Parents’ Perceptions of Anxiety Treatment for Autistic Children

PROTOCOL: Cognitive‐Behavioural Therapies for Young People in Outpatient Treatment for Non‐Opioid Drug Use

Autism spectrum disorder is a developmental disability affecting individuals across their entire lifespan. Autistic individuals have differences from nonautistic people (sometimes called allistic or neurotypical people) in social skills, communication, and atypical interests and/or repetitive behaviors. Applied behavior analysis is one of the first and most common interventions recommended for autistic children. However, autistic individuals argue that applied behavior analysis damages their mental health and treats them as though they are a problem to be fixed. This study examined the experiences of seven autistic individuals who received applied behavior analysis interventions as children to understand what autistic adults think about their applied behavior analysis interventions, how they feel about the applied behavior analysis interventions they received, and what recommendations autistic adults have for the future of applied behavior analysis. The findings include: Autistic adults remember traumatic events from applied behavior analysis, do not believe that they should be made to behave like their peers, gained some benefits but suffered significant negative long-term consequences, believe that applied behavior analysis is an unethical intervention, and recommend that applied behavior analysis practitioners listen to autistic people and consider using interventions in place of applied behavior analysis.

Intervention programs based on applied behavior analysis (ABA) are currently viewed as the first line treatment for autism spectrum disorder (ASD) in early childhood (Vismara and Rogers 2010). Apart from beneficial effects on a group level, studies have consistently shown large variation in individual gains. Several factors have been suggested to explain this differential response, including child characteristics, intensity of training and level of trainer fidelity to the protocol. Despite scientific evidence, ABA treatment methods as well as goals remain controversial. The structured nature of the intervention program and use of reinforcers can be uncomfortable for parents and trainers in pre-schools. Previous psychotherapy research in adults has shown that therapist allegiance to treatment techniques is linked to the gains achieved (McLeod 2009). It is not unlikely that trainer allegiance to ABA treatment, and thus fidelity to the treatment protocol, is a crucial mediator of ABA efficacy and treatment outcome variation, respectively. To examine the hypothesis that the level of allegiance of trainers is important for ABA treatment gains in preschoolers, a pilot study of 24 children with ASD was conducted. Children were consecutively recruited from a larger ongoing ABA intervention follow-up study in Stockholm county (for details see Fernell et al. 2010) covering all children diagnosed with ASD by psychiatric outpatient departments before the of age 5 years and treated with ABA. Children included in the present pilot-study had received intensive ABA (30 h/week) for 2 years. Two children had been a priori excluded from the sample: the parents of one child declined participation; another child was not included due to a new diagnosis of Rett’s syndrome. Of remaining 24 children (20 boys and 4 girls, age range 2.5–5 years at intake), 19 had autistic disorder, 4 had PDDNOS and one had Asperger’s syndrome. One child had fragile X and one tuberous sclerosis with epilepsy. According to an evaluation of existing test results in records, nine had mental retardation, 12 had uncertain or borderline intellectual functioning, and 3 had normal IQ. Children scored at a mean of 69.9 on the composite score from Vineland Adaptive Behavior Scales (VABS, Sparrow et al. 2005; which includes norm data used) and 49.0 on the Autism Behavior Checklist, above the recommended cutoff of 45 points (Nordin and Gillberg 1996). Thus, this sample may have been representative of the larger group from the follow-up study, who, in turn, can be considered representative of all children receiving an ASD diagnosis in Stockholm (for discussion, see Fernell et al. 2010). For the assessment of treatment outcome, the children’s parents completed the VABS pre and post 2 years of intensive ABA treatment. The 24 children all had one preschool trainer each. These trainers were all employed at the kindergartens and worked exclusively with the child in the study. They were L. Klintwall (&) Akershus University College, P.O.Box 423, 2001 Lillestrom, Norway e-mail: lars.klintwall@hiak.no

Management of Premenstrual Syndrome: Green-top Guideline No. 48.

