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Who responds to cognitive-behavioral group treatment

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Who responds to cognitive-behavioral group treatment associations between anxiety symptom reduction and autism symptom domains
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Associations between anxiety symptom reduction and autism symptoms
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Schoultz, Peter ( author )
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Cognitive therapy ( lcsh )
Anxiety disorders ( lcsh )
Autism spectrum disorders ( lcsh )
Anxiety disorders ( fast )
Autism spectrum disorders ( fast )
Cognitive therapy ( fast )
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Across the country, the prevalence rate of autism spectrum disorder (ASD) is rising, and since anxiety disorders are more likely to occur in children with ASD than in the general population, the rates of children with ASD and a co-occurring anxiety disorder are rising as well. While there is evidence that cognitive-behavioral therapy (CBT) is effective for reducing anxiety symptoms in some children with ASD, little is known about which children are the best candidates for this treatment. Understanding the characteristics of treatment responders is helpful in determining who could benefit from group intervention. The current study examines associations between autistic traits as defined by scores on the Social Responsiveness Scale (SRS) and reduction in anxiety symptoms for children with ASD who received a group CBT intervention, Facing Your Fears. This is a secondary analysis of data collected as part of larger studies examining the effects of the Facing Your Fears intervention. It was hypothesized that there will be a negative correlation between the change in parent-reported child anxiety and severity of social awareness, social motivation, and social cognition; such that children with less social impairment will show greater reduction of anxiety symptoms after group treatment. Fifty-seven youth, ages 8-18, met inclusion criteria for this study. Results indicate a significant positive correlation between impairment in social motivation and anxiety symptom reduction (rs = .36, p = .007); suggesting that strengths in social motivation are not required for group CBT to be effective. Results also indicate a trend towards significance for positive correlations between anxiety symptom reduction and impairments in social cognition (rs = .23), as well as autistic mannerisms (rs = .29), and the overall total autistic social impairment (rs = .27). No significant correlations were found between anxiety symptom reduction and impairments in social awareness or social communication. The results of this study suggest that social impairment does not preclude readiness for a structured, group treatment for youth with ASD. Contrary to the hypothesis, even if a parent reports that his/her child is not socially motivated, group treatment may be beneficial. Further implications, limitations, and future directions are discussed.
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Thesis (Psy.D.)-University of Colorado Denver.
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by Peter Schoultz.

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Full Text
WHO RESPONDS TO COGNITIVE-BEHAVIORAL GROUP TREATMENT?
ASSOCIATIONS BETWEEN ANXIETY SYMPTOM REDUCTION AND AUTISM
SYMPTOM DOMAINS
by
PETER SCHOULTZ
B.A., University of Miami, 2008
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado in partial fulfillment
of the requirements for the degree of
Doctor of Psychology
School Psychology Program
2016


This thesis for the Doctor of Psychology degree by
Peter Schoultz
has been approved for the
School Psychology Program
by
Franci Crepeau-Hobson, Chair
Bryn Harris
Colette Hohnbaum
Date: April 25, 2016
11


Schoultz, Peter (PsyD, School Psychology)
Who Responds to Cognitive-Behavioral Group Treatment? Associations between Anxiety
Symptom Reduction and Autism Symptom Domains
Thesis directed by Associate Professor Franci Crepeau-Hobson
ABSTRACT
Across the country, the prevalence rate of autism spectrum disorder (ASD) is rising, and
since anxiety disorders are more likely to occur in children with ASD than in the general
population, the rates of children with ASD and a co-occurring anxiety disorder are rising as
well. While there is evidence that cognitive-behavioral therapy (CBT) is effective for
reducing anxiety symptoms in some children with ASD, little is known about which children
are the best candidates for this treatment. Understanding the characteristics of treatment
responders is helpful in determining who could benefit from group intervention. The current
study examines associations between autistic traits as defined by scores on the Social
Responsiveness Scale (SRS) and reduction in anxiety symptoms for children with ASD who
received a group CBT intervention, Facing Your Fears. This is a secondary analysis of data
collected as part of larger studies examining the effects of the Facing Your Fears
intervention. It was hypothesized that there will be a negative correlation between the change
in parent-reported child anxiety and severity of social awareness, social motivation, and
social cognition; such that children with less social impairment will show greater reduction
of anxiety symptoms after group treatment. Fifty-seven youth, ages 8-18, met inclusion
criteria for this study. Results indicate a significant positive correlation between impairment
in social motivation and anxiety symptom reduction (rs = 36, p = .007); suggesting that
strengths in social motivation are not required for group CBT to be effective. Results also
indicate a trend towards significance for positive correlations between anxiety symptom


