviour therapy. Conclusions were limited by reduced response rates, and the lack of control for possible maturation, repeat-testing experience, and regression to the mean effects.
The appraised studies represent a relatively narrow range of participants with respect to cognitive profile, gender, and ethnicity, making the studies generalisability to people with below average cognitive abilities, women, and New Zealand-relevant cultures uncertain.
Broadly consistent with recent systematic reviews on the topic, these findings suggest that CBT shows moderate potential to improve comorbid emotional, mental health and general well-being outcomes in adults with ASD but is unlikely to be effective in changing social and communication deficits.
It seems likely that some individuals benefit and some dont, however evidence is lacking regarding what are the mediators and moderators of treatment effectiveness. The heterogeneity and complexity of the evidence base makes it difficult to draw general conclusions about the effectiveness of cognitive behaviour therapy. The findings for similar outcomes varied across as well as within studies. There was wide variability in areas of programme content, components and intensity; whether the therapy was delivered in groups or individually; the large number of outcomes measures for similar outcomes; whether there were control groups, and if so, whether they offered active interventions with programme components overlapping with cognitive behaviour therapy. It was not possible to qualitatively discern a pattern as to what predicted treatment effects with respect to these factors.
Given these issues, it is not currently possible to offer clear conclusions about the necessary content, approach and intensity of cognitive behaviour therapy approaches, or whether they are more likely to be effective administered in groups or as one-to-one therapies. In two studies, CBT was not a significantly better intervention than anxiety management or recreational activities of a similar intensity, suggesting that gathering adults with ASD together regularly in a structured programme may have significant benefits regardless of their cognitive behavioural content.
One recent study from The Netherlands [25] stood out as an RCT of good quality which led to uniform improvements in all the measured outcomes, including anxiety, depression, rumination tendencies and positive general affect. However these outcomes were all self-reported with no independent blinded assessments measured, and there was no extended follow-up to determine whether these treatment effects were maintained. The intervention itself was somewhat different to the other CBT interventions evaluated in that it had a heavy emphasis on meditation, and less emphasis on cognitive restructuring, and also encouraged an hour of meditation at home 6 nights per week throughout the 9-week study period. This intervention seems worthy of further investigation in this population.
Whilst recommendations have been made on what adaptations to the content and process of CBT suit adults on the autism spectrum, these are largely built on the experience of therapists and are yet to be systematically evaluated.
Future research needs to establish empirically the effectiveness of modified CBT (i.e., adapted for people on the autism spectrum) through developing a standardised approach, investigating its effectiveness in randomised controlled trials, and systematically measuring the impact of the moderators and mediators of treatment effects in this heterogenous population. It is also crucial to see the degree to which improvements generalise to new situations and are maintained after therapy has ceased. Such research and refinements are needed in order to maximise the benefit of CBT for adults on the autism spectrum.
3 Recommendation development
The Living Guideline Group was tasked with considering the systematically updated evidence on cognitive behavioural therapy interventions for adults with ASD reported above in terms of its implications for the ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1]. Specifically, the LGG considered whether the new evidence required revisions of existing recommendations and Good Practice Points (GPP) as well as the development of any new recommendations and GPP. Both text of recommendations and their graded strength of evidence (see Appendix 1, HYPERLINK \l "TableGrading" Table A1.2) were revised/developed and considered at an all day face-to-face meeting. The LGGs decisions for recommendation development and grading are presented below. Revised or new recommendations and GPP are accompanied by a brief rationale which highlights any particular issues that the LGG took into account while formulating the recommendations.
Revision of existing recommendations
Two recommendations in the ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] were considered for revision by the Living Guideline Group.
Original Recommendation 4.3.9: Cognitive behaviour therapy should be considered as a suitable treatment for many behavioural, emotional and mental health difficulties. (Grade C)
Leave unchanged
Rationale: Recommendation 4.3.9 related to evidence for people with ASD of all ages. As the effectiveness of CBT for children and young people was out of scope and therefore excluded from the current review update, the Recommendation was left unchanged. To incorporate the updated evidence, a new Recommendation 4.3.9a was developed relating specifically to adults.
Original Recommendation 4.3.10: Cognitive behaviour therapists should adapt their techniques to take into account the characteristics of people with ASD. (Grade C)
Leave unchanged
New recommendation
A new recommendation was developed by the LGG (see HYPERLINK \l "TableNewRecs" Table 3.1).
New Recommendation 4.3.9a: Broadly defined cognitive behaviour therapy, adapted for ASD, may assist adults with mental health conditions. (Grade C).
Additional text: CBT is broadly defined as incorporating traditional cognitive and behavioural techniques in addition to so-called third wave CBT approaches which incorporate mindfulness, meditation, metacognitive therapy, compassion focussed therapy, and acceptance and commitment (ACT) therapies. These place less focus on addressing unhelpful cognitions, and more on teaching people to accept phenomena (bodily sensations, thoughts, feelings, sounds) as they appear, to counter avoidance strategies, and reduce anxiety.
It should be noted that the evidence base considered in developing this recommendation related to adults with ASD who do not have an intellectual disability.
Rationale: The LGG expressed some concern about the term suitable in the original Recommendation 4.3.9 as they considered that CBT that has not been modified for people on the autism spectrum may be unsuitable. Therefore the recommendation included a specification that CBT be adapted for ASD. It was challenging to grade this new recommendation given the inconsistency of response of CBT, and the methodological limitations of the research.
Table 3.1: New recommendations relevant to cognitive behaviour therapy.
ReferenceNew recommendationsGrade4.3.9aBroadly defined cognitive behaviour therapy, adapted for ASD, may assist adults with mental health conditions.C
New good practice points
Two new good practice points were developed by the LGG (see HYPERLINK \l "TableGPPs" Table 3.2).
New Good Practice Point 4.3.9b: Cognitive behaviour therapy (CBT) has been designed and evaluated predominantly for people without ASD. More research is recommended to further develop and evaluate effective cognitive behaviour therapies and their necessary adaptations for people on the spectrum as well as appropriate and valid outcome measures for research in this field. As it seems likely that some individuals receiving CBT benefit and some do not, future research should also investigate what personal characteristics and aspects of therapy best predict treatment effectiveness. (
Additional text: The heterogeneity and complexity of the current evidence base makes it difficult to draw general conclusions about cognitive behaviour therapys (CBT) effectiveness. The findings for similar outcomes varied across as well as within studies. There was wide variability in the evidence with respect to programme content, components and intensity; whether the therapy was delivered in groups or individually; the outcomes measures employed for assessing similar outcomes; and whether there were control groups, and if these were offered active interventions including cognitive behavioural components themselves. It was not possible to qualitatively discern a pattern as to what are the mediators and moderators of treatment effectiveness with respect to these factors.
New Good Practice Point 4.3.10a: The following adaptations to cognitive behaviour therapy are recommended:
Use a structured approach and minimise anxiety about the therapeutic process by being explicit about roles, times, goals and techniques.
Extend the number of sessions and time provided to conduct tasks to accommodate slower information-processing and the mental demands of the therapeutic process. Be flexible about the length of each session and offer breaks to allow for cognitive and motivational deficits.
Provide psycho-education about autism, emotions, and mental health challenges relevant to the client.
Concentrate on well defined and specific difficulties as the starting point for intervention, with less emphasis on changing clients cognitions.
Be more active and directive in therapy, where appropriate, including giving suggestions, information, and immediate and specific feedback on performance. Examine the rationale and evidence for inaccurate, automatic thoughts and collaboratively develop alternative interpretations, concrete strategies and courses of action.
Teach explicit rules and their appropriate context, including the use of verbal, nonverbal and paralinguistic cues to a social situation.
Incorporate specific behavioural techniques where appropriate, such as relaxation strategies, meditation, mindfulness, thought stopping or systematic desensitisation.
Communicate visually (e.g., using worksheets, images, diagrams, 'tool boxes', comic strip conversations, video-taped vignettes, peer-modelling, and working together on a computer).
Avoid ambiguity through minimising the use of colloquialisms, abstract concepts and metaphor. Use specific and concrete analogies relatable to the clients concerns.
Incorporate participants' interests in terms of content and modes of content delivery to enhance engagement.
Involve a support person, such as a family member, partner, carer or key worker (if the person with autism agrees) as a co-therapist to improve generalisation of skills learned within sessions. (
Table 3.2: New good practice points relevant to cognitive behaviour therapy.
ReferenceNew Good Practice PointsGrade4.3.9bCognitive behaviour therapy (CBT) has been designed and evaluated predominantly for people without ASD. More research is recommended to further develop and evaluate effective cognitive behaviour therapies and their necessary adaptations for people on the spectrum as well as appropriate and valid outcome measures for research in this field. As it seems likely that some individuals receiving CBT benefit and some do not, future research should also investigate what personal characteristics and aspects of therapy best predict treatment effectiveness.(4.3.10aThe following adaptations to cognitive behaviour therapy are recommended:
Use a structured approach and minimise anxiety about the therapeutic process by being explicit about roles, times, goals and techniques.
Extend the number of sessions and time provided to conduct tasks to accommodate slower information-processing and the mental demands of the therapeutic process. Be flexible about the length of each session and offer breaks to allow for cognitive and motivational deficits.
Provide psycho-education about autism, emotions, and mental health challenges relevant to the client.
Concentrate on well defined and specific difficulties as the starting point for intervention, with less emphasis on changing clients cognitions.
Be more active and directive in therapy, where appropriate, including giving suggestions, information, and immediate and specific feedback on performance. Examine the rationale and evidence for inaccurate, automatic thoughts and collaboratively develop alternative interpretations, concrete strategies and courses of action.
Teach explicit rules and their appropriate context, including the use of verbal, nonverbal and paralinguistic cues to a social situation.
Incorporate specific behavioural techniques where appropriate, such as relaxation strategies, meditation, mindfulness, thought stopping or systematic desensitisation.
Communicate visually (e.g., using worksheets, images, diagrams, 'tool boxes', comic strip conversations, video-taped vignettes, peer-modelling, and working together on a computer).
Avoid ambiguity through minimising the use of colloquialisms, abstract concepts and metaphor. Use specific and concrete analogies relatable to the clients concerns.
Incorporate participants' interests in terms of content and modes of content delivery to enhance engagement.
Involve a support person, such as a family member, partner, carer or key worker (if the person with autism agrees) as a co-therapist to improve generalisation of skills learned within sessions.(
Appendix 1: Methods
A1.1 Contributors
Living Guideline Group members
Matt Eggleston (Chair)
Child and Adolescent Psychiatrist, Clinical Head, Child and Family Specialty Service, Canterbury DHB
Andrew Marshall (Deputy Chair)
Developmental Paediatrician, Child Development Team at Puketiro Centre, Porirua and Clinical Leader, Child Health, Wellington Hospital
Tanya Breen
Consultant Clinical Psychologist in Private Practice, Specialist in Autism Spectrum Disorder and Disability Issues, and Clinical Consultant for Altogether Autism, Hamilton
Jill Bevan-Brown
Director, Inclusive Education Research Centre, Institute of Education, Massey University
Sally Clendon
Senior Lecturer, Speech and Language Therapy Programme, Institute of Education, Massey University
Debbie Fewtrell (did not attend LGG meeting)
General Practitioner (special interest in autism spectrum disorder), Kerikeri
Matt Frost
Senior Advisor, Office for Disability Issues, Ministry of Social Development
Ex-officio LGG members
Natasha Gartner
ASD Project Manager, Family and Community, Disability Support Services, National Services Purchasing, National Health Board, Ministry of Health
Julie Hook
National Manager, Practice, Special Education; Sector Enablement and Support; Ministry of Education
INSIGHT Research
Marita Broadstock
Director, INSIGHT Research Ltd, Living Guideline Group Project Manager and lead researcher
Declarations of competing interest
None
Acknowledgements
INSIGHT Research thanks the Ministry of Education Library staff including Rose Payne (Librarian) and Stella Sutton (Senior Librarian) for their skilled and efficient assistance in retrieval of articles pertinent to this review.