Neural mechanisms and predictors of SSRI and CBT treatment of anxiety: A randomized trial focused on emotion and cognitive processing

Social-communicative abilities and theory of mind (ToM) are crucial for successful social interactions. The developmental trajectories of social and communicative skills characterizing individuals with Autism Spectrum Disorder (ASD) are rather complex and multidimensional, including components related to theory of mind. Due to its mentalistic nature, theory of mind has been rarely addressed as an outcome for Applied Behavior Analysis (ABA) intervention in children and adolescents with ASD. However, there is evidence that ABA intervention might be effective in promoting social abilities in individuals with ASD. Thus, this topic is worth investigating. We present a systematic review to explore the Ins and Outs of an ABA approach to promote social and communicative abilities and ToM in children and adolescents with ASD. We applied a PRISMA checklist to consider studies published up to December 2024. The keywords that we used were ToM, perspective-taking, false belief, social cognition, and mental states, in combination with ABA intervention and ASD (up to age 18). We searched for studies using Scopus, Google Scholar, and Medline. We included twenty studies on perspective-taking, identifying emotions, helping, detecting eye gazing, and social engagement, reviewing fifteen dedicated to teaching the interpretation of mental states (involving 49 children and 10 adolescents). The ToM was addressed with a multiple baseline design on target behaviors associated with ToM components such as identifying emotion, helping behaviors, and mental states. The intervention included a behavioral package consisting of Behavioral Skill Training, Derived Relations, video modeling, and role playing. The results indicated a significant number of participants who followed ABA intervention to promote social abilities and mastered the target behavior in ToM tasks; however, they showed maintenance and generalization issues across trials and settings. The role of predictors was highlighted. However, the studies are still rare and exhibit specific methodological limitations, as well as some clinical and ethical considerations. More research is needed to define best practices in ABA intervention to promote social abilities in individuals with ASD.

Pediatric obsessive-compulsive disorder (OCD) is characterized by recurrent obsessions and compulsions. In this review we depict evidence-based treatments for pediatric OCD patients. We searched PubMed for relevant publications including randomized controlled trials, reviews, and expert guidelines. Substantial evidence for cognitive behavior therapy (CBT) and specific serotonin reuptake inhibitors (SSRIs) among treatment-naïve patients shows that both treatments are effective. CBT is significantly more effective than SSRI based on head-to-head trials. The evidence for CBT- or SSRI-resistant patients is limited but indicates that CBT and SSRI are effective treatments for CBT non-responders while a combination of CBT and SSRI is the most effective treatment for SSRI non-responders with no prior exposure to CBT. The current data support clinical guidelines indicating that when CBT expertise is present, one can successfully treat patients with CBT. CBT is also as effective as SSRI in non-responders after 14 weeks of CBT. The results did not indicate that combined treatment of CBT and SSRI is more effective than CBT delivered by experts. However, combined treatment is more effective than SSRI in SSRI non-responders. Obsessive-compulsive disorder, children and adolescents, treatment, Cognitive behavior therapy, selective serotonin reuptake inhibitors, atypical antipsychotics, treatment-resistant, treatment-refractory. Correspondence: Guðmundur Skarphedinsson, gudmundur.skarphedinsson@r-bup.no.

Objectives: Reduced reward responsiveness, as measured by the event-related potential (ERP) component, the reward positivity (RewP), has been shown to play a role in the development of internalizing disorders, but implications for treatment remain unclear. In adult patients with anxiety and/or depression, reduced RewP has emerged as a predictor of greater change in symptoms following cognitive behavior therapy (CBT) or selective serotonin reuptake inhibitor (SSRI) treatment. The objectives of this preliminary study were to extend these findings to children and adolescents with anxiety disorders by evaluating RewP to reward as a predictor of change in anxiety severity or depressive symptoms following treatment with CBT or SSRI and to explore whether RewP differentially predicts response to one type of treatment. Methods: Patients (7-19 years old) with social and/or generalized anxiety disorder (N = 27) completed baseline measures of anxiety severity and depressive symptoms, as well as an ERP monetary reward anticipation and feedback task. RewP was measured in response to reward and breaking even feedback. Patients were then randomly assigned to CBT or SSRI treatment, and completed measures of anxiety and depressive symptom severity at the last treatment session. Results: Reduced reward responsiveness, as measured by RewP to rewards, predicted greater change in depressive symptoms following treatment, adjusting for baseline symptoms, age, and RewP to breaking even. RewP was not a significant predictor of change in anxiety symptoms. Although preliminary, exploratory analyses suggested that among anxious youth, RewP specifically predicted change in depressive symptoms following CBT, rather than SSRI. Conclusion: Results provide preliminary support for the utility of ERP measures of reward responsiveness in predicting treatment response in youth. With further research and standardization, ERP assessments could potentially be implemented in clinical settings to inform prognosis and treatment planning for youth with internalizing disorders.