reduction and impairments in social cognition (rs = .23), as well as autistic mannerisms (rs =
.29), and the overall total autistic social impairment (rs = .27). No significant correlations
were found between anxiety symptom reduction and impairments in social awareness or
social communication. The results of this study suggest that social impairment does not
preclude readiness for a structured, group treatment for youth with ASD. Contrary to the
hypothesis, even if a parent reports that his/her child is not socially motivated, group
treatment may be beneficial. Further implications, limitations, and future directions are
discussed.
The form and content of this abstract are approved. I recommend its publication.
Approved: Franci Crepeau-Hobson
IV


ACKNOWLEDGEMENTS
I would like to recognize Judy Reaven, Susan Hepburn, & Audrey Blakeley-Smith for their
support in the research, as well as JFK Partners and the families that participated in the study.
I would also like to acknowledge the grants the research was funded by, and the grants that
funded my position at JFK Partners.
Association of University Centers on Disabilities (AUCD) UCD ACF-DHHS
90DD0699/010
Leadership Education in Neurodevelopmental and Related Disabilities (LEND) -
2T73MC11044-04-000
National Institutes of Health (NM) 1R21MH089291-01; 4R33MH089291-03
Autism Speaks
v


TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION...........................................................1
Problem and Significance................................................1
Research Questions and Hypotheses.......................................1
II. LITERATURE REVIEW.....................................................3
A Brief History of Autism...............................................3
Autism: 1943-2013................................................3
Current Diagnostic Criteria......................................4
Prevalence of Autism Spectrum Disorder...........................4
Anxiety Disorders.......................................................4
Anxiety Treatment.......................................................5
Treatments for Anxiety for Children with ASD............................6
Modified Coping Cat..............................................6
Behavioral Interventions for Anxiety in Children with Autism (BIACA).6
Facing Your Fears................................................7
Analysis of Treatment Groups.....................................7
III. METHOD...............................................................9
Data Collection.........................................................9
Participants and Measures...............................................9
Social Responsiveness Scale.....................................10
Screen for Child Anxiety Related Emotional Disorders........... 10
IV. RESULTS..............................................................12
vi


V. DISCUSSION AND FUTURE DIRECTIONS
15
Discussion..........................................................15
Future Directions...................................................15
REFERENCES................................................................17
vii


CHAPTER I
INTRODUCTION
Problem and Significance
According to the Centers for Disease Control and Prevention, the prevalence of
autism spectrum disorders (ASD) has continued to rise, with current estimates of 1 in 68
children in the United States meeting the diagnostic criteria of this disorder (CDC, 2014).
While this statistic in itself is alarming, children with ASD are more likely to have a co-
occurring anxiety disorder than children in the general population (Kim, Szatmari, Bryson,
Streiner, & Wilson, 2000). An anxiety disorder can negatively impact the lives of the
individual and their families across a variety of settings (Russell & Sofronoff, 2005). In
addition, the symptoms of anxiety can impact peer relationships and academic performance
in school (Reaven, 2008). However, cognitive-behavioral therapy (CBT) for anxiety
disorders has been shown to be effective for children (Velting, Setzer, & Albano, 2004) and
modified approaches for children with ASD has been shown to be effective for reducing
anxiety symptoms in some children as well (Reaven et al., 2012; Storch et al., 2013).
Delivery for these treatments differs by study; some are delivered individually, some in a
group format. Approximately 50-93% of children with ASD benefit from CBT (regardless of
modality), as defined by marked reductions in parent-reported anxiety symptoms (Storch et
al., 2013). Little is known about who the best candidates for CBT are, especially when the
treatment is delivered in a group context. Understanding the characteristics of treatment
responders is helpful in determining who could benefit from group intervention.
1