A1.2 Review scope
The current review updates evidence for the ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] on cognitive behaviour therapy for adults (aged 18 years or older) with Autism Spectrum Disorder.
The original searching for the ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] was performed in July 2004. For the original Guideline, papers published before the search dates and in some cases after the completion of searching were suggested by members of all workstreams and incorporated into the text and evidence tables, where appropriate.
In the current update, the search was limited to articles published in the English language on or beyond January 1 2004. Given the overlap in search periods in 2004, and the inclusion of papers outside the date range in the original Guideline, papers identified in the current search strategy which were already appraised in the original ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] were excluded (see HYPERLINK \l "Appendix3" Appendix 3). However these are still considered in deliberations by the LGG as being part of the entire body of evidence.
Publications were considered where evaluating the effectiveness of cognitive behaviour therapy for adults (aged 18 years or older) with Autism Spectrum Disorder. Eligible studies were randomised controlled trials evaluating cognitive behaviour therapy interventions among adults with ASD where pre- and post-therapy outcomes were measured. Comparators were wait list control groups, those receiving usual care, or an alternative treatment matched for intervention intensity.
A1.3 Research question
The Living Guideline Group identified cognitive behaviour therapy in adults with ASD as a priority topic to update. The lead researcher prepared the research questions in the PICO format (which identifies the Patient, Intervention, Comparison, and Outcomes of interest) to ensure effective and focused searches and reviews could be undertaken. The research question was:
What is the effectiveness of cognitive behavioural therapy for improving outcomes for adults with ASD.
A supplementary question was
What adaptations to CBT approaches are recommended when assisting adults with ASD?
A1.4 Search strategy
Search strategies were limited to publications from January 1 2004 onwards. Database searches were conducted over May 2015 and updated on August 2, 2015.
The INSIGHT Research lead researcher set the inclusion and exclusion criteria for the review in consultation with the Ministry of Health. Systematic database searching was designed and conducted by the INSIGHT lead researcher. Full search strategies are available upon request.
Search databases
Bibliographic, health technology assessment and guideline databases were included in the search strategy, listed below.
Medline
Cinahl
Embase
PsycInfo
Cochrane Database of Systematic Reviews (CDSR)
Central Register of Controlled Trials (CRCT)
Database of Abstracts of Reviews of Effects (DARE)
Health Technology Assessment Database (HTA Database)
A combination of search terms were used as free text and adapted for different databases. The following illustrative search is offered:
(asperger syndrome or autistic disorder) or (pdd* or asd*) or autis* or asperger*
AND
(cognitive behavio* therap* or cognitive therap* or cognitive behav$ or CBT or talking therap*).tw.
AND
adult.tw. OR limit to adult (subjects aged over 18 years)
limit to english language, 2004-current, academic journals
Cross-checking of references from retrieved studies was conducted to identify additional references.A1.5 Appraisal of studies
For this review, a single researcher performed study selection, critical appraisal and synthesis. The following steps were followed in appraising the evidence.
Assigning a level of evidence
Following the completion of searches, retrieved studies meeting the selection criteria were assigned a level of evidence. The level of evidence indicates how well the study eliminates bias based on its design. INSIGHT Research uses a published evidence hierarchy, designed by the National Health and Medical Research Council of Australia (NHMRC) ADDIN EN.CITE National Health and Medical Research Council20081275[40]127512756National Health and Medical Research Council, NHMRC additional levels of evidence and grades for recommendtaitons for developers of guidelines: pilot program 2005-20072008Canberra, AustraliaNHMRC[ HYPERLINK \l "_ENREF_40" \o "National Health and Medical Research Council, 2008 #1275" 40]. These describe research designs which are broadly associated with particular methodological strengths and limitations so as to rank them in terms of quality, from I (systematic reviews of level II studies) to IV (case series).
Table A1.1: NHMRC levels of evidence ADDIN EN.CITE National Health and Medical Research Council20081275[40]127512756National Health and Medical Research Council, NHMRC additional levels of evidence and grades for recommendtaitons for developers of guidelines: pilot program 2005-20072008Canberra, AustraliaNHMRC[ HYPERLINK \l "_ENREF_40" \o "National Health and Medical Research Council, 2008 #1275" 40]
LevelInterventionIA systematic review of level II studiesIIA randomised controlled trialIII-1A pseudo-randomised controlled trial (i.e., alternate allocation or some other method)III-2A comparative study with concurrent controls:
Non-randomised, experimental trial
Cohort study
Case-control study
Interrupted time series with a control groupIII-3A comparative study without concurrent controls:
Historical control study
Two or more single arm study
Interrupted time series without a parallel control groupIVCase series with either post-test or pre-test/post-test outcomes
In the hierarchy of evidence employed (described in HYPERLINK \l "NHMRChierarchy" Table A1.1), systematic reviews which included level II studies are ranked as level I evidence whereas systematic reviews of lower order evidence rank at the same level as that order of evidence.
Appraising the quality of included studies
Completing evidence tables
Evidence tables ( HYPERLINK \l "Appendix4" Appendix 4) were completed for each appraised study. Evidence tables present the key characteristics of each of the appraised studies including sample characteristics, methodology, results, the level of evidence, and the summary codes of study quality.
Appraisal of primary and secondary studies
Systematic reviews and experimental studies were appraised using adapted versions of the GATE (Graphic Appraisal Tool for Epidemiology) Frame tools (designed by the University of Aucklands School of Population Health) appropriate to study design (systematic reviews, and randomised controlled trials). The adapted GATE has been validated by the New Zealand Guidelines Group (NZGG). Case series studies were appraised narratively and were not formally coded for study quality.
In brief, the GATE checklists are comprised of slightly different criteria depending on the study design but all broadly address each part of the PICO framework. The case is slightly different for systematic reviews and meta-analyses where additional criteria are included to assess the appropriateness of combining and analysing multiple studies. In general however, the checklists help the researcher to assess study quality in three main areas:
study validity (steps made to minimise bias)
study results (size of effect and precision)
study relevance (applicability and generalisability).
For each checklist item, the reviewer codes whether the criterion for quality has been met (+), is unmet (X) or, where there is not enough information to make a judgement, is unknown (?). Reviewers then assign the same quality codes to each of three summary sections which assess the accuracy, relevance and applicability of the findings. Here, the reviewer indicates whether the study has any major flaws that could affect the validity of the findings and whether the study is relevant to clinical practice. The three summary sections include:
internal validity potential sources of bias
precision of results
applicability of results/external validity relevance to key questions and clinical practice.
Finally, reviewers assign an overall assessment of quality for the study as a whole based on a consideration of all checklist criteria; codes used are:
+ good; well reported and reliable
X poor: study not reliable, not useful
? unclear, not reported: insufficient detail provided to assess this aspect
Codes for each of the three summary domains, and an overall study quality code, are presented in the bottom row of the evidence tables for each study ( HYPERLINK \l "Appendix4" Appendix 4).
A1.6 Preparing recommendations
Developing recommendations
A one-day face-to-face meeting was held on 12 November 2015 where the Living Guideline Group considered the findings of the current systematic review and revised affected recommendations (and Good Practice Points) from the original ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1] and/or developed new ones. Using their collective professional judgement and experience, the LGG discussed the body of evidence with respect to the research questions and the applicability of the evidence within New Zealand.
Developing recommendations involves consideration of the whole evidence base for the research question. The quality and consistency of the evidence and the clinical implications of the evidence within a New Zealand context is weighed up by all the LGG members. The recommendations were agreed by consensus during the meeting.
Each recommendation is assigned a grade to indicate the overall strength of the evidence upon which it is based. Strength of the body of evidence is determined by three domains ADDIN EN.CITE National Health and Medical Research Council20081275[40]127512756National Health and Medical Research Council, NHMRC additional levels of evidence and grades for recommendtaitons for developers of guidelines: pilot program 2005-20072008Canberra, AustraliaNHMRC[ HYPERLINK \l "_ENREF_40" \o "National Health and Medical Research Council, 2008 #1275" 40]:
quality (the extent to which bias was minimised as determined by study design and the conduct of the study)
quantity (magnitude of effect, numbers of studies, sample size or power)
consistency (the extent to which similar findings are reported).
It should be noted that systematic reviews and meta analyses (secondary studies) considered which draw on publications over an overlapping timeframe could report on (some of) the same studies. For this reason it is important to be aware that the results from secondary studies should not be summated as independent sources of evidence as this would misrepresent the quantity of studies and give shared primary studies undue weight. Rather, recently published secondary evidence should be considered as background information and to validate the findings of the current review.
The grades of recommendations used by the Living Guideline Group, and also used in the original ASD Guideline ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1], are presented in HYPERLINK \l "TableGrading" Table A1.2.
Table A1.2: Guide to grading recommendations ADDIN EN.CITE Ministries of Health and Education20081255[1]1255125512Ministries of Health and Education,Ministry of HealthNew Zealand autism spectrum disorder guideline2008March 2008Wellington, NZMinistry of Health[ HYPERLINK \l "_ENREF_1" \o "Ministries of Health and Education, 2008 #1255" 1]
RecommendationsGradeThe recommendation is supported by good evidence (based on a number of studies that are valid, consistent, applicable and clinically relevant)AThe recommendation is supported by fair evidence (based on studies that are valid, but there are some concerns about the volume, consistency, applicability and clinical relevance of the evidence that may cause some uncertainty but are not likely to be overturned by other evidence)BThe recommendation is supported by international expert opinionCThe evidence is insufficient, evidence is lacking, of poor quality or opinions conflicting, the balance of benefits and harms cannot be determinedINote: Grades indicate the strength of the supporting evidence rather than the importance of the evidence.Good practice pointGradeWhere no evidence is available, best practice recommendations are made based on the experience of the Living Guideline Group or feedback from consultation within New Zealand.(Note: Good practice points are the opinion of the Living Guideline Group, or developed from feedback from consultation within New Zealand where no evidence is availableA1.7 Consultation
Seeking comments from stakeholders is vital for peer-review and quality assurance processes in developing the report. In a focused consultation 9 key stakeholder organisations/individuals were approached for feedback on a late draft of the report. These included: Altogether Autism, Autism New Zealand, Explore Specialist Advice New Zealand, IDEA, the Mental Health Directorate, Ministry of Education, Ministry of Health, the New Zealand College of Clinical Psychologists, and the New Zealand Psychological Society. Particular attention was sought regarding the relevance of the report to New Zealand services and needs, clarity and ease of use of the report, and implementability of the revised or new recommendations.
Responses were received from 8 organisations/individuals, 4 of whom provided detailed submissions.
The lead researcher (INSIGHT Research) collated feedback and drafted revisions for the LGG to consider. Amendments were finalised by group consensus. Suggestions identified in the consultation led to several improvements to the final report. INSIGHT Research and the LGG are grateful to those individuals and organisations who participated in the consultation process.
