DINOSAUR: an integrated cognitive-behavioral treatment for anxiety in young children with ASD

Amy Keefer, Roma A Vasa, Amy Keefer, Roma A Vasa

Abstract

Background: Anxiety disorders are highly prevalent in children and adolescents with autism spectrum disorder and often emerge before the age of 6 years. Yet, only a few studies have examined anxiety treatment for this group. Preliminary evidence from these studies suggests that utilizing cognitive behavioral therapy (CBT) as well as strategies to target intolerance of uncertainty (IU) and parental accommodation, known mechanistic and maintaining factors of anxiety may improve anxiety and optimize outcomes in this age group.

Main body: To meet this need, we developed an integrated treatment called DINO Strategies for Anxiety and intolerance of Uncertainty Reduction (DINOSAUR), a 12-week group telehealth treatment for 4- to 6-year-old children with ASD. DINOSAUR works with young children and their parents to deliver CBT along with interventions targeting IU and parental accommodation. In this paper, we first discuss the rationale for developing this treatment and then describe a pilot study of its feasibility and preliminary efficacy.

Conclusions: There is a great need to develop anxiety treatments for young children with ASD. We proposed a novel integrated treatment approach that aims to alter the way young children and parents respond to fear, which could potentially improve short- and long-term mental health outcomes for this age group.

Trial registration: ClinicalTrials.gov NCT04432077 on June 03, 2020.

Keywords: Anxiety; Autism; Treatment; Young child.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Treatment Overview