Research Questions and Hypotheses
The goal of this study is to examine the associations between anxiety symptom
reductions observed through participation in a multi-family group CBT intervention (Facing
Your Fears; Reaven et al., 2011) and quantitative autistic traits as defined by domain scores
on the Social Responsiveness Scale (SRS; Constantino, 2002). It is hypothesized that there
will be a negative correlation between the change in parent-reported child anxiety and
severity of social awareness, social motivation, and social cognition; such that children with
less social impairment will show greater reduction of anxiety symptoms after group
treatment.
2


CHAPTER II
LITERATURE REVIEW
A Brief History of Autism
Autism: 1943-2013
The first cases of autism were described by Kanner in his 1943 publication Autistic
Disturbance of Affective Contact. In this paper, he described 11 children who appeared
physically normal but preferred to be alone and had an unusual insistence on sameness.
Shortly after Kanner, Dr. Hans Aspergers 1944 work described four boys who all had
difficulty with social interaction, but had at least average intelligence and verbal abilities
(Klin, 2000). He referred to these boys as little professors due to their abilities to talk at
great length about a preferred topic (Klin, 2000). Over the next half century, these disorders -
described using the terms autism, infantile autism, childhood schizophrenia, Aspergers, and
autistic disorder vary in nomenclature, etiology, and diagnostic criteria. Then in 1994, the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) combined
all of these related disorders under the umbrella of Pervasive Developmental Disorders
(American Psychiatric Association, 1994). This umbrella included the separate disorders
Autistic Disorder, Asperger Syndrome, and another category for those who did not meet
criteria for either of those two, called Pervasive Developmental Disorder Not Otherwise
Specified (PDD-NOS) (American Psychiatric Association, 1994). Having separate
diagnoses for similar disorders led to inconsistency in diagnosis across diagnostic settings
(American Psychiatric Association, 2013a). This in part led to the creation of a single
disorder, called Autism Spectrum Disorder in the next DSM update, DSM 5 (American
Psychiatric Association, 2013b).
3


Current Diagnostic Criteria
Autism Spectrum Disorder is now defined by the presence of symptoms in two
categories: deficits in social communication and interaction, and restricted interests and/or
repetitive behavior (American Psychiatric Association, 2013b). Details within each of these
categories are examples listed as illustrative not exhaustive, which allows for a broad
variety of symptoms within a single diagnosis. Further, the DSM 5 states that an autism
spectrum disorder can exist with or without an accompanying intellectual impairment and
with or without an accompanying language impairment.
Prevalence of Autism Spectrum Disorder
There has been much debate about why there has been such an increase in reported
cases of autism spectrum disorder in the United States, but there is very little argument that
the prevalence rates have increased dramatically. Original estimates considered autism to be
rare, with prevalence around 2-4 in 10,000 (Wing & Potter, 2002). According to the Autism
and Developmental Disabilities Monitoring Network (ADDM) at the Centers for Disease
Control and Prevention (CDC), the estimated prevalence rate in 2010 was 1 in 68 children
(CDC, 2014). While a 1998 article suggested this increase may be caused by vaccines
(Wakefield, 1998), this was later retracted by the journal (Wakefield et al., 2000). Since
then, there have been many hypotheses regarding the real cause of the rise of the diagnosis,
but some suggest that a large proportion of the growth is due to a broadening of the
diagnostic criteria and the increased awareness of autism in society (Wing & Potter, 2002).
Anxiety Disorders
In the DSM 5, Anxiety Disorders is a larger category that has many specific
disorders that fall under it (American Psychiatric Association, 2013b). All of these disorders
4