Appendix 2: Abbreviations and glossary
A2.1 Abbreviations and acronyms
Miscellaneous Terms
ADHD attention-deficit hyperactivity disorder
ADD attention-deficit disorder
ANCOVA analysis of covariance
ANOVA analysis of variance
AS Asperger syndrome
ASD Autism Spectrum Disorder
cf compared with
CG control group
ERP exposure and response prevention
ES effect size
GDG Guideline Development Group
GPP Good Practice Points
HFA high functioning autism
IQ intelligence quotient
INSIGHT Research Independent Network of Specialists in Guidelines & Health Technology Research
LGG Living Guideline Group
M mean
MANOVA multivariate analysis of variance
N (or n) number (usually, sample size)
NHMRC National Health and Medical Research Council (Australia)
NICE National Institite for Health and Clinical Excellence (UK)
NIHS National Institute of Health Research (UK)
NIMH National Institute of Mental Health (US)
NZGG New Zealand Guidelines Group
OCD Obsessive Compulsive Disorder
PDD Pervasive Developmental Disorder
PDD-NOS Pervasive Developmental Disorder Not Otherwise Specified
PICO Patient, Intervention, Comparison, Outcome
RCT Randomised controlled trial
SAD Social Anxiety Disorder
SD Standard deviation
SR Systematic review
TG treatment group
UK United Kingdom
US United States of America
vs versus
Tests, scales and measures
ADI-R Aberrant Behavior Checklist
ADIS-R Anxiety Disorders Interview Schedule-Revised
ADOS Autism Diagnostic Observation Schedule
AM Anxiety Management
AQ Autism Spectrum Quotient
ASRS Adult ADHD Self-Report Scale
ASSQ Anxious Self-Statements Questionnaire
ATQ Automatic Thoughts Questionnaire
BAI Beck Anxiety Inventory
BDI Beck Depression Inventory
CGI-S/CGI-I Clinical Global Impressions Scale Severity/Improvement
DASS Depression Anxiety Stress Scales
DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders - IV (text revision)
DSM5 Diagnostic and Statistical Manual of Mental Disorders 5th edition
D-YBOCS Dimensional Yale-Brown Obsessive Compulsive Scale
FEIT Face Emotion Identification Test
FSAS-PR Family Accommodation Scale-Parent report
GAS Glasgow Anxiety Scale
GATE Graphic Appraisal Tool for Epidemiology
GMS Global Mood Scale
HNOS-LDV Health of the Nation Outcome Scale-Learning Disability Version
LSAS Liebowitz Social Anxiety Scale
OCI-R Obsession Compulsive Inventory-Revised
OQ Outcome Questionnaire
PR-CHOCI-R Childrens Obsessive-compulsive Inventory-Parent version
PTSD Post Traumatic Stress Disorder
QOLO Quality of Life Inventory
RRQ Rumination-Reflection Questionnaire
RSES Rosenberg Self-Esteem Scale
SCID-IV Structured Clinical Interview for Axis I DSM-IV Disorders
SCIT Social Cognitive Interaction Training
SCL-90-R Symptom Checklist-90-Revised
SCSQ Social Communication Skills Questionnaire
SoC Sense of Coherence scale.
SPAI Social Phobia and Anxiety Inventory
SPSI-R:L Social Problem Solving Inventory-Revised: Long Form
SSPA Social Skills Performance Assessment
WAIS Weschler Adult Intelligence Scale
WSAS Work and Social Adjustement Scale
YBOCS Yale-Brown Obsessive Compulsive Scale.
Databases
AMED Allied and Complementary Medicine Database
ASSIA Applied Social Services Index and Abstracts
AEI Australian Education Index
BEI British Education Index
CDSR Cochrane Database of Systematic Reviews
CENTRAL Cochrane Central Register of Controlled Trials
CINAHL Cumulative Index to Nursing and Allied Health Literature
DARE Database of Abstracts of Reviews of Effects
Embase Excerpta Medica Database
ERIC Education Resources Information Centre
HMIC Health Management Information Consortium
HTA database Health Technology Assessment Database
Medline Medical Literature Analysis and Retrieval System Online
PsycINFO Psychology Information Database
SSA Social Services Abstracts
A2.2 Glossary
Epidemiological and statistical terms
A priori
In the HYPERLINK "https://en.wikipedia.org/wiki/Design_of_experiments" design and analysis of experiments, a priori analysis (from HYPERLINK "https://en.wikipedia.org/wiki/Latin_language" Latin, meaning "from the earlier") consists of specifying planned analytical comparisons before the research is analysed.
Alexithymia
Alexithymia is a personality construct characterized by the sub-clinical inability to identify and describe emotions in the self. The core characteristics of alexithymia are marked dysfunction in emotional awareness, social attachment, and interpersonal relating. Individuals suffering from alexithymia also have difficulty in distinguishing and appreciating the emotions of others. Alexithymia is prevalent in approximately 10% of the general population and is known to be comorbid with a number of psychiatric conditions.
Before and after study
A design in which measures are repeated before and after an intervention or exposure.
Bias
Bias is a systematic deviation of a measurement from the true value leading to either an over- or under-estimation of the treatment effect. Bias can originate from many different sources, such as allocation of patients, measurement, interpretation, publication and review of data
Bonferronis correction
In statistics, the Bonferroni correction is a method used to counteract the problem of multiple comparisons increasing the likelihood of chance effects being interpreted as significant. The correction increases the p value accepted as denoting a statistically significant difference or effect.
Bootstrapping procedure
Bootstrapping in statistics can refer to any test or metric that relies on random sampling with replacement. Bootstrapping allows assigning measures of accuracy (defined in terms of bias, variance, confidence intervals, prediction error or some other such measure) to sample estimates.
Case series
Case series are collections of individual case reports, which may occur within a fairly short period of time. Cases consist of either only the exposed people with the outcomes, or people with the outcome regardless of the exposure. In neither of these examples can the risk for the outcome be determined
Comorbid condition
One that exists at the same time as another condition in the same individual. The two conditions are usually independent of each other. For example a child who has autism might also have an eating disorder. Co-morbidities occur in association with another condition (e.g., ASD) more commonly than in the general population (e.g., anxiety).
Detection bias
Detection bias refers to systematic differences between groups in how outcomes are determined. Awareness by outcome assessors/respondents of whether an intervention was received or not (i.e., they are not blind to allocated condition) may increase the risk of their measurements/ratings/reports being affected by detection bias.
Effect size
A quantitative measure of the strength of a phenomenon, a standardised measure of the size of the difference between two groups.
Effectiveness
A measure of the extent to which a specific intervention, procedure, regimen, or service, when deployed in the field in routine circumstances, does what it is intended to do for a specified population.
Generalisability
Applicability of the results to other populations.
High functioning
Whilst it is acknowledged that the term high functioning is not universally favoured, in this report, the term high functioning is used to refer to people with higher cognitive functioning either as established by intelligence tests (generally indicated by full IQ scores of 70 or above), or through the diagnosis of high-functioning autism or Asperger syndrome (under DSM-IV criteria). In light of the removal of Asperger syndrome as a separate diagnostic classification in HYPERLINK "http://en.wikipedia.org/wiki/DSM-5" DSM-5, these distinctions may no longer be used clinically.
Level of evidence
A hierarchy of study evidence that indicates the degree to which bias has been eliminated in the study design. See HYPERLINK \l "NHMRChierarchy" Table A1.1.
Matched controls
Matching is a method used to ensure that two study groups are similar with regards to factors that might distort or confound a relationship that is being studied (e.g., age, sex).
Mean
Calculated by adding all the individual values in the group and dividing by the number of values in the group.
Neurotypical
An abbreviation of neurologically typical, a term coined in the autistic community as a label for people who are not on the autism spectrum.
Observational studies
Also known as epidemiological studies. These are usually undertaken by investigators who are not involved in the clinical care of the patients being studied, and who are not using the technology under investigation. Distinct from experimental studies.
Para-linguistic
Non-lexical parameters of speech, including verbal (e.g., speech rhythm, inflection) and nonverbal (e.g., facial expressions, eye contact, posture) communication.
Performance bias
Performance bias refers to systematic differences between groups in the care that is provided, or in exposure to factors other than the interventions of interest. After enrolment into the study,blinding(or masking)of study participants and personnelmay reduce the risk that knowledge of which intervention was received, rather than the intervention itself, affects outcomes. Effective blinding can also ensure that the compared groups receive a similar amount of attention, ancillary treatment and diagnostic investigations. Blinding is not always possible, however.
Post hoc
In the HYPERLINK "https://en.wikipedia.org/wiki/Design_of_experiments" design and analysis of experiments, post hoc analysis (from HYPERLINK "https://en.wikipedia.org/wiki/Latin_language" Latin, meaning "after this") consists of looking at the data after the experiment has concluded for patterns that were not specified HYPERLINK "https://en.wikipedia.org/wiki/A_priori_(epistemology)" beforehand.
Power
The probability that a statistical test or study will detect a defined pattern in data and declare the extent of the pattern as showing statistical significance.
Quality of evidence
Degree to which bias has been prevented through the design and conduct of research from which evidence is derived.
Randomised controlled trial (RCT)
An experiment in which subjects in a population are randomly allocated into groups to receive or not receive an experimental preventive or therapeutic procedure, manoeuvre, or intervention. The groups are compared prospectively.
Secondary study
An analysis or synthesis of research data reported elsewhere, including systematic reviews, meta analyses and guidelines.
Selection bias
Error due to systematic differences in characteristics between those who are selected for inclusion in a study and those who are not (or between those compared within a study and those who are not).
Strength of evidence
The strength of evidence for an intervention effect includes the level (type of studies), quality (how well the studies were designed and performed to eliminate bias) and statistical precision (P-value and confidence interval).
Systematic review (SR)
A literature review reporting a systematic method to search for, identify and appraise a number of independent studies.
Appendix 3: Evidence Tables of relevant papers included in the original NZ ASD Guideline
Reference, Study Type & RatingMethodsMeasuresOutcomes/ResultsNotesAttwood, T. (2003) ADDIN EN.CITE Attwood20031264[37]126412645Attwood, THolliday Willey, L.Cognitive Behaviour TherapyAsperger Syndrome in Adolescence: Living with the Ups, the Downs and Things in Between2003LondonJessica Kingsley Publishers Ltd[ HYPERLINK \l "_ENREF_37" \o "Attwood, 2003 #1264" 37]
Reference #28
EXPERT OPINION
Level of evidence: x
Book chapter.Not applicableWhen secondary mood disorder is diagnosed, clinicians need to know how to modify standard psychological treatments to accommodate AS.
CBT has direct applicability to clients with AS who are known to have distortions in thinking.
Sections on:
assessment
affective education
cognitive restructuring
stress management
self-reflection
practice
other modifications to CBT.Tony Attwood is an internationally respected professional who has an extensive knowledge of ASD.Attwood (2004) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_30" \o "Attwood, 2004 #1087" 30]
Reference #291
EXPERT OPINION
Level of evidence: xExpert opinion and advice.Not applicableCBT research only recently applied to people with ASD.
Few systematic and vigorous published research studies or case histories. Author is currently undertaking research.
Advice on modifying CBT covers the following areas:
affective education
cognitive restructuring
the emotional toolbox
physical tools
relaxation tools
social tools
thinking tools
special interest tools
other tools
inappropriate tools
unusual tools.Tony Attwood is an internationally respected professional who has an extensive knowledge of ASD.Reference, Study Type & RatingMethods MeasuresOutcomes/ResultsNotesHare, D. J. (2004) ADDIN EN.CITE Hare20041260[32]1260126017Hare, D. J.Developing cognitive behavioural work with people with ASDGood Autism PracticeGood Autism Practice18-22512004[ HYPERLINK \l "_ENREF_32" \o "Hare, 2004 #1260" 32]
Reference #287
EXPERT OPINION
Level of evidence: xOverview and opinion.Not applicableCognitive behaviour therapists can adapt techniques to suit people with ASD. Advice includes:
teach social skills training and strategies to improve theory of mind
minimise anxiety about the therapeutic process by being explicit about roles, times, goals, and using techniques like repertory grid
be flexible about the length of sessions, and leaving the treatment room
avoid direct challenges to personal beliefs, as these may be misinterpreted as a personal attack; instead, examine the rationale and evidence and collaboratively develop alternative interpretations and beliefs
use visual imagery
encourage clients to write down positive things, rather than rely on changing thoughts in their head
concentrate on well-defined and specific difficulties
incorporate specific behavioural techniques where appropriate, such as relaxation strategies, thought stopping or systematic desensitisation.
Appendix 4: Evidence Tables of included studies
Studies are ordered using the following hierarchy: study type (systematic reviews then primary studies), level of evidence (see HYPERLINK \l "NHMRChierarchy" Table A1.1) (higher in the hierarchy/most robust first), chronology by year of publication (oldest first), and alphabetically (by first author s surname).
