Psychological treatment for obsessive-compulsive disorder in people with autism spectrum disorders--a pilot study

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.

Anxiety and Depression Reduction as Distal Outcomes of a College Transition Readiness Program for Adults with Autism

Young adults with autism spectrum disorder (ASD) experience increased rates of anxiety and depression which can impact academic success. The Stepped Transition in Education Program for Students with ASD (STEPS) applies cognitive-behavioral principles to help young adults with ASD improve their adjustment to postsecondary education. We aimed to determine if STEPS had an effect on anxiety and depression. Treatment-seeking adults with ASD (n = 32; Mage = 19.74) were randomized to STEPS or transition as usual (TAU; i.e., waitlist control group). STEPS participants evinced significantly greater declines in depressive symptoms from pre-treatment to post-treatment compared to the waitlist. Anxiety symptoms did not significantly change. Results suggest that transition support for young people with ASD may improve mental health.

Non-pharmacological Interventions for Adults with Autism: a Systematic Review of Randomised Controlled Trials

To determine the effects of non-pharmacological randomised controlled trials in adults with autism, a systematic review was conducted across five electronic databases. A total of 3865 abstracts were retrieved, of which 41 articles met all inclusion criteria: randomised controlled trial; non-pharmacological intervention; adults with autism; and English publication. Twenty included studies had strong methodological quality ratings. No meta-analysis could be performed due to heterogeneity between studies. Articles reported on interventions for (1) social functioning and language skills, (2) vocational rehabilitation outcomes, (3) cognitive skills training, and (4) independent living skills. Social functioning was the most studied intervention. PEERS for young adults and Project SEARCH plus ASD support interventions had the strongest evidence. Emerging evidence suggests non-pharmacological interventions could be effective.

Co-occurrence, Assessment and Treatment of Obsessive Compulsive Disorder in Children and Adults With Autism Spectrum Disorder

PURPOSE OF REVIEW

This review aims to give an update on research in the past 5 years regarding the co-occurrence, assessment and treatment of obsessive compulsive disorder (OCD) in individuals with autism spectrum disorder (ASD).

RECENT FINDINGS

Recent findings affirm not only a high prevalence of OCD amongst individuals with ASD (and vice versa) but also notable variability in assessment methods and results. There remain limited validated measures with which to assess OCD in those with ASD, which are often difficult to differentiate. Adapted and function-based CBT programs specifically designed for ASD demonstrate promising results, but additional randomised controlled trials are needed. Though some exciting progress has been made in the area of treatment of OCD in ASD, progress remains hampered by inconsistent measurement of OCD in ASD. Future priorities include development of brief, valid assessment tools and determining the efficacy and effectiveness of newly developed and adapted treatment programs.

Guidance for identification and treatment of individuals with attention deficit/hyperactivity disorder and autism spectrum disorder based upon expert consensus

BACKGROUND

Individuals with co-occurring hyperactivity disorder/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) can have complex presentations that may complicate diagnosis and treatment. There are established guidelines with regard to the identification and treatment of ADHD and ASD as independent conditions. However, ADHD and ASD were not formally recognised diagnostically as co-occurring conditions until the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) was published in 2013. Hence, awareness and understanding of both conditions when they co-occur is less established and there is little guidance in the clinical literature. This has led to uncertainty among healthcare practitioners when working with children, young people and adults who present with co-existing ADHD and ASD. The United Kingdom ADHD Partnership (UKAP) therefore convened a meeting of professional experts that aimed to address this gap and reach expert consensus on the topic that will aid healthcare practitioners and allied professionals when working with this complex and vulnerable population.

METHOD

UK experts from multiple disciplines in the fields of ADHD and ASD convened in London in December 2017. The meeting provided the opportunity to address the complexities of ADHD and ASD as a co-occurring presentation from different perspectives and included presentations, discussion and group work. The authors considered the clinical challenges of working with this complex group of individuals, producing a consensus for a unified approach when working with male and female, children, adolescents and adults with co-occurring ADHD and ASD. This was written up, circulated and endorsed by all authors.

RESULTS

The authors reached a consensus of practical recommendations for working across the lifespan with males and females with ADHD and ASD. Consensus was reached on topics of (1) identification and assessment using rating scales, clinical diagnostic interviews and objective supporting assessments; outcomes of assessment, including standards of clinical reporting; (2) non-pharmacological interventions and care management, including psychoeducation, carer interventions/carer training, behavioural/environmental and Cognitive Behavioural Therapy (CBT) approaches; and multi-agency liaison, including educational interventions, career advice, occupational skills and training, and (3) pharmacological treatments.

CONCLUSIONS

The guidance and practice recommendations (Tables 1, 4, 5, 7, 8 and 10) will support healthcare practitioners and allied professionals to meet the needs of this complex group from a multidisciplinary perspective. Further research is needed to enhance our understanding of the diagnosis, treatment and management of individuals presenting with comorbid ADHD and ASD.

