Modified CBT for Treatment of OCD in a 7-Year-Old Boy With ASD-A Case Report

Behavioural and cognitive behavioural therapy for obsessive compulsive disorder (OCD) in individuals with autism spectrum disorder (ASD)

BACKGROUND

Autistic spectrum disorder (ASD) is an increasingly recognised neurodevelopmental condition; that is, a neurologically-based condition which interferes with the acquisition, retention or application of specific skills. ASD is characterised by challenges with socialisation and communication, and by stereotyped and repetitive behaviours. A stereotyped behaviour is one which is repeated over and over again and which seems not to have any useful function. ASD often co-occurs with mental health disorders, including obsessive compulsive disorder (OCD). People with ASD may show certain cognitive differences (i.e. differences in ways of thinking) which influence their response to therapies. Thus, there is a need for evidence-based guidelines to treat mental health issues in this group. OCD, a common condition characterised by repeated obsessional thoughts and compulsive acts, occurs with greater frequency in persons with ASD than in the general population. Genetic, anatomic, neurobiological and psychological factors have been proposed to explain this co-occurrence. However, care should be taken to distinguish stereotyped and repetitive behaviours characteristic of ASD from obsessive compulsive acts in OCD. Cognitive behavioural therapy (CBT) is the recommended treatment for OCD, but studies have suggested that this treatment may be less effective in those with OCD co-occurring with ASD. Hence, modifications to CBT treatment may be helpful when treating OCD co-occurring with ASD to optimise outcomes.

OBJECTIVES

To assess the effectiveness of behavioural and cognitive behavioural therapy for obsessive compulsive disorder (OCD) in children and adults with autism spectrum disorder (ASD).

SEARCH METHODS

We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, five other bibliographic databases, international trial registries and other sources of grey literature (to 24 August 2020). We checked the reference lists of included studies and relevant systematic reviews to identify additional studies missed from the original electronic searches. We contacted subject experts for further information when needed.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cross-over, cluster- and quasi-randomised controlled trials involving both adults and children with diagnoses of OCD and ASD. We included studies of participants with co-occurring conditions (i.e. those experiencing other mental illnesses or neurodevelopmental conditions at the same time), but we did not include individuals who had a co-occurring global learning difficulty. Treatment could be in any setting or format and include behavioural therapy (BT) and cognitive behavioural therapy (CBT), which may have been adapted for those with ASD. Comparator interventions included no treatment, waiting list, attention placebo (where the control group receives non-specific aspects of therapy, but not the active ingredient) and treatment as usual (TAU, where the control group receives the usual treatment, according to accepted standards).

DATA COLLECTION AND ANALYSIS

Three review authors independently screened studies for inclusion. The authors extracted relevant data from the one eligible study, assessed the risk of bias and certainty of evidence (GRADE). Outcomes of interest were changes in OCD symptoms and treatment completion (primary outcome), and severity of depressive symptoms, anxiety symptoms and behavioural difficulties, as well as degree of family accommodation (secondary outcomes). We did not conduct meta-analyses as only one study met the selection criteria.

MAIN RESULTS

We included only one RCT of 46 participants in our analysis. This study compared CBT for OCD in persons with high-functioning ASD with a control group who received anxiety management only. There were no differences in rates of treatment completion between the CBT (87%) and anxiety management (87%) groups (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.80 to 1.25; low-certainty evidence). Behavioural difficulties were not included as an outcome measure in the study. This study showed that there may be a benefit at the end of treatment favouring CBT compared with anxiety management in OCD symptoms (mean difference (MD) -3.00, 95% CI -8.02 to 2.02), depression symptoms (MD -1.80, 95% CI -11.50 to 7.90), anxiety symptoms (MD -3.20, 95% CI -11.38 to 4.98), and quality of life (MD 5.20, 95% CI -1.41 to 11.81), but the evidence was of low certainty.  AUTHORS' CONCLUSIONS: Evidence is limited regarding the efficacy of CBT for treatment of OCD in ASD. There is much scope for future study, not only examining the efficacy of CBT for OCD in ASD, but also the particular ways that OCD manifests in and affects people with ASD and the role of the family in treatment response.

An Evaluation of a New Autism-Adapted Cognitive Behaviour Therapy Manual for Adolescents with Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) and autism spectrum disorder (ASD) frequently co-occur. Standard cognitive behaviour therapy (CBT) for OCD outcomes are poorer in young people with ASD, compared to those without. The aim of this naturalistic study was to evaluate the effectiveness of a novel adolescent autism-adapted CBT manual for OCD in a specialist clinical setting. Additionally, we examined whether treatment gains were maintained at 3-month follow-up. Thirty-four adolescents underwent CBT; at the end of treatment, 51.51% were treatment responders and 21.21% were in remission. At 3-month follow-up, 52.94% were responders and 35.29% remitters. Significant improvements were also observed on a range of secondary measures, including family accommodation and global functioning. This study indicates this adapted package of CBT is associated with significant improvements in OCD outcomes, with superior outcomes to those reported in previous studies. Further investigation of the generalizability of these results, as well as dissemination to different settings, is warranted.