Systematic reviews
NICE (2012) ADDIN EN.CITE National Institute for Health and Clinical Excellence (NICE)20121267[22]126712676National Institute for Health and Clinical Excellence (NICE),Autism: recognition, referral, diagnosis and management of adults on the autism spectrum. National Clinical Guideline No. 1422012London, EnglandThe British Psychological Society and The Royal College of Psychiatristshttp://www.nice.org.uk/guidance/cg142[ HYPERLINK \l "_ENREF_22" \o "National Institute for Health and Clinical Excellence (NICE), 2012 #1267" 22]Country, study type, aimsReview scopeParticipants and search methodInclusion and exclusion criteriaResultsConclusionsCountry: UK
Study type: systematic review of the clinical effectiveness of CBT in adults with ASD
Evidence level: III-2 (systematic review includes level III-2 primary studies)
Review scope: benefits and potential harms of CBT for adults with ASD, using a range of study designs, published from database inception and September 2011.
Only reported here is review of studies relating to treatment of coexisting conditions with autism. Other studies relating to anti-victimisation and anger management did not include people with ASD.
Participants: adults aged 18 years or older with ASD
Search method: AMED, ASSIA, AEI, BEI, CDSR, CENTRAL, CINAHL, DARE, EMBASE, ERIC, HMIC, Medline, PsycINFO, Sociological Abstracts, SSA databases searched using broad search terms; reference checking; contacting key experts; checking key Journal contents; and tracking key papers prospectively through Science Citation Index.
Appraisal: GRADE checklists, Forest plots and Review Manager. Inclusion: assessment of CBT for common mental health problems for adults (aged 18 years or older) with suspected autism; minimum of n=10 per study arm.
Exclusion: >50% attrition from either study arm
Key findings:
- 1 pseudo-experimental controlled trial identified of CBT for adults with ASD & OCD ADDIN EN.CITE Russell20091241[48]1241124117Russell, A. J.Mataix-Cols, D.Anson, M. A. W.Murphy, D. G. M.Russell, A. J., Department of Psychology, Institute of Psychiatry, Kings College London, PO Box 77, De Crespigny Park, Denmark Hill, London, United Kingdom, SE5 8AFPsychological treatment for obsessive-compulsive disorder in people with autism spectrum disordersA pilot studyPsychotherapy and PsychosomaticsPsychotherapy and psychosomatics59-61781obsessive compulsive disorderautism spectrum disorderspsychological treatmentComorbidityPervasive Developmental DisordersPsychotherapy2009SwitzerlandKarger0033-3190
1423-03482010-25760-010http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-25760-010&site=ehost-livea.russell@iop.kcl.ac.ukhttp://www.karger.com/Article/Abstract/17262210.1159/000172622psyhEBSCOhost[ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48]; found no significant treatment effects.
- no studies assessed economic evidence
Limitations of evidence base
Methodological limitations highlighted:
- evidence was of low quality and indirect
- study failed to describe any adaptions made to CBT for the ASD population, which arguably could, in part, account for a lack of efficacy.
Specific adaptations to the method of delivery of CBT interventions for people with autism were recommended based on the GDGs knowledge and expertise (described in the body of current Report).
Recommended research to develop methods of delivery of CBT to take into account autism and nature and duration of the intervention, test treatment feasibility in pilot studies, and formally evaluate the outcomes in a large-scale randomised controlled trial.Author conclusions:
No specific evidence to support the development of adaptations to CBT to make it more effective for people with autism. It was recommended that for adults with autism and coexisting mental disorders, the existing NICE guidance on the specific disorder direct psychological interventions (predominantly CBT) be used (Recommendation 7.6.7.5), that staff should understand core symptoms of autism (Recommendation 7.6.7.6), and that they should make adaptations delivery to suit people with ASD (Recommendation 7.6.7.7).
Reviewers comments: Comprehensive search strategy; robust appraisal and tables. 1 study appraised also included in current review ADDIN EN.CITE Russell20091241[48]1241124117Russell, A. J.Mataix-Cols, D.Anson, M. A. W.Murphy, D. G. M.Russell, A. J., Department of Psychology, Institute of Psychiatry, Kings College London, PO Box 77, De Crespigny Park, Denmark Hill, London, United Kingdom, SE5 8AFPsychological treatment for obsessive-compulsive disorder in people with autism spectrum disordersA pilot studyPsychotherapy and PsychosomaticsPsychotherapy and psychosomatics59-61781obsessive compulsive disorderautism spectrum disorderspsychological treatmentComorbidityPervasive Developmental DisordersPsychotherapy2009SwitzerlandKarger0033-3190
1423-03482010-25760-010http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-25760-010&site=ehost-livea.russell@iop.kcl.ac.ukhttp://www.karger.com/Article/Abstract/17262210.1159/000172622psyhEBSCOhost[ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48]
Source of funding: NHS, NICE.Study quality: Internal validity: + Precision: ? Applicability: + Overall Score: +Key: AEI=Australian Education Index; AMED=Allied and Complementary Medicine Database; AS=Asperger syndrome; ASD=autism spectrum disorder; ASSIA=Applied Social Services Index and Abstracts; BEI=British Education Index; CBT=cognitive behaviour therapy; CDSR=Cochrane Database of Systematic Reviews; CENTRAL=Cochrane Central Register of Controlled Trials; CINAHL=Cumulative Index to Nursing and Allied Health Literature; DARE=Database of Abstracts of Reviews of Effects; Embase=Excerpta Medica Database; ERIC=Education Resources in Curriculum; HFA=high functioning autism; HMIC=Health Management Information Consortium; HTA Database=Health Technology Assessment; IBSS=International Bibliography of the Social Sciences; Medline=Medical Literature Analysis and Retrieval System Online; PsycINFO= Psychology Information Database; RCT=randomised controlled trial; SSA=Social Services Abstracts; UK=United Kingdom
Binnie & Blainey (2013) ADDIN EN.CITE Binnie20131157[41]1157115717Binnie, JamesBlainey, SarahBinnie, JamesThe use of cognitive behavioural therapy for adults with autism spectrum disorders: A review of the evidenceMental Health Review JournalMental Health Review Journal93-104182adultsautism spectrum disorderscognitive behavioural therapycomorbid psychiatric symptomsCognitive Behavior TherapyComorbidityPervasive Developmental DisordersPsychiatric Symptoms2013United KingdomEmerald Group Publishing Limited1361-9322
2042-87582013-27337-005http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-27337-005&site=ehost-livejamescbt@gmail.com10.1108/MHRJ-05-2013-0017psyhEBSCOhost[ HYPERLINK \l "_ENREF_41" \o "Binnie, 2013 #1157" 41] Country, study type, aimsReview scopeParticipants and search methodInclusion and exclusion criteriaResultsConclusionsCountry: UK
Study type: systematic review of CBT in adults with ASD
Evidence level: III-2 (systematic review includes level III-2 primary studies)
Review scope: CBT for reducing comorbid psychiatric symptoms and increasing social and communication skills in adults with ASD using a range of study designs, published between 1980 and 2009. Participants: adults aged 18 years or older with ASD
Search method: Ovid Medline, PsycINFO and EMBASE databases searched using broad search terms, as well as reference checking and contacting key experts.
Appraisal: Studies were critically appraised using qualitative- and RCT-specific checklistsInclusion: assessment of CBT for common mental health problems for adults (aged 18 years or older) with HFA or AS; in English; original data; peer reviewed journal; available electronically.
Exclusion: children aged under 18 years; having a learning disability; psychotherapy focused on treating the core deficits of ASD; expert opinion studies.7 eligible studies identified: 5 used a case study methodology, and 2 used pseudo-experimental designs.
Key findings:
Considering the 7 studies:
- no RCTs eligible for review
- in adults with AS or HFA individual CBT shows promise in decreasing comorbid psychiatric symptomatology
- 1 study used group CBT as intervention ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49]
Limitations of evidence base
Methodological limitations highlighted:
- lack of clarity regarding CBT intervention
- no studies reported adherence to protocol
- lack of information regarding diagnosis of participants, and recruitment strategies with likelihood of using opportunistic samples
- little information about previous or co-occurring treatment or medications.
Recommended future large-scale, high-quality trials using manualised CBT and checks on therapist adherence to inform what adaptions may be necessary to CBT for people with ASD. Need to assess impact of CBT on persons everyday living. Author conclusions:
The studies provide tentative evidence that CBT may be an effective intervention for comorbid mental health difficulties such as anxiety and depression(but are) unlikely to be effective in changing the core cognitive and social deficits associated with ASD.
Recommends need to distinguish comorbid psychiatric symptoms from core ASD deficits; e.g., OCD from a need for routine, or social anxiety from social-communication difficulties. Clinicians should have a good understanding of ASD.
Reviewers comments: Broad search strategy, scope limited to high functioning adults; detailed qualitative appraisal and tables. 3/7 studies appraised are included in current review ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48, HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49].
Source of funding: not stated, authors are cliniciansStudy quality: Internal validity: + Precision: X Applicability: + Overall Score: ?Key: AS=Asperger syndrome; ASD=autism spectrum disorder; CBT=cognitive behaviour therapy; Embase=Excerpta Medica Database; GDG= Guideline Development Group (GDG); HFA=high functioning autism; Medline=Medical Literature Analysis and Retrieval System Online; PsycINFO= Psychology Information Database; RCT=randomised controlled trial; UK=United Kingdom Spain et al (2015) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_13" \o "Spain, 2015 #1086" 13] Country, study type, aimsReview scopeParticipants and search methodInclusion and exclusion criteriaResultsConclusionsCountry: UK
Study type: systematic review of CBT for adults with ASD and psychiatric co-morbidity
Evidence level: I (systematic review includes level II primary studies)Review scope: Considered the effectiveness of CBT interventions for adults with ASD and psychiatric co-morbidity or associated mental health characteristics.Participants: adults aged 18 years or over with ASD and psychiatric co-morbidity
Search method: Databases: CENTRAL, MEDLINE, EMBASE, PsycINFO, PubMed; Web of Science, CENTRAL, searched from 1993 to August 2013 using broad search strategies, and reference checking of published papers.
Appraisal: One reviewer selected studies for retrieval, and another reviewed a 10% random sample with full agreement. Data extraction form employed. Inclusion: adults aged 18 years or older with ASD; papers published in peer-reviewed English-language journals; studies employing at least one pre- and post-treatment self-, informant-, or clinician-rated outcome measure relevant to mental health or functioning.
Exclusion: non-English language publications; grey literature; interventions primarily offered to target core ASD symptoms, such as social skills training or enhancement of social cognition; CBT delivered primarily to children and adolescents with ASD.6 studies were included: two RCTs; one pseudo-experimental study; one case series; and two case studies.
Key findings:
- Decrease in co-morbid mental health symptoms found for all 6 studies.
- In the more rigorous two RCTs (targeting OCD; and low mood and rumination), a proportion of participants were reported as showing global improvements including a decrease in co-morbid mental health problems, improved functioning, and increased positive affect. One of these studies revealed preliminary evidence that CBT based on mindfulness may be of benefit.
- In the less robustly designed studies, several participants benefitted clinically in terms of reduced self-reported symptom severity, and in one study, clinician-administered measure of OCD symptoms.
Limitations of evidence base
A small number of studies and small sample sizes included. Varied participant characteristics. Psychometric properties of self-report outcome measurements utilised in the ASD population not established. Author conclusions:
CBT interventions were moderately effective treatments for co-morbid anxiety and depression symptoms.
CBT shows promise but authors suggest that adaptions are likely to be needed to augment the acceptability and effectiveness of interventions.
Reviewers comments: Comprehensive search strategy, detailed narrative synthesis and appraisal, detailed tables of study characteristics and results. 5/6 studies appraised are included in current review ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_18" \o "Spek, 2013 #1239" 18, HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42, HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47, HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48, HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50]. Meta-analysis was not possible due to study heterogeneity.