consist of excessive fear or anxiety, and include disorders such as Separation Anxiety
Disorder, Selective Mutism, and Social Anxiety Disorder, as well specific phobias and
the broader Generalized Anxiety Disorder. Anxiety disorders are one of the most common
disorders among children, with studies estimating that anywhere from 8 to 20% of the
population would meet diagnostic criteria for at least one anxiety disorder (Spence, 1998;
Velting, Setzer, & Albano, 2004).
Anxiety Treatment
There has been a large body of research investigating the effects of cognitive-behavioral
therapy (CBT) for people with anxiety. A meta-analysis conducted by Covin and colleagues
built on previous research (Westen & Morrison, 2001), but applied a more stringent criteria
that also showed that CBT was effective in reducing worry for people with generalized
anxiety and was more effective for younger populations (Covin, Ouimet, Seeds & Dozois,
2008). Velting and her colleagues (2004) go as far to say that when discussing CBT, there
are no well-controlled, systematic studies attesting to the acute and long-term efficacy of any
other psychosocial treatment modality for anxiety disorders in youth (p. 48), and cite many
other studies supporting the efficacy of CBT for children with anxiety (Kazdin & Weisz,
1998; Ollendick & King, 1998). When looking specifically at social phobia, separation
anxiety, and generalized anxiety disorders (identified to be common anxiety disorders in
children), Velting et al. identify six crucial components of effective CBT: psychoeducation,
somatic management, cognitive restructuring, problem solving, exposure, and relapse
prevention. One of the most well-known and studied manualized treatments for children with
anxiety is Coping Cat (Kendall, Kane, Howard, & Siqueland, 1990). While meeting all six
5


components identified by Velting et al., Coping Cat has also been shown to be effective for
diverse populations of children and settings (Albano & Kendall, 2002).
Treatments for Anxiety for Children with ASD
While the prevalence rates of autism spectrum disorder continue to rise and up to
20% of children could meet criteria for an anxiety disorder, it is even more alarming that
children with autism spectrum disorder are more likely to have a co-occurring anxiety
disorder than children in the general population (Kim, et al., 2000). Given this, and the fact
that children with autism spectrum disorders learn differently, anxiety treatment programs for
children with autism need to be created and/or existing programs need to be modified.
Modified Coping Cat
One research team, led by McNally Keehn, modified the Coping Cat curriculum
(Albano & Kendall, 2002) to make the intervention more accessible for children with ASD
(McNally Keehn, Lincoln, Brown & Chavira, 2012). Some of the modifications included
longer sessions, increased visual supports, using more concrete language, sensory breaks as
needed, and individualized reinforcement strategies. Results from the randomized control
trial (RCT) 16-week intervention indicated children who received the intervention had a
greater reduction in anxiety symptoms when compared to a control group, and that these
differences were maintained two months later.
Behavioral Interventions for Anxiety in Children with Autism (BIACA)
Storch and his colleagues created a program based on the Building Confidence
Program (Wood, Piacentini, Southam-Gerow, Chu & Sigman, 2006) that they called
Behavioral Interventions for Anxiety in Children with Autism, or BIACA (Storch, et al.,
2013). This program also made ASD-specific modifications based on the individual childs
6


needs, including: repetition of previous information, token economies, social skills and
adaptive skills training, and in vivo coaching. BIACA also has a strong parent component,
where parents focus on separate topics than the children. Results from the Storch et al. RCT
were also positive: the treatment group showed significant improvement in anxiety symptom
severity when compared to the control group both at post-treatment and three-month follow-
up time points.
Facing Your Fears
Reaven and her colleagues developed Facing Your Fears specifically for children
with autism spectrum disorders, but based the program on other evidence-based treatments
for anxiety like Coping Cat (Reaven, Blakeley-Smith, Culhane-Shelburne & Hepburn, 2012).
Their modifications include: a token reinforcement system, hands-on activities, and video-
modeling. There is also a separate parent and child component to this intervention. The
Reaven et al. RCT also yielded encouraging results, with significantly greater reduction in
anxiety symptoms compared to the treatment as usual group.
Analysis of Treatment Groups
The results of the above RCTs for treating anxiety with CBT for children with ASD
all indicated a significant reduction in reported anxiety symptoms. The publications about the
RCTs did not offer any information regarding which participants assigned to the intervention
conditions responded better than others. While all participants in BIACA did complete the
Social Responsiveness Scale (SRS; Constantino, 2002), the questionnaire was used as an
outcome measure (e.g., the effects of treatment on autism symptoms). Reaven and her
colleagues did examine treatment response for Facing Your Fears participants, but chose to
look specifically at parental anxiety as a factor affecting child response to treatment (Reaven
7


et al., 2015). Storch et al. also examined treatment response for participants, but examined
hoarding behavior as a factor (Storch et al., 2016). Neither Reaven nor Storch found
significant correlations.
8