PurposeThis study aims to evaluate and summarize the effectiveness of cognitive behavioral therapy (CBT) and internet-based CBT (ICBT) interventions on relapse prevention and severity of symptoms among individuals with major depressive disorder (MDD). CBT is one of the most used and suggested interventions to manage MDD, whereas ICBT is a novel effective proposed approach.Design/methodology/approachThe review was conducted following the preferred reporting items for systematic review and meta-analysis protocol. A comprehensive and extensive search was performed to identify and evaluate the relevant studies about the effectiveness of CBT and ICBT on relapse prevention and severity of symptoms among patients with MDD.FindingsA total of eight research studies met the inclusion criteria and were included in this systematic review. RCT studies were conducted to assess and evaluate the effectiveness of CBT and ICBT on relapse prevention and severity of symptoms among patients with MDD. It has been found that CBT is a well-supported and evidently based effective psychotherapy for managing depressive symptoms and reducing the relapse and readmission rate among patients diagnosed with MDD. The ICBT demonstrated greater improvements in depressive symptoms during major depressive episodes among patients with MDDS. The ICBT program had good acceptability and satisfaction among participants in different countries.Research limitations/implicationsDespite the significant findings from this systematic review, certain limitations should be acknowledged. First, it is important to note that all the studies included in this review were exclusively conducted in the English language, potentially limiting the generalizability of the findings to non-English speaking populations. Second, the number of research studies incorporated in this systematic review was relatively limited, which may have resulted in a narrower scope of analysis. Finally, a few studies within the selected research had small sample sizes, which could potentially impact the precision and reliability of the overall conclusions drawn from this review. The authors recommend that nurses working in psychiatric units should use CBT interventions with patients with MDD.Practical implicationsThis paper, a review of the literature gives an overview of CBT and ICBT interventions to reduce the severity of depressive symptoms and prevent patients’ relapse and rehospitalization and shows that CBT interventions are effective on relapse prevention among patients with MDD. In addition, there is still no standardized protocol to apply the CBT intervention in the scope of reducing the severity of depressive symptoms and preventing depression relapse among patients with major depressive disorder. Further research is needed to confirm the findings of this review. Future research is also needed to find out the most effective form and contents of CBT and ICBT interventions for MDD.Social implicationsCBT is a psychological intervention that has been recommended by the literature for the treatment of major depressive disorder (MDD). It is a widely recognized and accepted approach that combines cognitive and behavioral techniques to assist individuals overcome their depressive symptoms and improve their overall mental well-being. This would speculate that effectiveness associated with several aspects and combinations of different approaches in CBT interventions and the impact of different delivery models are essential for clinical practice and appropriate selection of the interventional combinations.Originality/valueThis systematic review focuses on the various studies that explore the effectiveness of face-to-face CBT and ICBT in reducing depressive symptoms among patients with major depressive disorder. These studies were conducted in different countries such as Iran, Australia, Pennsylvania and the USA.