Source of funding: internal funding from National Institute for Health Research (NIHR).Study quality: Internal validity: + Precision: ? Applicability: + Overall Score: +Key: ASD=autism spectrum disorder; CBT=cognitive behaviour therapy; CENTRAL=Cochrane Central Register of Controlled Trials; Embase=Excerpta Medica Database; Medline=Medical Literature Analysis and Retrieval System Online; OCD=Obsessive Compulsive Disorder; PsycINFO= Psychology Information Database; RCT=randomised controlled trial; UK=United Kingdom
Primary studies
Cardaciotto and Herbert (2004) ADDIN EN.CITE Cardaciotto20041240[42]1240124017Cardaciotto, LeeAnnHerbert, James D.Cardaciotto, LeeAnn, Department of Psychology, Drexel University, M.S. 988, 245 N. 15th Street, Philadelphia, PA, US, 19102-1192Cognitive behavior therapy for social anxiety disorder in the context of Asperger's syndrome: A single-subject reportCognitive and Behavioral PracticeCognitive and Behavioral Practice75-81111Aspergers syndromecognitive behavior therapysocial anxiety disorderdevelopmental disordercomorbiditytreatmentAnxiety DisordersSocial Anxiety2004Win 2004USAssociation for Advancement of Behavior Therapy1077-72292004-15843-008http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2004-15843-008&site=ehost-livelc52@drexel.eduhttp://www.sciencedirect.com/science/article/pii/S107772290480009910.1016/S1077-7229(04)80009-9psyhEBSCOhost[ HYPERLINK \l "_ENREF_42" \o "Cardaciotto, 2004 #1240" 42]Country, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issuesCountry: US
Study type: case study with pre- and post-test measures
Evidence level: IVSetting/recruitment: University-based clinical psychology unit
Participant: Male Caucasian adult aged 23 years with ASDI verified Asperger syndrome (AS) and Social Anxiety Disorder (SAD) established by SCID-IV. Inclusion criteria: Not specified, single case study.
Follow-up: assessment (6 mths pre-CBT); pre-CBT (2 wks pre-); Session 1 (just prior); mid-treatment; and post-test. LSAS and BDI-II: weekly during therapy.
Maintenance: 2 mths post CBT.
Fidelity: CBT not manualised and fidelity not reportedIntervention: 14-week course of individual CBT including cognitive restructuring, role-play, thought-listing, homework, with emphasis on social skills training.
Outcomes (completed by):
- SPAI=social phobia and anxiety subscales (self)
- LSAS=fear, avoidance (self)
- BDI-II=depression (self)
- CGI-I/S=symptom improvement/severity (for anxiety) (assessor)
- ADIS-R=overall rating of impairment (from social anxiety) (self)
- Behavioural assessment of a conversation exercise, and a speech=rating of videotapes of verbal content, nonverbal behaviour, paralinguistic behaviour, and overall social skills (assessors);
- post conversation, & speech=self-report of anxiety impairment, thought-listing, and performance (self).Key findings:
Pre-CBT to follow-up
CGI-S: severely ill to mildly ill
CGI-I: very much improved.
SPAI social phobia: decreased to normal range (50th percentile of nonanxious controls, 40th at 2 mths post).
LSAS fear: initially increased to mid-treatment, and then decreased to baseline at 2 mth follow-up.
LSAS avoidance: initial rise then steady decrease post 3rd session.
BDI-II depression: steady decrease to 4 (within normal range)
ADIS-R anxiety impairment: very severe to moderate
Behavioural assessments: minimal changes observed, subjective improvements from client reported.
Maintenance:
At 2 month follow-up, anxiety symptoms and avoidance generally decreased, depressive symptoms remained in normal range. No longer met criteria for SAD.
Author conclusions: CBT was successful in reducing symptoms of social anxiety, and comorbid depression, in an individual with comorbid AS and SAD. Improvements in social skills were limited.
Reviewers comments: ASD diagnoses independently verified by researchers. Therapy not manualised. Direct observational data collected. Assessor open to bias in assessments. Only one individual and no comparison/control group.
Source of funding: Research grants from NIMH.Study quality: not assessed as case study Overall Score: NAKey: AS=Asperger Syndrome; ADIS-R=Anxiety Disorders Interview Schedule-Revised; ASD=autism spectrum disorder; ASDI=Asperger Syndrome Diagnostic Interview; BDI-II=Beck Depression Inventory II; CBT=cognitive behaviour therapy; CGI-I(S)=Clinical Global Impression-improvement(severity); LSAS=Liebowitz Social Anxiety Scale; M=mean; mth=month; NIMH=National Institute of Mental Health; SAD=Social Anxiety Disorder; SCID-IV=Structured Clinical Interview for Axis I DSM-IV Disorders; SPAI=Social Phobia and Anxiety Inventory; US=United States of America; wks=weeks
Weiss and Lunsky (2010) ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_50" \o "Weiss, 2010 #261" 50] Country, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issuesCountry: Canada
Study type: case series with pre- and post-test measures
Evidence level: IVSetting/recruitment: referred by community service agencies or through self-referral from online postings on AS websites.
Participants: 3 (of 6 screened) adults with AS: 2 men, 1 woman, aged late 30s-mid 50s; comorbid with conditions:
- Frank with Major Depressive Disorder
- Shelli with PTSD from sexual assaults
- Jake with Major Depressive Disorder, Panic Disorder, Agoraphobia, symptoms of Social Phobia.Inclusion criteria: diagnosis of Asperger syndrome using AAA; aged 18-60; IQ >85 on WASI; DSM-IV-TR diagnosis of anxiety and/or depressive disorder (SCID-I/P); clinically significant symptoms of anxiety (BAI) or depression (BDI-II); desire to participate in group therapy (SSTC).
Exclusion criteria: psychotic symptoms, substance dependence.
Follow-up: assessments at screening, weekly during therapy, and followed up 8 weeks post therapy.
Fidelity: CBT manualised and fidelity not reportedIntervention: 12 weekly 1-hour sessions of group-based CBT targeting anxiety and mood using manualised Mind over Mood programme and workbook. Included situation/activity mood monitoring; thought records; examining evidence; explored strengths; behavioural experiments and action plans.
Outcomes (completed by):
- BAI=anxiety (self)
- BDI-II=depression (self).Key findings:
Pre-CBT to follow-up
- Frank: BDI-II increased from 1st to 5th sessions, then reduced but elevated at 8 wk-post follow-up;
BAI decreased from 15 to 5 through therapy; was 8 at 8-wk follow-up.
- Shelli: BDI-II reduced from 18 to 8 through therapy; BAI also reduced. At session 9, Shelli was upset by a thought record of trauma and was voluntarily hospitalised but continued with therapy. No follow-up.
- Jake: BDI-II sharply decreased to session 9 (54 17), then increased sharply at anniversary of mothers death at session 10, remained high at follow-up (above baseline). BAI increased through therapy and remained elevated at follow-up.
Maintenance:
There was 8-week follow-up for only 2 participants, with symptomatology somewhat increased. Author conclusions: The group showed some promise in addressing symptoms, but (any) gains were not maintained. Qualitatively participants reported appreciating the socialising function of the group, and liked the predictability and structure of the sessions. Homework completion and attendance was high. Authors noted that participants needed extra time to grasp the concept of cognitive restructuring and hot thoughts. They also suggest participants may have benefited from assistance in the community after therapy.
Reviewers comments: ASD diagnoses independently clinically verified. Therapy manualised. Direct observational data not collected. No statistical analysis. Thorough narrative description of each individuals progress in therapy. Assessor not blinded. Only 3 individuals and no comparison/control group. Heterogeneous group. Diagnosed late in life.
Source of funding: Not reported but authors from York University, and Dual Diagnosis Program Centre for Addiction and Mental Health, Toronto.Study quality: not assessed as case seriesOverall Score: NAKey: AAA=Adult Asperger Assessment; AS=Asperger Syndrome; BAI=Beck Anxiety Inventory; BDI-II=Beck Depression Inventory II; CBT=cognitive behaviour therapy; DSM-IV-TR=Diagnostis and Statistical Manual of Mental Disorders, version 4, text revision; IQ=intelligence quotient; PTSD=Post-traumatic stress disorder; SCID-I/P=Structured Clinical Interview for Axis I DSM-IV-TR Disorders; SSTC=Suitability for Short-Term Cognitive Therapy interview; WASI=Weschler Abbreviated Scales of Intelligence; wk=weekMarwood & Hewitt, 2012 ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_44" \o "Marwood, 2013 #579" 44] Country, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issuesCountry: UK
Study type: case series with pre- and post-test measures
Evidence level: IVSetting/recruitment: NHS referrals from various agencies to the psychological service for people with a learning disability.
Participants: 8 adults with mild learning disability and requiring anxiety management, one of whom was on the autism spectrum, whose results are reported here.
- Nigel (aged 42) with anxiety associated with autism.Inclusion criteria: having a learning disability (as recorded in health or social care files) and presenting with anxiety requiring management (not a diagnosed anxiety disorder).
Exclusion criteria: not suitable for intervention as determined through individual assessment with the group facilitator; e.g., lacking understanding of the problem, or poor communication skills.
Follow-up: pre- and post-intervention.
Fidelity: CBT not manualised and fidelity not reportedIntervention: 6 weekly 1-hour sessions of group-based CBT targeting anxiety. Participants brought along a support person. Included linking thoughts and feelings, cognitive behavioural model, and exercises in breathing/relaxation and distraction. Diaries and worksheets used. Session with support partners only run at conclusion.
Outcomes (completed by):
- QLS=quality of life one question (self)
- GAS=anxiety, designed for people with an intellectual disability (self)
- HNOS-LDV=global functioning (self)Key findings:
Pre-CBT to post-CBT
- Nigel: Anxiety decreased slightly but not statistically significantly (31 to 27), quality of life increased significantly (dissatisfied to very satisfied); global functioning decreased slightly suggesting improvement (2 to 1).
Maintenance:
Not assessed. Author conclusions: The results suggest that CBT was successful in treating anxiety for people with learning disabilities.
Reviewers comments: Status of disorder and learning disability not independently verified. Anxiety disorder not diagnosed. Clients screened before entry to assess suitability for CBT approach. Feelings diaries adapted to include pictures. Therapy not manualised. Direct observational data not collected. Small sample and only one with ASD reported here. Maintenance of effects not followed up. No comparison/control group. Interviews with 4 participants excluding Nigel were qualitatively analysed. Non-participants either refused or had moved away.
Source of funding: Not reported. Authors from NHS funded Psychological Service for People with Learning Disabilities, UK.Study quality: not assessed as case seriesOverall Score: NAKey: CBT=cognitive behaviour therapy; GAS=Glasgow Anxiety Scale; HNOS-LDV=Health of the Nation Outcome Scale-Learning Disability Version; QLS=Quality of Life Scale; UK=United KingdomPugliese & White, 2014 ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_46" \o "Pugliese, 2014 #401" 46] Country, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issuesCountry: USA
Study type: case series with pre- and post-test measures
Evidence level: IVSetting/recruitment: college (university) students recruited through the student disabilities office.
Participants: 5 Caucasian males aged 18-23 years (M=21.3) with ASD, 4 previously diagnosed with AS and one with Autistic Disorder. All had IQ over 100 supported by testing within the previous 3 years.Inclusion criteria: ADOS-verified ASD.
Exclusion criteria: severe psychopathology.
Follow-up: pre- and post-intervention, with 2 month follow-up to assess maintenance. At each point, 3 assessments were made across a week and averaged to provide a stable measure.
Fidelity: CBT manualised and treatment integrity (from independently rated videotapes) and therapist fidelity were high. 4/5 participants completed at least 8 sessions, 83% completion of assignments. Client satisfaction was also moderately high, though homework assignments were rated as only somewhat helpful.Intervention: 9 weekly 1-hour sessions of group-based CBT targeting problem solving (Problem Solving Therapy). Included psycho-education about ASD, feedback on performance, modelling of new skills, direct instruction, homework assignments.
Outcomes (completed by):
- SPSI-R:L=problem solving (self)
- OQ=general distress (self).
Reliable Change Indices were used to calculate clinical significance of change.Key findings:
Pre-CBT to post-CBT
Two of 5 participants demonstrated reliable improvements in total scores for problem solving (SPSI-R:L), and for subjective distress (OQ).