Adapted cognitive behavior therapy for obsessive-compulsive disorder with co-occurring autism spectrum disorder: A clinical effectiveness study

Obsessive-compulsive disorder and autism spectrum disorder commonly co-occur. Adapted cognitive behavior therapy for obsessive-compulsive disorder in adults with autism spectrum disorder has not previously been evaluated outside the United Kingdom. In this study, 19 adults with obsessive-compulsive disorder and autism spectrum disorder were treated using an adapted cognitive behavior therapy protocol that consisted of 20 sessions focused on exposure with response prevention. The primary outcome was the clinician-rated Yale-Brown Obsessive-Compulsive Scale. Participants were assessed up to 3 months after treatment. There were significant reductions on the Yale-Brown Obsessive-Compulsive Scale at post-treatment (d = 1.5), and improvements were sustained at follow-up (d = 1.2). Self-rated obsessive-compulsive disorder and depressive symptoms showed statistically significant reductions. Improvements in general functioning and quality of life were statistically non-significant. Three participants (16%) were responders at post-treatment and four (21%) were in remission from obsessive-compulsive disorder. At follow-up, three participants (16%) were responders and one (5%) was in full remission. Adapted cognitive behavior therapy for obsessive-compulsive disorder in adults with co-occurring autism spectrum disorder is associated with reductions in obsessive-compulsive symptoms and depressive symptoms. However, outcomes are modest; few patients were completely symptom free, and treatment engagement was low with few completed exposures and low adherence to homework assignments. We identify and discuss the need for further treatment refinement for this vulnerable group.

Crossing the divide: a longitudinal study of effective treatments for people with autism and attention deficit hyperactivity disorder across the lifespan

Background

Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) frequently persist into adolescence and young adulthood. However, there are few clinical services that support those with these disorders through adulthood.

Objective

Our aim was to determine if clinical services meet the needs of people with ASD and ADHD, who are ‘at transition’ from childhood to adulthood.

Design

A longitudinal study of individuals with ASD and ADHD, the impact of services and treatments.

Methods

Our research methods included (1) interviewing > 180 affected individuals (and their families) with a confirmed diagnosis of ASD and/or ADHD, (2) screening for ASD and ADHD in approximately 1600 patients and (3) surveying general practitioner prescribing to 5651 ASD individuals across the UK. In addition, we tested the effectiveness of (1) new ASD diagnostic interview measures in 169 twins, 145 familes and 150 non-twins, (2) a magnetic resonance imaging-based diagnostic aid in 40 ASD individuals, (3) psychological treatments in 46 ASD individuals and (4) the feasability of e-learning in 28 clinicians.

Setting

NHS clinical services and prisons.

Participants

Focus – young people with ASD and ADHD as they ‘transition’ from childhood and adolescence into early adulthood.

Interventions

Testing the utility of diagnostic measures and services, web-based learning interventions, pharmacological prescribing and cognitive–behavioural treatments.

Main outcome measures

Symptom severity, service provision and met/unmet need.

Results

People with ASD and ADHD have very significant unmet needs as they transition through adolescence and young adulthood. A major contributor to this is the presence of associated mental health symptoms. However, these are mostly undiagnosed (and untreated) by clinical services. Furthermore, the largest determinant of service provision was age and not severity of symptoms. We provide new tools to help diagnose both the core disorders and their associated symptoms. We also provide proof of concept for the effectiveness of simple psychological interventions to treat obsessional symptoms, the potential to run treatment trials in prisons and training interventions.

Limitations

Our findings only apply to clinical service settings.

Conclusions

As individuals ‘transition’ their contact with treatment and support services reduces significantly. Needs-led services are required, which can both identify individuals with the ‘core symptoms’ of ASD and ADHD and treat their residual symptoms and associated conditions.

Future work

To test our new diagnostic measures and treatment approaches in larger controlled trials.

Trial registration

Current Controlled Trials ISRCTN87114880.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

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.

Autism spectrum disorder in adults: diagnosis, management, and health services development

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder characterized by pervasive difficulties since early childhood across reciprocal social communication and restricted, repetitive interests and behaviors. Although early ASD research focused primarily on children, there is increasing recognition that ASD is a lifelong neurodevelopmental disorder. However, although health and education services for children with ASD are relatively well established, service provision for adults with ASD is in its infancy. There is a lack of health services research for adults with ASD, including identification of comorbid health difficulties, rigorous treatment trials (pharmacological and psychological), development of new pharmacotherapies, investigation of transition and aging across the lifespan, and consideration of sex differences and the views of people with ASD. This article reviews available evidence regarding the etiology, legislation, diagnosis, management, and service provision for adults with ASD and considers what is needed to support adults with ASD as they age. We conclude that health services research for adults with ASD is urgently warranted. In particular, research is required to better understand the needs of adults with ASD, including health, aging, service development, transition, treatment options across the lifespan, sex, and the views of people with ASD. Additionally, the outcomes of recent international legislative efforts to raise awareness of ASD and service provision for adults with ASD are to be determined. Future research is required to identify high-quality, evidence-based, and cost-effective models of care. Furthermore, future health services research is also required at the beginning and end of adulthood, including improved transition from youth to adult health care and increased understanding of aging and health in older adults with ASD.