Programs based on applied behavior analysis (ABA) have become increasingly popular as interventions for childhood autism. A number of leading behavior analysts even have claimed that many children with autism can be cured through such programs and therefore strongly recommend ABA over alternative interventions. The extant research literature, however, does not support these claims. ABA programs for childhood autism are indeed promising, but exaggerated claims may undermine confidence in approach, and are misleading to families of autistic children and to other stakeholders. ********** Empiricism has always been one of key defining features of applied behavior analysis (ABA) (Cooper, Heron & Heward, 1987). Both theoretical and technological developments are closely tied to objective data (Zuriff, 1985). In keeping with high value placed on pragmatism, link between basic behavioral principles and technological developments that stem from these principles emphasized. Technological developments such as interventions for psychological disorders and behavioral problems are not relegated to an afterthought, but are central to entire enterprise. The recent movement toward empirically supported treatments (ESTs) in field of clinical psychology therefore represents nothing new to applied behavior analysts. Although debates are currently raging among clinical psychologists and other mental health professionals regarding relevance of outcome research to clinical practice, idea that interventions should be informed by data axiomatic to behavior analyst. Applied behavior analysts may join other empirically-minded professionals in quibbling over details (e.g., specific criteria that should be used to justify claims of empirical support for an intervention; cf. Herbert, 2000; Lohr, DeMaio, & McGlynn, in press), but idea that the data matter not in dispute. ABA AND CHILDHOOD AUTISM The conventional wisdom within field of ABA that one of most significant if not single most significant - empirically supported success story ABA-based early intervention for developmental disabilities, and childhood autism in particular. In fact, association of ABA with intervention programs for childhood autism has become so strong that Hayes (2001) recently warned that ABA is gradually becoming a subfield of developmental disabilities (p. 61). Indeed, Internet home page of Cambridge Center for Behavioral Studies (www.behavior.org)prominently features ABA programs for autism. The premier ABA journal, Journal of Applied Behavior Analysis, frequently publishes articles on application of ABA for developmental disabilities. In a feature article on Autism, Newsweek magazine described ABA as the standard approach to intervention with autism (Cowley, July 31, 2000, p. 52). The ABC News program Nightline recently featured ABA for autism (March 9, 2001). The New York State Department of Health (1999) recently issued clinical practice guidelines for autism in which ABA recommended as a critical element of any intervention program for childhood autism. The astounding success of ABA early intervention programs for children with autism proclaimed not only in professional literature, but also in books and Internet sites targeted to parents and other stakeholders. These publications frequently announce that ABA programs can result in dramatic developmental gains for many autistic individuals. In fact, it claimed that many of these children can eventually function in normal education settings, and are indistinguishable from their normally developing peers. In other words, many can be cured of their disorder. Consider, for example, following passages gleaned from literature on ABA for autism: Several studies have now shown that one treatment approach--early, intensive instruction using methods of Applied Behavior Analysis--can result in dramatic improvements for children with autism: successful integration in regular schools for many, completely normal functioning for some (Green, 1996b, p. …

Obsessive-compulsive disorder (OCD) is a common psychiatric illness with lifetime prevalence of 1-3% [1]. It is the fourth-most common psychiatric illness and a leading cause of disability. OCD is associated with significant impairment in functioning, quality of life and disability. If untreated, OCD is a chronic illness with a waxing and waning of symptoms. A recent meta-analysis of long-term naturalistic prospective studies demonstrated that nearly a half of patients experience remission with much higher rates of remission in Indian patients compared to those in the west [2]. Early diagnosis and appropriate treatment may improve outcomes. Despite OCD being a common mental illness, most seek treatment after several years of suffering. Those who suffer from OCD tend to be secretive about their symptoms and suffer from shame and embarrassment. Less than a third of OCD sufferers receive appropriate pharmacotherapy and even less receive evidence-based psychotherapy. Symptoms The hallmarks of OCD are presence of obsessions and compulsions. Obsessions are repetitive, unwanted, intrusive thoughts, images or urges that are mostly ego-dystonic and cause severe distress or anxiety. Compulsions (or rituals) are repetitive behaviours or mental acts that are performed in response to an obsession to reduce anxiety/distress or prevent a dreaded consequence. Obsessions and compulsions are time consuming, distressing and are often resisted unsuccessfully. Clinical manifestations of OCD are remarkably similar across cultures and geographic locations. Common obsessions and compulsions and symptom dimensions identified through factor-analytical studies are shown in Table 1. Table 1 Common symptoms of OCD