Of the other 3 participants, 2 demonstrated trends toward improvement in problem solving and distress, whereas one experienced sub-threshold (non-significant) worsening from baseline to end-point.
Maintenance:
Improvements for one subscale of problem solving (SPSI-R:L) was maintained at follow-up, but not any subscales of subjective distress (OQ).Author conclusions: Overall, the results from SPSI-R and OQ are inconclusive. Most participants experienced positive change at either a clinical or sub threshold level. Noted that the participants who exhibited the least improvements both had co-occurring symptoms of anxiety and depression.
Reviewers comments: ASD independently verified. Therapy manualised. Direct observational data not collected. Small sample with no control group. Maintenance of effects investigated. Primarily a feasibility study with preliminary investigation of efficacy.
Source of funding: Conducted as part of first authors doctoral dissertation. Partially funded by the Graduate Research Program Dissertation Award at Virginia Tech. Study quality: not assessed as case seriesOverall Score: NAKey: ADOS=Autism Diagnostic Observation Schedule; AS=Asperger syndrome; ASD=Autism Spectrum Disorder; CBT=cognitive behaviour therapy; IQ=intelligence quotient; SPSI-R:L=Social Problem Solving Inventory-Revised: Long Form; OQ=Outcome Questionnaire; US=United States of America.Russell et al, 2009 ADDIN EN.CITE Russell20091241[48]1241124117Russell, A. J.Mataix-Cols, D.Anson, M. A. W.Murphy, D. G. M.Russell, A. J., Department of Psychology, Institute of Psychiatry, Kings College London, PO Box 77, De Crespigny Park, Denmark Hill, London, United Kingdom, SE5 8AFPsychological treatment for obsessive-compulsive disorder in people with autism spectrum disordersA pilot studyPsychotherapy and PsychosomaticsPsychotherapy and psychosomatics59-61781obsessive compulsive disorderautism spectrum disorderspsychological treatmentComorbidityPervasive Developmental DisordersPsychotherapy2009SwitzerlandKarger0033-3190
1423-03482010-25760-010http://ezproxy.canterbury.ac.nz/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-25760-010&site=ehost-livea.russell@iop.kcl.ac.ukhttp://www.karger.com/Article/Abstract/17262210.1159/000172622psyhEBSCOhost[ HYPERLINK \l "_ENREF_48" \o "Russell, 2009 #1241" 48] Country, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issuesCountry: UK
Study type: non-randomised, experimental study
Evidence level: III.2Setting: Referrals to a specialist ASD clinic in London, UK.
Participants: 24 adults: 21 male (88%), 3 female; with high functioning autism, comorbid with Obsessive-Compulsive Disorder (OCD); 50% had spent some time as inpatients during the study; 42-50% had an additional comorbidity (usually depression or anxiety); 50-67% were on medication at baseline but were on a stable dose for 6 weeks prior.
Treatment group (TG): N=12
Control group (CG); N=12
Dropout: none reported
Inclusion: adults who had an independent clinical diagnosis of ASD (by psychiatrist, supplemented by ADI, ADOS for n=19); IQ in the average range (WAIS-III): Verbal IQ M=100.3, SD-14.1; Performance IQ M=95.5, SD=12.3.
Exclusion: not reported
Follow-up: pre-test, post-test (immediately after treatment for TG). Averaged 15.9 months (SD=10.7). Reported that there no difference between TG and CG in follow-up interval. Not clear how follow-up intervals were determined for the control group.
Fidelity: attendance: M=27.5 sessions, range 10-50. Treatment integrity not reported.Treatment (TG): Non-manualised individual CBT for between 10 and 50 sessions. CBT-based including exposure and response prevention, and cognitive appraisal of OCD-related beliefs. Three therapists.
Control (CG): treatment as usual (no CBT during follow-up period)
Outcomes (completed by):
- YBOCS: obsessive-compulsive scale; total severity score, obsessions subscale, and compulsions subscale (self, and for half of TG, assessor).
- BDI: depression (self)
- BAI: anxiety (self)
At baseline, no significant differences between groups in gender, IQ, additional psychopathology, time between measures, time as inpatients during study period, or medication use. The TG were significantly younger than the CG (23.8 cf 32.1, p<0.017), and had significantly more severe OCD (YBOCS) at baseline than the CG.
Key findings:
2 (Group: treatment & control) X 2 (Time: baseline & post-test) mixed model ANOVA found significant main effects for Group, Time and Group X Time interaction such that TG improved on YBOCS cf CG: F=4.341, d.f.=1; p<0.05. Standardised effect size (Cohens d=1.01) indicated a large treatment effect for total YBOCS in the TG.
Repeated measures t-tests found significant improvement in OCD for TG (not CG) in severity and obsession scores. Non-significant trend in improved compulsions in TG (p=0.09), but not in CG.
Treatment response (defined as >25% reduction on the total YBOCS) was found for more people in the TG than in the CG (7 cf 2; p=0.035).
No difference between groups in anxiety or depression.Author conclusions: A considerable proportion of individuals with ASD and OCD show significant improvement with standard psychological treatment (CBT-based therapy), with some adaptions. OCD symptoms in ASD do not show any change over time in the absence of treatment.
Reviewers comments: ASD diagnoses independently verified. Ethnicity and age not reported. Non-randomised sample and not reported how people were allocated to CBT, possibly by choice and/or suitability, introducing bias. No direct observational data collected. No blinding of assessment; YBOCS assessed by therapists for half of CBT group. Maintenance of effects not followed up. YBOCS not standardised for people with ASD.
Medications were changed during the trial for 6 participants, 4 in TG and 2 in the CG.
The TG had significantly more severe OCD (YBOCS) at baseline than the CG, which could suggest a regression to the mean in response of TG. Also may have influenced why those people were offered CBT, as allocation not randomised.
Study limited by small sample size. Also limited ability to explore confounding effects or reason for why 40% of TG (n=5) were non-responders.
Source of funding: Research grants: South London and Maudsley NHS Foundation Trust.Study quality: Internal validity: X Precision: + Applicability: ? Overall Score: XKey: ANOVA=analysis of variance; ASD=autism spectrum disorder; BAI=Beck Anxiety Inventory; BDI=Beck Depression Inventory; CBT=cognitive behaviour therapy; CG=control group; IQ=intelligence quotient; M=mean; NHS=National Health Service (UK); OCD=Obsessive Compulsive Disorder; TG=Treatment Group; UK=United Kingdom; WAIS-III=Weschler Adult Intelligence Scale; YBOCS=Yale-Brown Obsessive Compulsive Scale.Turner-Brown et al, 2008 ADDIN EN.CITE Turner-Brown20081242[49]1242124217Turner-Brown, Lauren M.Perry, Timothy D.Dichter, Gabriel S.Bodfish, James W.Penn, David L.Brief report: feasibility of social cognition and interaction training for adults with high functioning autismJournal of autism and developmental disordersJournal of autism and developmental disorders1777-84389Adult*Autistic Disorder/px [Psychology]*CognitionFeasibility StudiesFemaleHumans*Interpersonal RelationsMaleMiddle AgedQuestionnaires*Social Perception2008United StatesTurner-Brown,Lauren M. Neurodevelopmental Disorders Research Center, University of North Carolina at Chapel Hill School of Medicine, CB #3367, UNC-Chapel Hill, Chapel Hill, NC 27599-3367, USA. lauren_turner@med.unc.edu0162-3257http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=18246419http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646378/pdf/nihms-94811.pdf[ HYPERLINK \l "_ENREF_49" \o "Turner-Brown, 2008 #1242" 49] Country, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issuesCountry: US
Study type: pseudo-experimental study
Evidence level: III.1Setting: Recruited from a North Carolina state-provided autism agency and psychologist in the community.
Participants: 11/13 young adults aged 25-55 years; 10 male (91%), 1 female; with High Functioning Autism (defined as including Asperger Syndrome, autism, and PDD-NOS with average intellectual ability); 9 identified as Caucasian, 2 non white.
Treatment group (TG): N=6
Control group (CG); N=5
Dropout: 2/13 dropped out of follow-up assessmentsInclusion: aged 18-55 years; clinical diagnosis of ASD (ADOS); Full scale IQ in the average range (WAIS).
Exclusion: not reported
Follow-up: pre-test, 18 week post-test (immediately after treatment for TG).
Fidelity: attendance was high (92%) and satisfaction primarily positive. Treatment integrity not reported.Treatment (TG): Manualised group-based Social Cognitive Interaction Training (SCIT) over 18, 50-minute, weekly sessions. Targeted emotion recognition, theory of mind, and attributions and social interaction skills. Included videotaped examples of socially challenging situations.
Control (CG): received treatment as usual, including job skills coaching, medication management, and/or individual therapy (also offered to those in TG). No group therapy of any kind.
Outcomes (completed by):
- FEIT: emotion recognition of faces (using photographs) (self)
- Hinting Task: Theory of Mind skills (using vignettes) (self)
- SCSQ: perceived social communication skills (self)
- SSPA: performance-based role play exercise assessing social skills (tapes rated by two observers blinded to group status, with high inter-rater reliability, Cronbachs alpha=0.7; scores averaged).No significant differences between groups at baseline in IQ, gender or outcome measures. The TG was significantly older than CG (M=42.5 cf 28.8 respectively, p<0.05) and TG had more Caucasian versus non white participants (6/6 cf 3/5, p<0.05). However age and ethnicity not related to outcomes (p>0.1).
Key findings:
Repeated measures 2 (Group: treatment & control) X 2 (Time: baseline & post-test) repeated measures ANOVAs.
- Main group effect such that emotion recognition performance (FEIT) was improved over time in the TG cf the CG; F(1,8)=10.02, p<0.05; Within-group effect size for TG (Cohens d=0.94) indicated a large treatment effect.
- Significant main effect for Time, and Group X Time interactions such that TG improved on Theory of Mind skills (Hinting Task) than CT group participants: F(1,9)=10.02, p<0.05; Within-group effect size for TG (Cohens d=0.84) indicated a large treatment effect.
- No significant main effects or interactions found for perceived communication skills (SCSQ) or social skills performance (SSPA).Author conclusions: Social Cognitive Interaction Training shows promise as an intervention for adults with HFA. This initial study demonstrated both treatment feasibility and improvements in social cognition and perceived social functioning.
Reviewers comments: Not clear if ASD diagnoses independently verified. No assessment of whether dropouts differed from those retained. Mostly male sample. Ethnicity data limited. Individual therapy was a potential confounder. Treatment integrity not reported. Maintenance of effects not followed up. Whilst sample were initially randomised, 2 changed from TG to CG due to work commitments and change of mind, introducing bias. Direct observational data collected of role-play performances through blinded assessment by two independent raters.
Regarding social cognition, strong within-groups effect for emotion recognition in TG but not in CG, and statistically significant improvement in Theory of Mind skills in TG cf CG. Regarding social functioning, non-significant trend for improvement in perceived social communication skills, but no significant changes in observer-rated social skills.
Power to detect significant results may have been limited by the small sample size.
Source of funding: Research grants: NIMH, Foundation of Hope, autism agency.Study quality: Internal validity: X Precision: + Applicability: ? Overall Score: ?Key: ANOVA=analysis of variance; AS=Asperger syndrome; ASD=autism spectrum disorder; CG=control group; HFA=High Functioning Autism; FEIT=Face Emotion Identification Test; IQ=intelligence quotient; M=mean; NIMH=National Institute of Mental Health; PDD-NOS=pervasive developmental disorder not otherwise specified; SCIT=Social Cognitive Interaction Training; SCSQ=Social Communication Skills Questionnaire; SSPA=Social Skills Performance Assessment; TG=Treatment Group; US=United States; WAIS=Weschler Adult Intelligence Scale McGillivray et al, 2014 ADDIN EN.CITE McGillivray2014244[45]24424417McGillivray, J. A.Evert, H. T.Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASDJournal of autism and developmental disordersJournal of autism and developmental disorders2041-51448AdolescentAdult*Anxiety/th [Therapy]Asperger Syndrome/px [Psychology]*Asperger Syndrome/th [Therapy]Autistic Disorder/px [Psychology]*Autistic Disorder/th [Therapy]*Cognitive Therapy*Depression/th [Therapy]FemaleHumansMale*Psychotherapy, GroupStress, Psychological/th [Therapy]Treatment OutcomeYoung Adult2014United StatesMcGillivray,J A. School of Psychology, Centre for Mental Health and Wellbeing Research, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia, jane.mcgillivray@deakin.edu.au.1573-3432http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=24634065http://link.springer.com/article/10.1007%2Fs10803-014-2087-9[ HYPERLINK \l "_ENREF_45" \o "McGillivray, 2014 #244" 45] Country, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issuesCountry: Australia
Study type: pseudo-experimental study
Evidence level: III.1
Setting: Advertisements via community-based agencies delivering support services.