CHAPTER III
METHOD
Data Collection
This is a secondary analysis of data collected as part of two larger studies examining
the efficacy of Facing Your Fears, a multi-family CBT intervention targeting anxiety in
youth with high-functioning ASD. As a secondary analysis, approval from the Institutional
Review Board (IRB) was not required. The original studies however, did obtain IRB
approval for working with human subjects. Cohorts were divided by age and two separate
developmentally-appropriate manuals were created. Both manuals include critical
components of CBT (e.g., graded exposure, somatic management, cognitive self-control, and
a focus on improving emotion regulation). Modifications to the 14-week treatment were
made to meet the cognitive, linguistic, and social needs of youth with ASD, in line with
previous recommendations (Moree & Davis, 2010; Reaven et al., 2009). Inclusion criteria for
these analyses were: data completeness, timeliness of data collection (i.e., within 3 months of
starting treatment and within 4 months of completing), and attendance (i.e., 3 or fewer
absences).
Participants and Measures
Fifty-seven youth, ages 8-18 (M= 12.49, SD = 2.74), with confirmed Autism
Spectrum Disorder (ASD) and their parents met eligibility criteria for this study. Additional
inclusion criteria were a near average verbal intelligence quotient (IQ) and clinically
significant symptoms of anxiety. For participants with a verbal IQ under 80, the clinicians
evaluated the participants on a case by case basis to determine appropriateness of the
intervention. Parents completed the Social Responsiveness Scale (SRS) and the Screen for
9


Child Anxiety Related Emotional Disorders (SCARED; Birmaher et al., 1997) before
treatment and then completed the SCARED again at post-treatment.
Social Responsiveness Scale
The Social Responsiveness Scale (SRS) is a 65-item parent-report questionnaire that
covers the various dimensions of interpersonal behavior, communication, and
repetitive/stereotypic behavior that are characteristic of ASD. It has five treatment subscales,
Social Awareness, Social Cognition, Social Communication, Social Motivation, and Autistic
Mannerisms. These five scales combine to create an overall Total Autistic Impairment index.
Social awareness, or the ability to pick up on social cues, includes items examining
awareness of others and their feelings, as well as ones role in interacting with others. Social
cognition, or the ability to interpret social cues once they are picked up, includes items
examining the ability to understand the intent of others and insight into ones own social
thinking. Social communication, or ones expressive social communication in a reciprocal
setting, includes items examining conversational skills, relating to peers and adults, and
communicating with others in an appropriate manner. Social motivation, or the extent to
which one is generally motivated to engage in social-interpersonal behavior, including social
anxiety and inhibition, includes items examining ones desire to interact with others as well
as ones feelings during social interactions. Autistic mannerisms include stereotypical
behaviors or highly restricted interests characteristic of ASD. All scores are reported as
reported as '/'-scores, with 59 and below within normal limits.
Screen for Child Anxiety Related Emotional Disorders
The Screen for Child Anxiety Related Emotional Disorders (SCARED) consists of
both a parent-report and a self-report version; however, only the parent report was used for
10


this analysis. It is a 3-point Likert scale, 41-item questionnaire that is used as a screening tool
for anxiety disorders in children. It has 5 subscales that correspond to specific anxiety
disorders (e.g., separation anxiety disorder, social phobia) as well as a total score. While
scores on the SCARED are not standardized, each of the responses to the 41 items receives a
score of 0, 1, or 2, and total scores of 25 or greater may indicate the presence of an anxiety
disorder. There are separate cutoff scores for each of the subscales.
11


