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head: RESEARCH ARTICLE SUMMARY

ESPS 549 Research Article Summary Chris Law University of British Columbia

RESEARCH ARTICLE SUMMARY

Research article summary:

My topic of interest is Cognitive Behaviour Therapy (CBT). I chose this topic because I am currently working with youth with mental health issues at an inpatient care setting. A handful of youth that have been admitted to the tertiary hospital setting that I am working at, have had diagnoses of High functioning Autism (HFA) or been suspected of being on the Autism Spectrum. These youth all have had difficulty with anxiety, depression, anger management and suicidal ideation. As teenagers with HFA, they seem to be particularly susceptible to and affected by mental illness and I wanted to find out about any potentially evidence based treatments for these young people so that I am in a better position to provide support. CBT seems to be the treatment of choice in this area.

RESEARCH ARTICLE SUMMARY Sofronoff, K., Attwood, T., Hinton, S. (2005). A randomized controlled trial of a CBT intervention for anxiety in children with Asperger syndrome. Journal of Child Psychology and Psychiatry, 46, 1152-1160. Purpose

Kate Sofronoff and her colleagues (2005) wanted to find out if a version of Cognitive Behaviour Therapy (CBT) would decrease anxiety levels in youth with Asperger Syndrome (AS) and whether or not parent involvement in the treatment would affect the outcome. Participants Sofronoff et al. (2005) recruited 71 children, aged 10 to 12 years old, who all had a diagnosis of AS for their study. To corroborate the parental report of the diagnosis, the Childhood Asperger Syndrome Test (CAST) was administered. In initial phone interviews, parents reported levels of anxiety in their children. These reports were scored using the Spence Childrens Anxiety Scale (SCAS) and found to be significantly higher than a non-clinical sample reported by Nauta, Scholing, Rapee, Abbot, Spence, & Waters (2004). Research Design and Procedures This 6-week, ethically approved research study randomly assigned participants to three conditions to assess the effectiveness of the CBT treatment program. Eight groups of three children comprised the Intervention 1 condition. This condition involved only the children and therapists. Parents were not trained, but did receive information as to how their child did in sessions and details of the weekly home-based projects. The Intervention 2 condition included nine groups of three children. Additionally, parents formed two groups and received extensive training by therapists to implement the intervention and support generalization outside the training environment. The remaining children comprised the waitlist group.

RESEARCH ARTICLE SUMMARY Measures: James and The Maths Test o Participants generate coping strategies after being read an anxiety provoking situation Spence Child Anxiety Scale Parent (SCAS-P) o Parent-report measure of child anxiety Social Worried Questionnaire Parent o Parent-report measure of child social worry Each measure was administered before intervention began, immediately after intervention completed and at a six-week follow-up. Results

Post intervention and follow up scores on the James and The Maths Test described a significant increase in coping strategies to anxiety provoking situations for both intervention groups compared to the waitlist group. Parental report of their childs anxiety decreased significantly at follow up in both intervention groups compared to the waitlist group. Additionally, results indicate that the intervention group with parent training had significantly better outcomes than did the intervention group with no parent training. Conclusions/Recommendations Sofronoff et al. (2005) comment that an interesting phenomenon in their study was that many instances of significant change occurred at follow up instead of what one would expect to see. Specifically, that there is often immediate change directly after intervention compared to before intervention. The authors did report some significant changes post intervention but much more at follow up. They postulate that this may be due to more time needed to internalize the treatment strategies before parental reports indicate significant change. Another conclusion the authors

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came to was that children who showed significantly more coping strategies needed to have better generalization skills. Children whose parents received training and support did significantly better on the James and the Maths Test. Not surprisingly, involving the parents in treatment strategies greatly improved results. Finally, parents approved of the intervention program. Sofronoff et al. (2005) recommend that future research include direct measurement of participants behaviours as well as parent report and that the potential for parents anxiety affecting their children be looked at.