Participants: 42/57 eligible young people approached (after 15 excluded): 32 male (76%), 10 female (24%); M age=20.6 years (SD=4.1); 72% Asperger syndrome and 28% High Functioning Autism (HFA).
Randomisation by alternating group offered (TG, CG) but different number in each group demonstrates this was compromised.
CBT group (TG): N=26
Control group (CG): N=16
Dropout: 27 completed 3 and 9 month follow-up assessments.Inclusion: youth/adults who had a clinical diagnosis of an ASD (verified by clinical interviews); were aged 15-25; with AS or HFA; and were above the normal range for any of the outcome measures DASS, ATQ, or the ASSQ.
Exclusion: cognitive impairment that might limit their ability to fully participate (informally assessed in face-to-face interview)
Follow-up: pre-test, post-test. Long term-follow-up to assess maintenance assessed at 3, and 9 months following post-test.
Fidelity: Treatment integrity not reported.Treatment (TG): group-run CBT-based programme for 9, weekly 2-hour sessions. Included thought restructuring, and muscle relaxation and visualisation techniques.
Control (CG): wait list controls
Outcomes (completed by):
Primary:
- DASS: psychological distress, subscales for depression, anxiety and stress (self)
- ATQ: automatic self-statements associated with depressed mood (self)
- ASSQ: anxious self-statements (self)
At baseline, no significant differences between groups in sample characteristics, receipt of treatment, or outcome measures.
Key findings:
2 (Group: TG & CG) X 2 (Time: baseline & post-test) repeated measures ANOVA found significant main effect for DASS for time but no Group X Time interaction (i.e., equal improvements in groups over time). The same pattern observed for the DASS subscales of depression, anxiety, & stress, ATQ, and ASSQ.
Subgroup analyses for those above normal range (i.e., symptomatic) for each related outcome. Significant Group X Time effects found for:
- DASS depression subscale: F(1,23)=4.25; p<0.05); and for
- DASS stress subscale: F(1,26)=18.78; p<0.01)
indicating improvements over time for TG more than the CG. However no significant Group X Time interactions found for the DASS anxiety subscale, the ATQ, or the ASSQ.
Maintenance
The increase over time for TG above normal range for outcome was maintained at 3 & 9 month follow-up for DASS depression subscale (p<0.001) and for DASS stress subscale (p<0.01).Author conclusions: Our results demonstrate the potential of CBT in a small group setting for assisting young people with ASD who have symptoms of depression and stress. Suggested that changes in anxiety as measured on the DASS (e.g., self-reported symptoms of autonomous arousal, situational anxiety, subjective experiences) may not be sensitive to detection. Also suggested that some negative self-statements (measured in the ATQ, ASSQ) may reflect real-life concerns about studies and employment that havent changed.
Reviewers comments: ASD diagnoses independently verified. Ethnicity not reported. Verbal IQ not measured.
Randomisation not adequate. Unequal numbers in treatment groups suggest randomisation was compromised. Groups were the same at baseline. Treatment integrity not monitored. Not manualised.
Subgroup analyses not planned a priori.
Small sample, especially for sub-group analyses. All outcomes were unblinded self-report. No direct observational data. Uncommon outcomes for ASD.
Source of funding: Victorian Government funders.Study quality: Internal validity: X Precision: ? Applicability: ? Overall Score: XKey: ANOVA=analysis of variance; AS=Asperger syndrome; ASSQ=Anxious Self-Statements Questionnaire; ATQ=Automatic Thoughts Questionnaire; CG=Control Group; DASS=Depression Anxiety Stress Scales; HFA=High Functioning Autism; M=mean; TG=Treatment Group
Hesselmark et al, 2013 ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43] Country, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issuesCountry: Sweden
Study type: randomised controlled trial
Evidence level: II
Setting: Referrals from psychiatric clinics and through advertisements. The setting was an outpatient tertiary clinic for difficult-to-treat psychiatric patients. Participants presented with high psychiatric comorbidity (75%), high use of psychotropic medication (79%), with about a third having been a psychiatric inpatient (31%), and having made a previous suicide attempt (35%).
Participants: 68/75 eligible adults approached (after 6 excluded): 41 male (60%), 27 female (40%); M age=32 years; with ASD.
Sample stratified by gender and randomised through paper-based lottery. Two patients added after randomisation to control group.
CBT group (CBT): N=34
Control group (RA): N=34
Dropout: 14 not attending >10 sessions. Missing data: used last observation carried forward method. Used intention-to-treat analysis.Inclusion: adults who had a diagnosis of an ASD (verified by clinical intervie w s , s u p p l e m e n t e d b y A D O S ) ; w e r e a g e d e"1 8 ; w i t h i n t e l l i g e n c e i n t h e n o r m a l r a n g e ( b a s e d o n m a i n s t r e a m s c h o o l i n g , h e a l t h r e c o r d s ) .
E x c l u s i o n : c u r r e n t s u b s t a n c e a b u s e , p s y c h o s i s .
F o l l o w - u p : p r e - t e s t ( a f t e r r a n d o m i s a t i o n ) , p o s t - t e s t ( d u r i n g t h e l a s t s e s s i o n ) . Long term-follow-up (for QOLI, CGI-I only) to assess maintenance assessed 8-57 months following therapy by questionnaire or telephone interview.
Fidelity: Treatment integrity not reported.Treatment (CBT): Manualised group-run intensive CBT-based programme for 36, weekly 3-hour sessions in groups of 6-8. Involved psycho-education, mindfulness, relaxation, social skills training, goal setting, role-playing (with peer-tutors), exposure exercises, and behaviour analysis.
Control (RA): recreational activities for 36, weekly 3-hour sessions in groups of 6-8. Therapists took group to activities they suggested and voted for, including museum visits, board games, cooking, boating, cinema, walks.
Outcomes (completed by):
Primary:
- QOLI: quality of life satisfaction (self)
- SoC: sense of coherence, (self)
- RSES: self esteem (self)
Secondary (exploratory):
- SCL-90-R: psychological distress (self)
- AQ: Autism Quotient (self)
- BDI: depression (self)
- ASRS: ADHD (self)
- CGI-S/-I: global functioning, severity & improvement (self)
Continued over pageAt baseline, no significant differences between groups in sample characteristics, diagnostic or outcome measures except that the CBT group had higher current diagnoses of anxiety and depression than the RA group (p<0.05).
Key findings:
2 (Group: treatment & control) X 2 (Time: baseline & post-test) repeated measures ANOVA found significant increase in QOLI scores at follow-up cf baseline for both groups: F(1,59)=10.49; p=0.002; indicating a medium effect size (Cohens d=0.031). However there were no significant differences in QOLI between groups.
No significant change between pre- and post-test assessments for SoC or RSES primary outcomes or for secondary outcomes measuring psychiatric health.
However participants self-rated an improvement (CGI-I) in global functioning at post-test, with a between group difference favouring CBT (p<0.01; missing data n=29).
Maintenance
The increase over time for both groups in QOLI scores was maintained at extended (variable length) follow-up (p<0.001, d=0.39).
Continued over pageAuthor conclusions: Both interventions appear to be promising treatment options for adults with ASD. The interventions similar efficacy in terms of quality of life may be due to the common elements, including structure and group setting. Note that QoL scores at baseline (M=-0.19) indicated a general dissatisfaction with life similar to untreated PTSD scores, but increased to the satisfied range at post-test (M=0.43).
Reviewers comments: ASD diagnoses independently verified. Ethnicity not reported. Limited to people on the spectrum with average to high IQ (not independently verified), and to group that had a significant psychiatric history, which may impact on generalisability. Randomisation not adequate. Groups differed at baseline in anxiety and depression. Treatment integrity not monitored. Lack of a non-treated control group.
All outcomes were self-reported and necessarily unblinded, with no direct observational data, blinded clinician ratings or informant data.
Many diagnostic outcomes with no adjustment to p value to allow for chance findings. Follow-up time was extremely variable (8-57 months) and not controlled in analyses. Need a standardised point of follow-up assessment. Significant missing data, reportedly based on difficulty for some participants in completing the outcome schedules.
Continued over pageKey: ANOVA=analysis of variance; ASD=autism spectrum disorder; AQ=Autism Quotient; ASRS=Adult ADHD Self-Report Scale; BDI=Beck Depression Inventory; CGI-S/CGI-I=Clinical Global Impressions Severity/Improvement; M=mean; PTSD=Post Traumatic Stress Disorder; QoL=Quality of Life; QOLI=Quality of Life Inventory; RSES=Rosenberg Self-Esteem Scale; SCL-90-R=Symptom Checklist-90-Revised; SoC=Sense of Coherence scale.
Hesselmark et al, 2013 ADDIN EN.CITE ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_43" \o "Hesselmark, 2014 #617" 43] continuedCountry, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issues.Continued
Non-standardised or validated questions developed by the study asked at follow-up not reported here.Continued
No sustained self-rated improvement at follow-up (CGI-I, missing data n=20).
Drop out rates reported as marginally higher for RA group than CBT (p=0.05). Most dropouts occurred at allocation to group. Dropouts showed lower SoC (sense of coherence) scores at baseline than completers (p<0.01).Continued
Higher dropout rate in RA cf CBT group may be related to practical concerns for inpatient participants or those who might find public outings challenging
A larger sample would permit comparisons between participants with different comorbidities.
Source of funding: Research grants: L. J. Boethius Foundation, The Swedish National Board of Health and Welfare, Swedish Research Council, and regional research (ALF) agreement.Study quality: Internal validity: ? Precision: ? Applicability: ? Overall Score: ?Key: ANOVA=analysis of variance; ASD=autism spectrum disorder; AQ=Autism Quotient; ASRS=Adult ADHD Self-Report Scale; BDI=Beck Depression Inventory; CGI-S/CGI-I=Clinical Global Impressions Severity/Improvement; M=mean; QoL=Quality of Life; QOLI=Quality of Life Inventory; RSES=Rosenberg Self-Esteem Scale; SCL-90-R=Symptom Checklist-90-Revised; SoC=Sense of Coherence scale
Russell et al, 2013 ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47] Country, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issuesCountry: UK
Study type: randomised controlled study
Evidence level: II Setting: 75 referrals to a specialist ASD, and OCD, clinics, generic mental health services, voluntary sector services and self-referrals.
Participants: 46/58 adolescent and adults: aged 14-65 years (M=26.9 years) 35 male (76%), 11 female; with ASD, verbal IQ>70; comorbid with Obsessive-Compulsive Disorder (OCD).
Randomisation by blinded use of random number table. Groups matched for treatment duration.
Treatment group (CBT): N=23 (20 completers)
Control group (AM); N=23 (20 completers)
Dropout: 6/46 excluded from analyses as discontinued/lost to follow-up. However 1-month post-test follow-up was reduced to 17 in the CBT group and 11 in the AM group due to people crossing over to receive the alternative therapy.Inclusion: people with independently confirmed clinical diagnosis of ASD (ADI, ADOS); Verbal IQ > 70; comorbid OCD (YBOCS severity >16, MINI 5.0 neuropsychiatric interview); aged between 14 and 65 years. Any psychiatric medication needed to be at a stable dose for previous 6 weeks.
