CRITICALLY APPRAISED PAPER (CAP) Drahota, A., Wood, J. J., Sze, K. M., & Van Dyke, M. (2011). Effects of cognitive behavioral therapy on daily living skills in children with high-functioning autism and concurrent anxiety disorders. Journal of Autism & Developmental Disorders, 41(3), 257 265. https://doi.org/10.1007/s10803-010- 1037-4 CLINICAL BOTTOM LINE The results of this randomized controlled trial indicate that a cognitive behavior therapy (CBT) program of weekly 90-minute sessions over a 16-week period for families and children with autism spectrum disorder (ASD) and anxiety was effective in improving children s daily living skills, according to parental perceptions, when compared with the performance of the waitlist group. Cognitive-based intervention which included training in the areas of coping skills, adaptive skills, social skills, attention, and motivation geared toward both the child with ASD and parents have been shown to statistically improve independence with daily living skills. Although the CBT was conducted by researchers in the field of psychology, the concepts of intervention involved in this therapy are well within the scope of practice for occupational therapy. The study was adequately powered, and the results show a small to medium effect size. Although the results are statistically significant, children in the sample continued to perform adaptive skills well below the expected norms for their age. The sample was skewed toward families whose income was greater than $90,000 per year, which may limit the generalization of the study outcomes to families of a different socioeconomic status. RESEARCH OBJECTIVE(S) Examine the effects of a family-based CBT program on parents perceptions of daily living skills of children with ASD and concurrent anxiety disorder 1
DESIGN TYPE AND LEVEL OF EVIDENCE Level I: Randomized controlled trial PARTICIPANT SELECTION How were participants recruited and selected to participate? Children were assessed for eligibility from referrals obtained from a medical center based autism clinic; regional centers; parent support groups; and school personnel, including inclusion specialists. Further details on how referrals were solicited were not provided. Children were randomly assigned to immediate treatment or waitlist groups according to a stratified technique based on age and gender. Inclusion criteria: Participants needed to Meet criteria for a diagnosis of autism, Asperger syndrome, or pervasive developmental disorder not otherwise specified (PDD-NOS); Meet research criteria for one of the following anxiety disorders: separation anxiety disorder, social phobia, or obsessive compulsive disorder; Not be taking psychiatric medication at the time of the baseline assessment or be taking a stable dose of psychiatric medication (at least 1 month at the same dosage before the baseline assessment); and Maintain the same dosage of any medication they were taking. Exclusion criteria: The child had a verbal IQ of less than 70. The child was currently in psychotherapy or social skills training or was receiving behavioral interventions, such as applied behavioral analysis. The family was currently in family therapy or taking a parenting class. Medication was initiated or dosage was changed during the intervention. For any reason, the child or parent seemed unable to participate in the intervention program. PARTICIPANT CHARACTERISTICS N= 40 #/ % Male: 27/(67.5%) #/ % Female: 13/(32.5%) 2
Ethnicity: Nineteen participants were Caucasian, 5 were Latino, 6 were Asian, 1 was African American, and 9 were multiracial or other ethnicities. Disease/disability diagnosis: All participants were diagnosed with ASD: 20 with autistic disorder, 17 with PDD-NOS, and three with Asperger syndrome. In addition, the participants were diagnosed with an anxiety disorder. INTERVENTION AND CONTROL GROUPS Group 1: Immediate treatment (IT) group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Group 2: Waitlist (WL) group Brief description of the intervention How many participants in the group? Where did the intervention take place? The intervention involved implementation of the Building Confidence CBT program, which was modified for use with children with ASD. The intervention included modules focusing on building independence in age-appropriate self-help skills, coping skills training, and social skills. 17 participants, randomly assigned In the research setting, with the exception of the social skills module, which included two treatments scheduled at the child s school (Wood et al., 2009) 11 doctoral students in clinical or educational psychology and two doctoral-level psychologists who had experience working with children with autism, as well as 8 hours of initial training on the intervention, including audiotapes to model and weekly meetings with a clinical supervisor The intervention was provided on a weekly basis, with sessions lasting for 90 minutes, which included 30 minutes with the child and 60 minutes with the parents or family. 16 weekly sessions The WL group was essentially the control group; the intervention was not conducted for 3 months. 23 participants, randomly assigned No intervention was provided. 3
Who delivered? How often? For how long? NA NA NA INTERVENTION BIASES (Check yes or no, and include a brief explanation) Contamination: YES NO Explanation: No members of the control group received intervention during the experiment period. Co-intervention: YES NO Explanation: Participants were excluded if they changed or initiated medications or if they were currently undergoing therapy for social, behavioral, or parenting skills. Timing of intervention: YES NO Site of intervention: YES NO Explanation: The possibility of maturation can factor into the improvements seen in research with children; however, the intervention time period might not have been adequate to see meaningful change in adaptive behavior skills measured in this study. Explanation: Except for two intervention sessions, all sessions took place in the research setting for the IT group. No treatment was provided to the WL group. Use of different therapists to provide intervention: Baseline equality: Explanation: Although different therapists provided the intervention, they all completed the prescribed training and had weekly meetings with a clinical supervisor. Explanation: The children were randomly assigned to the IT and WL groups through stratification, which allowed for increased equality between groups at baseline. There were not statistical differences between the IT and WL groups. MEASURES AND OUTCOMES Measure 1: Anxiety Diagnosis Interview Schedule Child and Parent Name/type of measure used: Anxiety Diagnosis Interview Schedule Child and Parent 4