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Sofronoff, K., Attwood, T., Hinton, S., & Levin, I., (2007). A randomized controlled trial of a cognitive behavioural intervention for anger management in children diagnosed with Asperger syndrome. Journal of Developmental Disorders, 37, 1203-1214. Purpose Kate Sofronoff and her colleagues (2007) wanted to find out if Cognitive Behaviour Therapy (CBT) would improve anger management skills in youth with Asperger Syndrome (AS). Participants Sofronoff et al. (2007) recruited 52 children, aged 10 to 14 years old, who all had a diagnosis of AS for their study. To corroborate the parental report of the diagnosis, the Childhood Asperger Syndrome Test (CAST) was administered. Seven participants were lost to attrition or not meeting the diagnostic criteria, leaving a total of 45 participants. Parent and child interviews were used to gather information on anger management skills, or lack thereof. Research Design and Procedures Participants were randomly assigned to the intervention group or the waitlist group. The intervention group comprised of pairs of children with two therapists who took them through 6 2-hour session of CBT. Additionally, parents were set up in two groups and concurrently went through the intervention materials with therapists. Waitlist families were assessed at the same times as the intervention groups but did not complete the intervention program until after the intervention group. Measures: Dylan is being Teased test done pre, post intervention and at 6-week follow-up. o Participants asked to come up with anger management strategies for Dylan.

RESEARCH ARTICLE SUMMARY What Makes me Angry questionnaire o Source for child identified issues to be used in group contexts Parent tracking of childs angry outburst for one week at pre, post intervention and follow-up Parent report of confidence in dealing with childs anger outburst Parent report of childs confidence in dealing with their own anger Children Inventory of Anger Parent version (ChIA-P)

o Adapted from the original ChIA (Nelson and Finch, 2000) that measures various aspects of a childs experience of anger (Sofronoff et al., 2007). Qualitative reports o Parent: had they noticed change in their childrens anger and if they felt the program had been helpful? o Teacher: had they noticed any behavioural changes in students due to participation in the program? Results Participants in the intervention group generated significantly more anger management strategies on the Dylan is being Teased test than waitlist group did post intervention. This group also generated significantly more anger management strategies post intervention than they did at pre treatment and they maintained them at 6-week follow-up. Parents in the intervention group reported a significant decrease in frequency of angry outbursts at post intervention and follow-up when compared to waitlist group. These parents also reported a significant decrease in frequency of angry outbursts at post intervention compared to pre intervention and this effect was maintained at follow-up. Similar significant findings were reported for parental confidence in their ability to manage outbursts and their confidence in their childs ability to deal with their own anger. Intervention group scores from the ChIA-P described significant decreases in anger over the length of the study and with regard to frustration and authority relations subscales.

RESEARCH ARTICLE SUMMARY Conclusions/Recommendations Sofronoff et al. (2007) comment that the scores from the Dylan is being Teased measure constitute evidence of generalization of the skills learned in intervention. Their findings add

weight to other research indicating that CBT is an effective treatment for youth with AS and that parental involvement continues to be shown to be an important, critical component of any intervention using best practices. Sofronoff and her colleagues (2007), report that it was evident that families now had a common language with which to talk about their emotions on a day-today basis. Teachers described similar outcome and that they had noticed some generalization of learned skills to the school environment. The authors recommend training for generalization in specific environments like school and home and attempting to collect more data for replication purposes.

RESEARCH ARTICLE SUMMARY Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A., (2009). Cognitive behavioural therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224-234. Purpose Wood et al. (2009) wanted to test their hypothesis that a modified version of CBT specifically geared to children with Autism would significantly decrease anxiety levels compared to waitlist participants. Participants Jeffrey Wood and his colleagues (2009) recruited 40 children, aged 7 to 11 years old for their

study. The children in this sample all had an Autism Spectrum Disorder (ASD) diagnosis as well as an anxiety disorder. ASD included Autism, Asperger syndrome and PDD-NOS. Anxiety disorders included separation anxiety, social phobia or obsessive-compulsive disorder. Research Design and Procedures Participants were randomly assigned to an immediate treatment condition or a 3-month waitlist. The immediate treatment condition involved a CBT program modified to fit the needs of children with autism. The intervention consisted of 16 weekly sessions of child and parent training based on the Building Confidence CBT program developed by Wood and McLeod (2008). Anxiety measures were conducted pre and post intervention and at 3-month follow up by independent evaluator blind to treatment conditions. Participants completed the Anxiety Disorders Interview Schedule for DSM-IV Child and Parent versions Clinical Severity Rating scale (ADIS-C/P

RESEARCH ARTICLE SUMMARY CSR), the Clinical Global Impression-Improvement Scale (CGI-I) and the Multidimensional Anxiety Scale for Children (MASC). Results Participants in the immediate treatment group scored significantly better than waitlist group at