CHAPTER IV
RESULTS
A lack of normality in the distribution of the sample was observed, thus Spearmans
rho was used to examine correlations. Results indicate a significant positive correlation
between impairment in social motivation and anxiety symptom reduction (rs = 36, p = .007);
suggesting that strengths in social motivation are not required for group CBT to be effective.
No significant correlations were found between anxiety symptom reduction and impairments
in social awareness or social communication. Results of correlational analyses are presented
in Table 1.
Table 1
Descriptive Statistics and Correlations for Social Responsiveness Scale (SRS) Scores and
Screen for Child Anxiety Related Emotional Disorders (SCARED) Scores
Standard Change in Significance
Mean Deviation SCARED rs O <-0i)
Change in SCARED 12.43 11.65
SCARED Baseline 33.42 14.00
SCARED Post-Treatment 20.98 11.04
SRS Social Awareness 71.28 10.62 -.003 .492
SRS Social Cognition 78.37 11.03 .229 .043
SRS Social Communication 79.58 11.13 .174 .098
SRS Social Motivation 76.19 12.98 .355* .003*
SRS Autistic Mannerisms 85.30 12.76 .291 .014
SRS Total Autistic Impairment 82.30 9.31 .269 .022
* Significant at the p <.01 level
12


Results also indicate a trend towards significance for positive correlations between anxiety
symptom reduction and impairments in social cognition (rs= .23), as well as autistic
mannerisms (rs = .29), and the overall total autistic social impairment (rs = .27). See Figures
1 and 2 for these results.
40
Figure 1. Relationship between SRS Motivation scores and change in SCARED scores
13


Change in SCARED Score
40
30
20
10
-10
20
40
60
80
100
Linear (Social Motivation)
Linear (Social Cognition)
Linear (Social Awareness)
Linear (Social Communication)
^-Linear (Autistic Mannerisms)
Linear (Total Autistic Impairment)
-20
-30
SRS 7-scores
Figure 2. Linear trend lines for the relationship between SRS scores and change in SCARED
scores
14


CHAPTER V
DISCUSSION AND FUTURE DIRECTIONS
Discussion
The prevalence of autism spectrum disorder (ASD) has increased dramatically in
recent years (CDC, 2014). Previous research has indicated that children with ASD are more
likely to have a co-occurring anxiety disorder than the general population (Kim, et al., 2000).
Research has also demonstrated that cognitive behavior therapy (CBT) is an effective
treatment for anxiety in youth in general (Covin, Ouimet, Seeds & Dozois, 2008), and for
those with ASD (McNally et al., 2012). However, it is not clear if CBT is more or less
effective for individuals with various symptoms of traits of ASD. The purpose of this study
was to examine the relationship between quantitative autistic traits and response to anxiety
treatment. It was hypothesized that results would demonstrate that children with less social
impairment would show a greater reduction of anxiety symptoms after group treatment. This
hypothesis was not supported: even if a parent reported that his/her child was not socially
motivated, group treatment appeared to be beneficial. In fact, results of the present study
suggest that group CBT for anxiety may be more beneficial for those with less social
motivation or greater social impairment in general. One possible reason for this may be that
children with less social impairment may be more self-conscious, and thus less willing to
fully commit to the group treatment. Overall, the results of this study suggest that social
impairment does not preclude readiness for a structured, group anxiety treatment for youth
with ASD.
15


Future Directions
Future research should be geared towards examining these relationships in larger
samples to examine generalizability of findings. Also, using more rigorous measurement
tools to assess anxiety (e.g., ADIS-C/P; Silverman & Albano, 1996) and/or other methods of
social impairment beyond parent report (e.g., ADOS-2; Lord, et al. 2012) would increase the
overall validity of these findings. Further examination into different youth characteristics that
may influence treatment response (e.g., executive functioning) would also be beneficial to
research in this area. Given the wide spectrum of abilities, symptoms, and behaviors
exhibited by children with ASD, it is unreasonable to assume that there is any one size fits
all treatment plan for reducing anxiety. In addition, given the limited resources available for
this specialized treatment, it behooves the research community to further investigate what
factors indicate a positive response to treatment.
16


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