What outcome is measured? Is the measure reliable (as reported in the article)? Is the measure valid (as reported in the article)? When is the measure used? This semistructured interview was used to diagnose anxiety on a rating scale of 0 (not at all) to 8 (very, very much). Ratings of 4 or above were considered to be at a clinical level. Not Reported Not Reported At baseline as well as at posttreatment for the IT group, and postwaitlist for the WL group Measure 2: Vineland Adaptive Behavior Scale (VABS) Name/type of measure used: What outcome is measured? Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? VABS, in particular the Daily Living Skills domain Adaptive behavior was measured in five domains: communication, daily living skills, socialization, motor skills, and maladaptive behavior. The daily living skills domain was further subdivided into personal, community, and family daily living skills. Not Reported Not Reported At baseline as well as postintervention for the IT group, and postwaitlist for the WL group Measure 3: Parent Child Interaction Questionnaire (PCIQ) Name/type of PCIQ, in particular the Parent Intrusiveness subscale measure used: What outcome is measured? This questionnaire measures concrete, observable parent child interactions. The Parent Intrusiveness subscale examines parental help with private daily routines that most children over the age of 5 are capable of performing independently, as well as intrusions on the child s personal space and infantilizing behaviors. Is the measure Not Reported reliable as reported in the article? Is the measure valid as reported in the article? YES Not Reported When is the measure used? At baseline as well as postintervention for the IT group, and postwaitlist for the WL group. 5
MEASUREMENT BIASES Were the evaluators blind to treatment status? Explanation: The trained graduate students who completed the assessments were independent evaluators and blinded to the intervention condition. Was there recall or memory bias? Other measurement biases: Explanation: There might have been a possibility of recall or memory bias in terms of parental responses to the interview questions related to intrusiveness and daily living skills. Parents completing the questionnaires were not blinded to the treatment condition, so they might have been influenced by a desire to give responses in line with treatment goals. RESULTS List key findings based on study objectives: Analysis of covariance found a significant difference between the IT and WL groups at posttreatment or postwaitlist for total Daily Living Skills score on the VABS (p =.05). The mean standard score increased for the IT group but remained the same for the WL group. Children in the IT group improved by half of a standard deviation on the mean standard Daily Living Skills score and almost a full year in age-equivalency scores. There was a significant change from pretreatment to posttreatment in VABS total score and Personal Daily Living Skills score for the IT group (p <.01 for both measures); however, a significant change was not noted with the WL group (p =.48 and p =.24, respectively). The effect size for change on the VABS Total Daily Living Skills score was small (d = 0.45). The effect size for VABS Personal Daily Living Skills score was medium (d = 0.50). Despite positive gains, children still remained well below age-expected norms (average age = 5.7). There was a statistically significant difference between the IT and WL groups at posttreatment or postwaitlist for the PCIQ measure, with unnecessary parental involvement scores lower at posttreatment for the IT group. Parents in the IT group made significantly more reductions in parental involvement from pre- to posttreatment compared with the WL group (p <.01 and p =.29, respectively). At the 3-month follow-up, the treatment effect was maintained, evidenced by a nonstatistical difference between posttest and follow-up scores (p >.7). 6
Correlational analysis suggests a positive association between changes in the Anxiety Diagnosis Interview Schedule Severity score and daily living skills and parental intrusiveness, as reported by parents. Was this study adequately powered (large enough to show a difference)? Explanation: A power analysis was used to determine the sample size of 40. Were the analysis methods appropriate? Explanation: The researchers appropriately used analysis of variance to compare raw scores of two groups for both the VABS and the PCIQ. They further analyzed the raw scores of the VABS by converting to standard scores and age equivalencies for better clinical use. They used within-subject t tests to compare posttreatment and follow-up scores on the VABS and PCIQ to show treatment effect after intervention and at follow-up within groups. The authors conducted a Pearson analysis to describe the impact of anxiety severity on treatment effects. They completed intent-to-treat analyses of the sample, and they carried baseline scores forward to posttreatment or postwaitlist for the 4 children who dropped out, allowing for a conservative analysis of treatment efficacy. Were statistics appropriately reported (in written or table format)? p values, F statistics, and correlational statistics were detailed in written and table format. Was participant dropout less than 20% in total sample and balanced between groups? YES NO Explanation: Dropout rate was less than 8%, with 2 dropouts in the IT group and 1 in the WL group. No significant differences were found in either group in baseline measures or demographics between participants who dropped out and those who did not. What are the overall study limitations? Because parent reporting was used, the responses might have been influenced by respondents knowledge of the treatment goals. If a parent knew his or her child was in the intervention group, the parent might have reported more positive outcomes, indicating a potential blinding bias (Bennett & Hoffmann, 2013). The sample was skewed toward middle- and upper middle-class income and college-educated parents, and therefore the results may not be generalizable to the population as a whole. 7
CONCLUSIONS Providing CBT techniques to families of children with ASD seemed to produce statistically significant improvements in daily living skills. Parents who received the treatment reported reduced intrusions, allowing for the child to function more independently. References Bennett, S., & Hoffmann, T. (2013). Evidence about effects of intervention. In T. Hoffmann, S. Bennett, & C. Del Mar (Eds.), Evidence-based practice across the health professions (p. 61 96). Chatswood, Australia: Elsevier Australia. Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224 234. https://doi.org/10.1111/j.1469-7610.2008.01948.x This work is based on the evidence-based literature review completed by Lisa Sakemiller, MOT, OTR/L, and Alison Bell, OTD, OTR/L, faculty advisor, Thomas Jefferson University. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 8