Modified Cognitive Behavior Therapy for Severe, Treatment Resistant Obsessive-Compulsive Disorder in an Adolescent With Autism Spectrum Disorder: The Importance of Parental Involvement

The prevalence of obsessive-compulsive disorder (OCD) is higher among young people with autism spectrum disorders (ASD). Case studies and randomized controlled trials show that modified cognitive behavioral therapy (CBT) can be effective for young people with OCD and co-morbid ASD. This case study describes modified CBT for an adolescent with severe, treatment-resistant OCD and co-morbid ASD, and highlights the importance of family accommodation and parental mental health in pediatric OCD. Modifications to the standard evidence-based CBT for OCD protocol included extended psychoeducation, visual session material, mini exposure and response prevention hierarchies and parallel parent sessions to address familial accommodation and parental mental health. Progress was measured at seven times points throughout treatment using clinician administered, youth and parent self-report measures. Outcome data indicated significant improvements in OCD symptoms, general functioning, and maternal mental health as well as significant reductions in family accommodation. Gains were maintained over a 12-month follow-up period. This case study illustrates that modified CBT can be effective in youth with OCD and ASD and discusses the importance of familial accommodation and parental mental health.

Modular Cognitive-Behavioral Therapy for an Early Adolescent With Autism Spectrum Disorder and Comorbid Obsessive Compulsive Disorder

This case report outlines the use of a modular cognitive-behavioral therapy (CBT) protocol used to treat “Larry,” a 12-year-old male, with obsessive compulsive disorder (OCD) and autism spectrum disorder (ASD). Larry participated in 16 weekly 90-min CBT sessions, following a protocol developed for youth with ASD and anxiety/OCD. Upon completion of the treatment, Larry was remitted of his OCD diagnosis (as defined by a subthreshold score of 3 on the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders–4th ed. [ DSM-IV]–parent [ADIS]) and demonstrated marked improvements in his top presenting problems (washing hands immediately after touching something, checking tablet for smudges, and being around litter). This case report indicates useful adaptations to traditional CBT for OCD when working with youth with ASD.

An Initial Case Series of Intensive Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in Adolescents with Autism Spectrum Disorder

Obsessive-compulsive disorder (OCD) is prevalent among youth with autism spectrum disorder (ASD). Cognitive-behavioral therapy (CBT) with ASD-specific modifications has support for treating OCD in this population; however, use of intensive CBT in youth with ASD and severe OCD has not been tested. The current study examined the preliminary effectiveness of an individualized intensive CBT protocol for OCD in adolescents with ASD. Nine adolescents (aged 11-17 years) completed a regimen of intensive CBT (range 24-80 daily sessions) incorporating exposure with response prevention (ERP). Treatment materials, language and techniques were modified in accordance with evidence-based findings for this population. Seven of nine participants (78%) were treatment responders, and large treatment effects (d = 1.35-2.58) were obtained on primary outcomes (e.g., obsessive-compulsive symptom severity). Preliminary findings suggest that an intensive CBT approach for OCD is effective among adolescents with ASD.

Effectiveness of Cognitive Behavioral Therapy for Individuals with Autism Spectrum Disorders and Comorbid Obsessive-Compulsive Disorder: A Review of the Research

Autism spectrum disorders (ASD) and obsessive-compulsive disorder (OCD) are highly comorbid, precipitating an urgent need to identify evidence-based practices that might be used to address this comorbidity exclusively. The aim of this study was to conduct a review of intervention research and clinical reports to examine the use of cognitive behavioral therapy (CBT) with individuals who have comorbid ASD and OCD. Based on the pre-determined review inclusion criteria, 11 studies were included in the review: three randomized control trials (RCT), one case controlled study, two single subject experimental designs, and five case studies. These studies offer promising data on the use of CBT interventions for individuals with ASD and comorbid OCD as well as for individuals with OCD and comorbid ASD when standard CBT protocol is enhanced with modifications such as parental involvement, increased use of visuals, personalized treatment metaphors, self-monitoring, positive reinforcement, and use of clear language and instructions. Limitations and implications for future research and practice are discussed.

Restricted, Repetitive Behaviors in Autism Spectrum Disorder and Obsessive-Compulsive Disorder: A Comparative Review

This review paper critically examines literature regarding restricted and repetitive behaviors (RRBs) in Autism Spectrum Disorder (ASD) and Obsessive-Compulsive Disorder (OCD). The similar behavioral profiles of these disorders presents the potential for confusion regarding diagnoses and intervention efforts. As such, this review highlights the similarities and differences between RRBs in ASD and OCD. The developmental trajectories of RRBs are presented, followed by an exploration of three constructs implicated in RRB manifestation: anxiety, executive functioning, and sensory phenomena. While RRBs tend to develop with some similarity in both disorders, the differing role of anxiety highlights important distinctions between ASD and OCD. We urge researchers and clinicians to think critically about the dimensions that affect RRB presentation. Future research should use this review as a starting point to further elucidate the differences between RRBs in these two populations.

Outcomes of cognitive behaviour therapy for obsessive-compulsive disorder in young people with and without autism spectrum disorders: A case controlled study

Obsessive-compulsive disorder (OCD) and autism spectrum disorders (ASD) are highly co-morbid. It is suggested that youth with ASD will respond less well to cognitive behaviour therapy (CBT), as compared to their typically developing counterparts. To date there is no empirical evidence to support this view. The current study sought to compare CBT for OCD outcomes among youth with and without ASD. 22 young people with ICD-10 diagnoses of OCD and ASD (OCD+ASD) were matched with 22 youth with OCD, but no ASD (OCD+NoASD) according to base line OCD symptom severity, age, and gender. Outcomes were assessed for the two groups following a course of individually tailored, but protocol-driven CBT for OCD. While both groups responded to treatment the OCD+ASD group's outcomes were inferior to the OCD+NoASD group, as indicated by a significantly smaller decrease in symptoms over treatment (38.31% vs. 48.20%) and lower remission rates at post-treatment (9% vs. 46%). Overall, young people experiencing OCD in the context of ASD benefitted from CBT, but to a lesser extent than typically developing children. Recent efforts to modifying standard CBT protocols for OCD in ASD should continue in order to optimise outcomes among youth with this particular dual psychopathology.