Exclusion: current psychotic symptoms, major depression, uncontrolled epilepsy, current substance misuse.
Follow-up: pre-test (< 4 weeks pre-treatment), and post-test (1 week post-treatment; M=25 weeks). Maintenance: 1, 3, 6, and 12 month follow-up.
Fidelity: Blind rated audio-tapes of 20% of sessions established no cross-contamination of CBT. Good homework compliance (79%). Treatment satisfaction was good (around 5/8) but did not differ between groups.Treatment (CBT): Manualised individual CBT adapted for ASD, for up to 20 1-hour sessions (M=17.4). Included ERP, cognitive appraisal of OCD beliefs, & homework.
Control (AM): Anxiety Management (no CBT) for up to 20 1-hour sessions (M=14.4). Included psycho-education; diaphragmatic breathing; and muscle relaxation and practice.
Outcomes (completed by):
Primary outcome: YBOCS: obsessive-compulsive; total severity, insight (assessor).
Secondary outcomes:
- CGI/CGI-I global symptom impression/improvement (assessor)
- D-YBOCDS: dimensions of OCD (assessor)
- OCI-R: OCD (self)
- BDI/Youth: depression (self)
- BAI: anxiety (self)
- LSAS: social anxiety (self)
- WSAS: work/social adjustment (self)
- SCAS: anxiety (child) (self)
continued over pageAt baseline, no significant differences between groups in gender, verbal IQ, ADOS, proportion aged <18 years, time between pre and post-test, or OCD symptom (YBOCS) severity or dimensions. CBT group received marginally more treatment sessions than then AM group (17.4 cf 14.4; p=0.05).
Key findings:
2 (Group) X 2 (Time) ANCOVA controlling for baseline YBOCS found no significant differences between treatment groups on YBOCS at end of treatment (F(1,37)=1.127, p=0.295).
Univariate ANOVAs found significant decreases in YBOCS severity over time for the CBT group (p=0.001), and for the AM group (p<0.0001), with significant within group treatment effect sizes (Cohens d=1.15 for CBT; d=0.6 for AM). There was a small advantage in effect size for CBT group cf AM.
Significant reductions in YBOCS severity were maintained at each follow-up point to 12 months for the CBT group (n=10), although half the group were lost to follow-up by this point.
continued over pageAuthor conclusions: evidence-based psychological interventions, both Anxiety Management and CBT, were effective in treating comorbid OCD in young people and adults with ASD.
Reviewers comments: ASD diagnoses independently verified. Ethnicity not reported. Fully randomised. Clinician, self-report and informant measures included. Blinding of all assessments on the YBOCS. Maintenance of effects followed up to 12 months post therapy. YBOCS not standardised for people with ASD. OCD scale for informants was designed for parents to report on their children.
Groups were the same at baseline in all key characteristics and symptom variables, although CBT group received marginally more sessions than the AM group.
Participants were offered to cross-over to the alternative therapy from 1 month follow-up; 9 AM and 3 CBT group members did this, which may have compromised maintenance assessment. Those remaining may have been more likely to be satisfied with and benefitted from treatment.
Some borderline findings reported as significant were p=0.05. No adjustment to p value for the many tests conducted, increasing the likelihood of chance findings. Lack of a non-treated control group.
continued over pageKey: AM=Anxiety Management; ANOVA=analysis of variance; ASD=autism spectrum disorder; BAI=Beck Anxiety Inventory; BDI/Youth=Beck Depression Inventory/Youth version; CBT=cognitive behaviour therapy; CGI/CGI-I=Clinical Global Impressions/Improvement; D-YBOCS=dimensional Yale-Brown Obsessive Compulsive Scale; ERP=exposure and response prevention; FSAS-PR=Family Accommodation Scale-Parent report; IQ=intelligence quotient; LSAS=Liebowitz Social Anxiety Scale; M=mean; OCD=Obsessive Compulsive Disorder; OCI-R=Obsession Compulsive Inventory-Revised; PR-CHOCI-R=Childrens Obsessive-compulsive Inventory-Parent version; UK=United Kingdom; WAIS-III=Weschler Adult Intelligence Scale; WSAS=Work and Social Adjustement Scale; YBOCS=Yale-Brown Obsessive Compulsive Scale.
Russell et al, 2013 ADDIN EN.CITE Russell2013249[47]24924917Russell, Ailsa J.Jassi, AmitaFullana, Miguel A.Mack, HilaryJohnston, KateHeyman, IsobelMurphy, Declan G.Mataix-Cols, DavidCognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trialDepression and anxietyDepression and anxiety697-708308AdolescentAdultAged*Child Development Disorders, Pervasive/px [Psychology]*Cognitive Therapy/mt [Methods]FemaleHumansMaleMiddle AgedObsessive-Compulsive Disorder/px [Psychology]*Obsessive-Compulsive Disorder/th [Therapy]Severity of Illness IndexTreatment OutcomeYoung Adult2013United StatesRussell,Ailsa J. Department of Psychology, Institute of Psychiatry, Kings College London, London, United Kingdom. a.j.russell@bath.ac.uk1520-6394http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=23389964http://onlinelibrary.wiley.com/doi/10.1002/da.22053/abstract[ HYPERLINK \l "_ENREF_47" \o "Russell, 2013 #249" 47] continuedCountry, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issuescontinued
Parent/Spouse/Carer:
- PR-CHOCI-R: obsessive-compulsive (informant)
- FSAS-PR: family accommodation (informant)continued
Clinician CGI ratings also increased pre-test to post-test for both groups (p<0.001), but with no significant difference between CBT and AM groups (p=0.014).
Marginal effect for higher proportion of participants very much or much improved cf minimally improved, unchanged or worse (CGI-I) in CBT vs AM groups (11 vs 5; p=0.05).
Age, verbal IQ, or ADOS scores had no moderating affect on YBOCS treatment response. Treatment responders in the AM group (but not CBT group) had lower YBOCS severity ratings at baseline than non-responders (p=0.003).
No improvement over time for any self-report measures for either CBT or AM group.
Informant interviews revealed improvement over time for AM group only in OCD symptoms.continued
Relatively small sample size prevented robust investigation of moderating variables, particularly given the samples broad symptom severity and age group.
Small number of participants did minimally or much worse (CGI) after CBT (10%) and AM (15%), in addition to the 6 who dropped out or were lost to follow-up who may have also not received benefit.
Source of funding: Research grant from the National Institute of health Research, and one authors supported by a Marie Curie Fellowship.Study quality: Internal validity: + Precision: ? Applicability: ? Overall Score: +Key: AM=Anxiety Management; ANOVA=analysis of variance; ASD=autism spectrum disorder; BAI=Beck Anxiety Inventory; BDI/Youth=Beck Depression Inventory/Youth version; CBT=cognitive behaviour therapy; CGI/CGI-I=Clinical Global Impressions/Improvement; D-YBOCS=dimensional Yale-Brown Obsessive Compulsive Scale; ERP=exposure and response prevention; FSAS-PR=Family Accommodation Scale-Parent report; IQ=intelligence quotient; LSAS=Liebowitz Social Anxiety Scale; M=mean; OCD=Obsessive Compulsive Disorder; OCI-R=Obsession Compulsive Inventory-Revised; PR-CHOCI-R=Childrens Obsessive-compulsive Inventory-Parent version; UK=United Kingdom; WAIS-III=Weschler Adult Intelligence Scale; WSAS=Work and Social Adjustment Scale; YBOCS=Yale-Brown Obsessive Compulsive Scale. Spek et al, 2013 [25]Country, study type, aimsParticipants Inclusion and exclusion criteriaIntervention, comparison and outcome measuresResultsConclusions, quality issuesCountry: The Netherlands
Study type: randomised controlled trial
Evidence level: IISetting: Referrals to an adult autism centre, Eindhoven, The Netherlands.
Participants: 41/42 eligible adults approached (after 7 excluded): 27 male (66%), 14 female; M age=42 years; diagnosis: autism (n=21); Asperger (n=11); and PDD-NOS (n=9).
Randomisation by computer generated number. Groups matched on verbal ability (verbal comprehension scale, WAIS-III).
Treatment group (TG): N=20
Control group (CG); N=21
Dropout: 1 from serious physical illness, excluded from all analyses
Used intention-to-treat analysis.Inclusion: adults who had a clinical diagnosis of an ASD (by psychologist, supplemented by ADI-R); w e r e a g e d b e t w e e n 1 8 a n d 6 5 y e a r s ; w e r e e x p e r i e n c i n g s y m p t o m s o f d e p r e s s i o n , a n x i e t y a n d / o r r u m i n a t i o n a s i d e n t i f i e d b y c l i n i c i a n s .
E x c l u s i o n : g e n e t i c c o n d i t i o n o r o t h e r n e u r o d e v e l o p m e n t a l d i s o r d e r ( e . g . , T o u r e t t e ) ; b e i n g i n s t i t u t i o n a l i s e d ; d"8 5 i n f u l l s cale IQ and verbal comprehension index of WAIS-III; use of drugs or problematic use of alcohol; change in medication during research study.
Follow-up: pre-test, post-test (immediately after treatment for TG).
Fidelity: Treatment integrity not reported.Treatment (TG): Manualised group-run Mindfulness Behaviour Therapy modified for ASD (MBT-AS) for 9 weekly 2.5 hour sessions in groups of 10/11. Instructed to practice 40-60 minutes of daily meditation 6 days per week. Included mindfulness exercises relating to breathing, eating, sitting, movement (yoga), and listening; psycho-education about ruminative thoughts and relationship with autism; and regular planning and review of home mindfulness practice.
Control (CG): wait-list control
Outcomes (completed by):
- SCL-90-R: psychological distress, subscales of anxiety, and depression (self)
- RRQ: Rumination tendencies (self)
- GMS: positive general affect (self report)At baseline, no significant differences between groups in gender, age, diagnosis, or outcome measures.
Key findings:
2 (Group: treatment & control) X 2 (Time: baseline & post-test) MANOVA found significant main effects for Time, & Time and Group interactions such that TG cf CG:
- decreased more on depressive symptoms (SCL-90-R): F(1,39)=6.15; p<0.05
- decreased more on anxiety (SCL-90-R): F(1,39)=5.50; p<0.05
- decreased more on rumination symptoms (RRQ) F(1,39)=15.73; p<0.001
- and increased more on positive affect (GMS): F(1,39)=6.32; p<0.05.
Effect sizes (Cohens d) for all outcomes were significant, ranging from between 0.76 and 0.79 for depression, anxiety and positive affect (p<0.05), to a large 1.25 for rumination (p<0.001).
There were significant correlations between change in rumination and change in depressive symptoms, and with anxiety. A bootstrap procedure for the test of meditation showed an indirect significant effect for anxiety symptoms, and a trend for depressive symptoms. Author conclusions: Results suggest that adults with ASD can acquire meditation skills and generalise these into their private life in a way that alleviates comorbid symptoms and improve their wellbeing. Further results suggested that rumination may be a potentially important mediating factor in reducing comorbid anxiety and depression.
Reviewers comments: ASD diagnoses independently verified. Ethnicity not reported. Limited to people on the spectrum with average to high verbal abilities. No direct observational data collected. Moderately small sample size.
Correlations between rumination and other outcomes could be due to regression to the mean effects. Only self-report measures used.
Source of funding: Not reported but authors are academics from Tilburg University, The Netherlands.Study quality: Internal validity: + Precision: + Applicability: ? Overall Score: +Key: ASD=autism spectrum disorder; CG=control group; GMS= Global Mood Scale (Dutch version); IQ=intelligence quotient; M=mean; MANOVA=multivariate analysis of variance; MBT-AS=Mindfulness Behavioural Therapy for ASD; RRQ= Rumination-Reflection Questionnaire; SCL-90-R= Symptom Checklist-90-Revised; TG=Treatment Group; WAIS-III=Weschler Adult Intelligence Scale.
References
Studies included for appraisal in the current review are identified by an asterix (*)
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