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post treatment on the ADIS-C/P CSR and the CGI-I. Interestingly, scores from the parent report of the MASC showed a significant difference between the immediate treatment group and the waitlist group at post intervention but there was no significant difference on the child report. Finally, maintenance of treatment effects was evident at 3-month follow up. Conclusions/Recommendations Wood et al. (2009) comment that CBT interventions modified to fit the needs of children with ASD can be effective treatments for anxiety. They also remind the reader of the benefits of having the parents/caregivers and teachers involved in the intervention process and that to do this it is necessary to expand the scope of the intervention setting out from the clinic and into the childs natural environments (home and school). Wood et al. (2009) suggest that it would be necessary to replicate the study by independent researchers to give weight to the validity of their intervention manual. Finally, they recommended that in future studies data be collected on participant families treatment implementation fidelity. Summary The three articles I chose to review all involved the use of Cognitive Behavioural Therapy to improve the lives of children on the Autism Spectrum. It was fascinating to read these articles and discover their many similarities and differences. With regard to their participants, Sofronoff et al. (2005, 2007) specifically identified children with Asperger Syndrome whereas Wood et al.

RESEARCH ARTICLE SUMMARY (2009) had a variety of children on the Autism spectrum (autism, Aspergers and PDD-NOS)

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participate in their study. The ages of the participants in all three studies were somewhat similar in that Sofronoff et al. (2005, 2007) had 10-12/14 year olds whereas Wood et al. (2009) had slightly younger participants, aged 7-11 years old. From a procedural or methodological perspective, all three studies randomly assigned participants to conditions and used a waitlist as their control condition. They also all relied heavily on parental report measures although both Sofronoff et al. (2005, 2007) studies included one direct observation measure where children had to come up with positive coping strategies to deal with an anxiety or anger-provoking situation. The Wood et al. (2009) study relied exclusively on rating scales to score the dependent variable. Anxiety was the dependent variable for the Sofronoff et al. (2005) and Wood et al. (2009) studies whereas Sofronoff and colleagues (2007) had anger management as their dependent variable. Both Sofronoff et al. (2005, 2007) studies took extra steps to confirm an Asperger syndrome diagnosis (CAST) whereas the Wood et al. (2009) study made no such efforts. A methodological strength of the Wood et al. (2009) study was that they used blind, independent evaluators to assess their participants. Another way the Wood et al. (2009) study stood out was that their participants received twice as many treatment hours as either of the Sofronoff et al. (2005, 2007) studies. One way the Sofronoff et al. (2005) study distinguished itself was to enquire specifically if there would be a difference between whether children would do better with or without parental involvement in treatment. The results from this comprehensive enquiry in 2005 greatly influenced the later studies in 2007 and 2009 to include parents in the intervention protocols of those studies and who subsequently demonstrated similar results that parental involvement is very beneficial. To continue with outcome comparisons, all three studies had difficulty measuring child report of their emotions. All three studies found that CBT was successful at

RESEARCH ARTICLE SUMMARY improving the lives of children on the Autism spectrum by teaching them coping strategies to deal with anxiety and anger issues. They also reported some generalization and maintenance at follow up.

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As a youth counselor working with adolescents admitted to an inpatient mental health facility, I could use the information from these studies to provide better support for the patients with autism that enter our facility. I now have a treatment protocol structure and common language to reference when consulting with expert service providers of CBT for children with autism. I will be able to advocate for an evidence-based treatment that has shown good results to the multidisciplinary team I work on. I will be able to encourage and foster parental involvement in the treatment. The results of these studies indicate that parental involvement is generally beneficial. However, it is often the case that the anxiety level and/or the anger management skills, or lack thereof, of the parents have a strong impact and interaction on their children. Future research to explore this impact and interaction would be very informative. Each of these three studies requires replication to strengthen the validity of their findings. They all have slightly different content in their intervention packages. It would be very helpful if future research could illuminate critical components of an intervention package that was beneficial to all children with Autism.

RESEARCH ARTICLE SUMMARY References Nauto, M. H., Scholing, A., Rapee, R. M., Abbott, M., Spence, S. H., & Waters, A. (2004). A parent-report measure of childrens anxiety: Psychometric properties and comparison with child-report in a clinic and normal sample. Behaviour Research and Therapy, 42, 813-839. Sofronoff, K., Attwood, T., Hinton, S. (2005). A randomized controlled trial of a CBT intervention for anxiety in children with Asperger syndrome. Journal of Child Psychology and Psychiatry, 46, 1152-1160. Sofronoff, K., Attwood, T., Hinton, S., & Levin, I., (2007). A randomized controlled trial of a cognitive behavioural intervention for anger management in children diagnosed with Asperger syndrome. Journal of Developmental Disorders, 37, 1203-1214. Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A., (2009). Cognitive behavioural therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224-234.

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