References

    1. Achenbach T, Rescorla L. Manual for the ASEBA preschoool forms & profiles. Burlington: University of Vermont, Research Centre for Children, Youth, & Families; 2000.
    1. Achenbach TM, Rescorla LA. Manual for the ASEBA school-age forms & profiles. Burlington: University of Vermont, Research Center for Children, Youth, & Families; 2001.
    1. Bischof NL, Rapee RM, Hudry K, Bayer JK. Acceptability and caregiver-reported outcomes for young children with autism spectrum disorder whose parents attended a preventative population-based intervention for anxiety: a pilot study. Autism Res. 2018;11(8):1166–1174. doi: 10.1002/aur.1963.
    1. Boulter C, Freeston M, South M, Rodgers J. Intolerance of uncertainty as a framework for understanding anxiety in children and adolescents with autism spectrum disorders. J Autism Dev Disord. 2014;44(6):1391–1402. doi: 10.1007/s10803-013-2001-x.
    1. Carleton RN. Into the unknown: a review and synthesis of contemporary models involving uncertainty. J Anxiety Disord. 2016;39:30–43. doi: 10.1016/j.janxdis.2016.02.007.
    1. Carrow-Woolfolk E. Oral and written language scales. 2. Torrance: Western Psychological Services; 2011.
    1. Christensen DL, Maenner MJ, Bilder D, Constantino JN, Daniels J, Durkin MS, et al. Prevalence and characteristics of autism spectrum disorder among children aged 4 years—early autism and developmental disabilities monitoring network, seven sites, United States, 2010, 2012, and 2014. MMWR Surveillance Summaries. 2019;68(2):1. doi: 10.15585/mmwr.ss6802a1.
    1. Cook JM, Donovan CL, Garnett MS. Parent-mediated cognitive behavioural therapy for young children with high-functioning autism spectrum disorder and anxiety: a randomized control trial. Early Child Dev Care. 2019;189(1):119–134. doi: 10.1080/03004430.2017.1303684.
    1. Driscoll K, Schonberg M, Stark MF, Carter AS, Hirshfeld-Becker D. Family-centered cognitive behavioral therapy for anxiety in very young children with autism spectrum disorder. J Autism Dev Disord. 2020;50(11):1–16. doi: 10.1007/s10803-020-04446-y.
    1. Edwards SL, Rapee RM, Kennedy SJ, Spence SH. The assessment of anxiety symptoms in preschool-aged children: the revised preschool anxiety scale. J Clin Child Adolesc Psychol. 2010;39(3):400–409. doi: 10.1080/15374411003691701.
    1. Ford L, Plows S, Garnett M. Fun with feelings, an emotion management group program for 4-6 year old children with Asperger’s syndrome. Unpublished manuscript. 2010.
    1. Frank HE, Kagan ER, Storch EA, Wood JJ, Kerns CM, Lewin AB, et al. Accommodation of anxiety in youth with autism spectrum disorder: results from the TAASD study. J Clin Child Adolesc Psychol. 2020:1–11.
    1. Gadow KD, Sprafkin J. Child symptom inventory-4 screening and norms manual. New York: Stony Brook, Checkmate Plus; 2002.
    1. Goldsetin S, Naglieri JA. Autism spectrum ratings scales. North Tonawanda: Multi-Health Systems Inc; 2010.
    1. Hewitt KC, Rodgin S, Loring DW, Pritchard AE, Jacobson LA. Transitioning to telehealth neuropsychology service: considerations across adult and pediatric care settings. Clin Neuropsychol. 2020;34(7-8):1335–1351. doi: 10.1080/13854046.2020.1811891.
    1. Higa-McMillan CK, Francis SE, Rith-Najarian L, Chorpita BF. Evidence base update: 50 years of research on treatment for child and adolescent anxiety. J Clin Child Adolesc Psychol. 2016;45(2):91–113. doi: 10.1080/15374416.2015.1046177.
    1. Hirshfeld-Becker DR, Masek B, Henin A, Blakely LR, Pollock-Wurman RA, McQuade J, et al. Cognitive behavioral therapy for 4-to 7-year-old children with anxiety disorders: a randomized clinical trial. J Consult Clin Psychol. 2010;78(4):498–510. doi: 10.1037/a0019055.
    1. Keefer A, Kreiser NL, Singh V, Blakeley-Smith A, Duncan A, Johnson C, et al. Intolerance of uncertainty predicts anxiety outcomes following CBT in youth with ASD. J Autism Dev Disord. 2017;47(12):3949–3958. doi: 10.1007/s10803-016-2852-z.
    1. Kendall PC. Treating anxiety disorders in children: Results of a randomized clinical trial. J Consult Clin Psychol. 1994;62(1):100–110. doi: 10.1037/0022-006X.62.1.100.
    1. Kendall PC, Norris LA, Rabner JC, Crane ME, Rifkin LS. Intolerance of uncertainty and parental accommodation: promising targets for personalized intervention for youth anxiety. Curr Psychiatry Rep. 2020;22(9):49. doi: 10.1007/s11920-020-01170-3.
    1. Kerns CM, Kendall PC, Berry L, Souders MC, Franklin ME, Schultz RT, et al. Traditional and atypical presentations of anxiety in youth with autism spectrum disorder. J Autism Dev Disord. 2014;44(11):2851–2861. doi: 10.1007/s10803-014-2141-7.
    1. Kerns CM, Kendall PC, Zickgraf H, Franklin ME, Miller J, Herrington J. Not to be overshadowed or overlooked: functional impairments associated with comorbid anxiety disorders in youth with ASD. Behav Therapy. 2015;46(1):29–39. doi: 10.1016/j.beth.2014.03.005.
    1. Kerns CM, Renno P, Kendall PC, Wood JJ, Storch EA. Anxiety disorders interview schedule–autism addendum: reliability and validity in children with autism spectrum disorder. J Clin Child Adolesc Psychol. 2017;46(1):88–100. doi: 10.1080/15374416.2016.1233501.
    1. Lebowitz ER, Marin C, Martino A, Shimshoni Y, Silverman WK. Parent-based treatment as efficacious as cognitive-behavioral therapy for childhood anxiety: a randomized noninferiority study of supportive parenting for anxious childhood emotions. J Am Acad Child Adolesc Psychiatry. 2020;59(3):62–372. doi: 10.1016/j.jaac.2019.02.014.