This study aims to investigate the process of fostering inclusivity for children with autism spectrum disorder (ASD) within educational contexts, with a specific focus on understanding the efficacy of Applied Behavior Analysis (ABA) and Assessment of Basic Language and Learning Skills (ABLLS) programs. It draws from experiences gained through collaboration with professionals and parents at the Princesse Lalla Meryem Pour Enfants Autistes Institute in Tangier. Set within the dynamic landscape of Morocco's disability support and education sector, this research unfolds within the framework of the Princesse Lalla Meryem Pour Enfants Autistes Institute in which ABA and ABLLS programs are used extensively, complemented by individualized support provided by dedicated assistants for each student. Furthermore, cognitive behavioral therapy is integrated into the educational approach. The overarching goal of the organization is to equip children with ASD with the necessary skills to integrate successfully into mainstream educational institutions. By employing a participatory action research methodology, this study engages closely with professionals, parents, and autistic students. Qualitative interviews, observations, and collaborative reflections serve as key methods to understand the nuances and effectiveness of ABA, ABLLS, and cognitive behavioral therapy in fostering inclusivity. Initial findings highlight the pivotal role of individualized support and evidence-based interventions such as ABA, ABLLS, and cognitive behavioral therapy in promoting the inclusion of children with ASD. Insights gleaned from the experiences of both professionals and parents shed light on promising practices and areas for further enhancement in preparing autistic children for successful integration into mainstream educational institutions. This study enriches the existing literature by providing firsthand insights into the practical applications of ABA, ABLLS, and cognitive behavioral therapy within the context of an inclusive educational organization in Morocco. By bridging theory and practice along with incorporating diverse perspectives, the study aims to inform the development of more effective inclusive policies and practices, ultimately contributing to the successful integration of children with ASD into mainstream educational settings.

Childhood anxiety is common. Multiple treatment options are available, but existing guidelines provide inconsistent advice on which treatment to use. To evaluate the comparative effectiveness and adverse events of cognitive behavioral therapy (CBT) and pharmacotherapy for childhood anxiety disorders. We searched MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and SciVerse Scopus from database inception through February 1, 2017. Randomized and nonrandomized comparative studies that enrolled children and adolescents with confirmed diagnoses of panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, or separation anxiety and who received CBT, pharmacotherapy, or the combination. Independent reviewers selected studies and extracted data. Random-effects meta-analysis was used to pool data. Primary anxiety symptoms (measured by child, parent, or clinician), remission, response, and adverse events. A total of 7719 patients were included from 115 studies. Of these, 4290 (55.6%) were female, and the mean (range) age was 9.2 (5.4-16.1) years. Compared with pill placebo, selective serotonin reuptake inhibitors (SSRIs) significantly reduced primary anxiety symptoms and increased remission (relative risk, 2.04; 95% CI, 1.37-3.04) and response (relative risk, 1.96; 95% CI, 1.60-2.40). Serotonin-norepinephrine reuptake inhibitors (SNRIs) significantly reduced clinician-reported primary anxiety symptoms. Benzodiazepines and tricyclics were not found to significantly reduce anxiety symptoms. When CBT was compared with wait-listing/no treatment, CBT significantly improved primary anxiety symptoms, remission, and response. Cognitive behavioral therapy reduced primary anxiety symptoms more than fluoxetine and improved remission more than sertraline. The combination of sertraline and CBT significantly reduced clinician-reported primary anxiety symptoms and response more than either treatment alone. Head-to-head comparisons were sparse, and network meta-analysis estimates were imprecise. Adverse events were common with medications but not with CBT and were not severe. Studies were too small or too short to assess suicidality with SSRIs or SNRIs. One trial showed a statistically nonsignificant increase in suicidal ideation with venlafaxine. Cognitive behavioral therapy was associated with fewer dropouts than pill placebo or medications. Evidence supports the effectiveness of CBT and SSRIs for reducing childhood anxiety symptoms. Serotonin-norepinephrine reuptake inhibitors also appear to be effective based on less consistent evidence. Head-to-head comparisons between various medications and comparisons with CBT represent a need for research in the field.

Established treatments for obsessive compulsive disorder (OCD) include cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication. Combined treatment may outperform monotherapy, but few studies have investigated this. A total of 49 community-based adults with OCD were randomly assigned to CBT, SSRI, or SSRI+CBT. Sertraline (50–200 mg/day) was given as the SSRI for 52 weeks. A 16-h-manualized individual CBT was delivered over 8 weeks with four follow-up sessions. Assessors were ‘blinded’ to treatment allocation. A preliminary health economic evaluation was conducted. At week 16, combined treatment (n=13) was associated with the largest improvement, sertraline (n=7) the next largest and CBT (n=9) the smallest on the observed case analysis. The effect size (Cohen’s d) comparing the improvement in Yale Brown Obsessive Compulsive Scale on CBT versus combined treatment was −0.39 and versus sertraline was −0.27. Between 16 and 52 weeks, the greatest clinical improvement was seen with sertraline, but participant discontinuation prevented reliable analysis. Compared with sertraline, the mean costs were higher for CBT and for combined treatment. The mean Quality Adjusted Life Year scores for sertraline were 0.1823 (95% confidence interval: 0.0447–0.3199) greater than for CBT and 0.1135 (95% confidence interval: ‑0.0290–0.2560), greater than for combined treatment. Combined treatment appeared the most clinically effective option, especially over CBT, but the advantages over SSRI monotherapy were not sustained beyond 16 weeks. SSRI monotherapy was the most cost-effective. A definitive study can and should be conducted.

BackgroundAnxiety disorders are among the most common psychiatric disorders diagnosed during childhood and adolescence. Reported lifetime prevalence of children or adolescents meeting criteria for at least one anxiety disorder in industrialized countries ranges from 8–27%. Current treatment includes psychotherapy (cognitive and behavioural therapies) as well as medication which is almost always used together with psychotherapy, rather than as a stand‐alone treatment.ObjectiveTo synthesize the evidence currently in the Cochrane Database of Systematic Reviews (CDSR) related to the question: ‘In the treatment of childhood and adolescent anxiety disorders, which pharmacologic or nonpharmacologic treatments are known to improve symptom response, response rates, functional capacity, adherence, persistence, and acceptability as well as increase diagnostic remission and decrease adverse events?’.MethodsThe CDSR was searched using the term ‘anxiety disorders’ in the title for all systematic reviews examining pharmacologic and nonpharmacologic interventions for the treatment of anxiety disorders in children and adolescents, including pharmacotherapy and psychotherapy. Data were extracted and entered into tables; data were synthesized using qualitative and quantitative methods.Main ResultsOf the studies included in the CDSR, treatment of childhood and adolescent anxiety disorders with cognitive behavioural therapy (CBT) led to significant reductions in anxiety symptoms and increased recovery. Treatment with CBT or behavioural therapy (BT) led to notable reductions in Obsessive–Compulsive Disorder (OCD) severity and a reduced risk of treatment failure. Use of selective serotonin reuptake inhibitors (SSRIs) and the selective norepinephrine reuptake inhibitor (SNRI) venlafaxine were superior to placebo in treating OCD and other anxiety disorders. There was no clear evidence that any particular SSRI or venlafaxine was most efficacious or best tolerated. While few studies were available, CBT combined with a SSRI or SNRI led to significant reductions in both anxiety and OCD symptoms. Psychotherapy (CBT/BT), used alone or in combination with medication, had a mixed impact on reducing risk of treatment failure for OCD.Author's ConclusionsFor childhood and adolescent anxiety disorders, including OCD, the CDSR reviews suggest that psychotherapy treatments are efficacious in reducing symptom severity. Although the CDSR does not include a number of recent research publications on CBT, these newer studies further reinforce CBT efficacy. Pharmacotherapy evidence from the CDSR supports using medication in treating anxiety disorders, and while few studies examined combined pharmacological and psychological treatment, results to date are also favourable for this combination. Clinicians should rely on expert consensus guidelines vis‐à‐vis this evidence as treatment decision‐making should be moderated by the patient's illness severity. Psychotherapy remains the first line treatment for mild to moderate symptoms, whereas pharmacotherapy is used for severe or treatment‐resistant disorders. In conclusion, there is a body of literature in the CDSR to support evidence‐based treatment decisions for pediatric anxiety disorders; however, as this is a field that is rapidly expanding its knowledge base, efforts must be made to ensure the most recent evidence is consistently incorporated. Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.