    1. Lebowitz ER, Woolston J, Bar-Haim Y, Calvocoressi L, Dauser C, Warnic E, et al. Family accommodation in pediatric anxiety disorders. Depress Anxiety. 2013;30(1):47–54. doi: 10.1002/da.21998.
    1. Lei J, Sukhodolsky DG, Abdullahi SM, Braconnier ML, Ventola P. Reduced anxiety following pivotal response treatment in young children with autism spectrum disorder. Res Autism Spect Disord. 2017;43:1–7. doi: 10.1016/j.rasd.2017.09.002.
    1. Lord C, Rutter M, DiLavore PC, Risi S, Gotham K, Bishop S. Autism diagnostic observation schedule. 2. Torrance: Western Psychological Services; 2012.
    1. McLeod BD, Sutherland KS, Martinez RG, Conroy MA, Snyder PA, Southam-Gerow MA. Identifying common practice elements to improve social, emotional, and behavioral outcomes of young children in early childhood classrooms. Prev Sci. 2017;18(2):204–213. doi: 10.1007/s11121-016-0703-y.
    1. Medeiros K, Mazurek MO, Kanne S. Investigating the factor structure of the Child Behavior Checklist in a large sample of children with autism spectrum disorder. Res Autism Spect Disord. 2017;40:24–40. doi: 10.1016/j.rasd.2017.06.001.
    1. Moree BN, Davis TI. Cognitive-behavioral therapy for anxiety in children diagnosed with autism spectrum disorders: modification trends. Res Autism Spect Disord. 2010;4(3):346–354. doi: 10.1016/j.rasd.2009.10.015.
    1. National Institute of Mental Health . CGI: clinical global impressions. In: Guy W, Bonato WW, editors. Manual for the ECDEU assessment battery. 2. Chevy Chase: National Institute of Mental Health; 1970. pp. 12–16.
    1. Orvaschel H. Schedule for Affective Disorders and Schizophrenia for School-Age Children--Epidemiologic Version (K-SADS-E) 5. Florida: Nova Southeastern University, Center for Psychological Studies; 1994.
    1. Otto MW, Reilly-Harrington NA. The impact of treatment on anxiety sensitivity. In: Taylor S, editor. The EA series in personality and clinical psychology. Anxiety sensitivity: Theory, research, and treatment of the fear of anxiety. New Jersey: Lawrence Erlbaum Associates Publishers; 1999. pp. 321–336.
    1. Pine DS, Cohen P, Gurley D, Brook J, Ma Y. The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry. 1998 Jan;55(1):56–64.
    1. Rapee RM, Kennedy SJ, Ingram M, Edwards SL, Sweeney L. Prevention and early intervention of anxiety disorders in inhibited pre-school children. J Consult Clin Psychol. 2005;73:488–497. doi: 10.1037/0022-006X.73.3.488.
    1. Reaven J, Moody EJ, Grofer-Klinger L, Keefer A, Duncan A, O’Kelley S, et al. Training clinicians to deliver group CBT to manage anxiety in youth with ASD: results of a multisite trial. J Consult Clin Psychol. 2018;86(3):205–217. doi: 10.1037/ccp0000285.
    1. Rogers SJ, Dawson G. Early Start Denver Model for young children with autism: promoting language, learning, and engagement. New York: Guilford Publications; 2010.
    1. Roid GH. Stanford-Binet intelligence scales, fifth edition (SB:V) Itasca: Riverside Publishing; 2003.
    1. Sanchez AL, Danielle C, Tommy C, Ovsanna L, Stefany C, Donna P, Comer JS. Development of a scale to evaluate young children’s responses to uncertainty and low environmental structure. J Anxiety Disord. 2017;4517–23. 10.1016/j.janxdis.2016.11.006.
    1. Silverman WK, Albano AM. The anxiety disorders interview schedule for children. San Antonio: Psychological Corporation; 1996.
    1. Simonoff E, Pickles A, Charman T, Chandler S, Loucas T, Baird G. Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity and associated factors. J Am Acad Child Adolesc Psychiatry. 2008;47(8):921–929. doi: 10.1097/CHI.0b013e318179964f.
    1. Spence SH, Rapee R, McDonald C, Ingram M. The structure of anxiety symptoms among preschoolers. Behav Res Ther. 2001;39(11):1293-316. 10.1016/S0005-7967(00)00098-X.
    1. Storch EA, Zavrou S, Collier AB, Ung D, Arnold EB, Mutch PJ, et al. Preliminary study of family accommodation in youth with autism spectrum disorders and anxiety: incidence, clinical correlates, and behavioral treatment response. J Anxiety Disord. 2015;34:94–99. doi: 10.1016/j.janxdis.2015.06.007.
    1. Ung D, Selles R, Small BJ, Storch EA. A systematic review and meta-analysis of cognitive-behavioral therapy for anxiety in youth with high-functioning autism spectrum disorders. Child Psychiatry and Hum Dev. 2015;46(4):533–547. doi: 10.1007/s10578-014-0494-y.
    1. Van Steensel FJ, Bögels SM, Perrin S. Anxiety disorders in children and adolescents with autistic spectrum disorders: a meta-analysis. Clin child fam psychol rev. 2011;14(3):302–317. doi: 10.1007/s10567-011-0097-0.
    1. Vasa RA, Carroll LM, Nozzolillo AA, Mahajan R, Mazurek MO, Bennett AE, et al. A systematic review of treatments for anxiety in youth with autism spectrum disorders. J Autism Dev Disord. 2014;44(12):3215–3229. doi: 10.1007/s10803-014-2184-9.
    1. Vasa RA, Keefer A, McDonald RG, Hunsche MC, Kerns CM. A scoping review of anxiety in young children with autism spectrum disorder. Autism Res. 2020;13(12):2038–2057. doi: 10.1002/aur.2395.
    1. Vasa RA, Kreiser NL, Keefer A, Sing V, Mostofsky SH. Relationships between autism spectrum disorder and intolerance of uncertainty. Autism Res. 2018;11(4):636–644. doi: 10.1002/aur.1916.
    1. THE RESEARCH UNITS ON PEDIATRIC P. The Pediatric Anxiety Rating Scale (PARS): Development and Psychometric Properties. J Am Acad Child Adolesc Psychiatry. 2002;41(9):1061–9. 10.1097/00004583-200209000-00006

Source: PubMed

3
Sottoscrivi