The People with Asperger syndrome and anxiety disorders (PAsSA) trial: a pilot multicentre, single-blind randomised trial of group cognitive-behavioural therapy

BACKGROUND

There is a growing interest in using cognitive-behavioural therapy (CBT) with people who have Asperger syndrome and comorbid mental health problems.

AIMS

To examine whether modified group CBT for clinically significant anxiety in an Asperger syndrome population is feasible and likely to be efficacious.

METHOD

Using a randomised assessor-blind trial, 52 individuals with Asperger syndrome were randomised into a treatment arm or a waiting-list control arm. After 24 weeks, those in the waiting-list control arm received treatment, while those initially randomised to treatment were followed up for 24 weeks.

RESULTS

The conversion rate for this trial was high (1.6:1), while attrition was 13%. After 24 weeks, there was no significant difference between those randomised to the treatment arm compared with those randomised to the waiting-list control arm on the primary outcome measure, the Hamilton Rating Scale for Anxiety.

CONCLUSIONS

Trials of psychological therapies with this population are feasible. Larger definitive trials are now needed.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

Cognitive behavioural therapy in the treatment of social skills deficits and social phobia in a man with an autism spectrum disorder: a single-case study

Autism spectrum disorders (ASD) including high-functioning types such as Asperger's syndrome (AS) are diagnosed when there is evidence of a triad of qualitative impairments in social interaction, communication, and stereotyped/repetitive behaviours. It is not uncommon for these impairments to be accompanied by social anxiety. The present single-case study investigates the use of cognitive behavioural therapy (CBT) to treat a 47-year-old man who was assessed as having difficulties with social skills and social phobia in the context of a late diagnosis of AS. He received 20 h of CBT adapted for his AS in 15 sessions including a 1-month follow-up. Following a highly individualized formulation, treatment included modelling, role-playing, reinforcement, thought challenging, and behavioural experimentation. Results from five self-report measures showed continued improvements from the start of therapy to follow-up in social anxiety, global distress, depression and self-esteem. The client gave positive feedback about his experience of treatment. The case study is discussed with reference to limitations and some reflections for CBT in ASD.

Psychological interventions for adults with ASD: clinical approaches

Purpose

– Empirical research indicates that adults who have autism spectrum disorders (ASD) can derive clinically and statistically meaningful benefits from individual and group-based psychological interventions, specifically those which employ skills-based, behavioural, and cognitive techniques. Given the inherent socio-communication, executive functioning, and theory of mind impairments that individuals with ASD can experience, it is deemed necessary to modify the design and delivery of interventions so as to enhance engagement and outcomes. The paper aims to discuss these issues.

Design/methodology/approach

– This general review provides a summary of the extant literature and clinical guidelines for the provision of psychological interventions for adults with ASD.

Findings

– Adaptations to the structure, process, content, and outcome measurement are outlined. It is likely that optimal treatment gains for adults with ASD are contingent on a prolonged assessment phase, pre-therapy interventions including psycho-education and skills-based interventions, thoughtful regard to the formulation of presenting difficulties, and consideration of, and methods to overcome, the difficulties that may arise when seeking to implement change, identify goals, and manage endings.

Originality/value

– This is one of the first reviews to condense the clinical implications for providing psychological interventions for adults with ASD.

Psychological interventions for adults with autism spectrum disorders: a review

Purpose

– Adults who have autism spectrum disorders (ASD) experience a range of core and co-morbid characteristics which impede daily functioning and quality of life. Children and adolescents with ASD derive clinically meaningful benefits from psychological interventions, including those designed to reduce socio-communication deficits and mental health conditions. Relatively little is known about the effectiveness of these interventions for the adult ASD population. The paper aims to discuss this issue.

Design/methodology/approach

– A selective search of English language, peer-reviewed publications was undertaken, in order to summarise the empirical data pertaining to psychological interventions for adults with high-functioning ASD (HF-ASD).

Findings

– Thus far, social skills interventions, cognitive behaviour therapy techniques, and mindfulness-based approaches have been researched most extensively. Interventions have primarily sought to: reduce the impact of core ASD characteristics; enhance skills; and improve co-morbid mental health symptoms. Methodological and clinical heterogeneity render it difficult to generalise study findings across population samples, but overall, interventions appear to be associated with reductions in co-morbid symptom severity, and improved functioning.

Research limitations/implications

– Further studies that seek to improve functioning, reduce co-morbid characteristics, and enhance the propensity for attaining and maintaining independence are now needed.

Practical implications

– Adaptations to standard treatment protocols are likely required in order to enhance engagement and optimise treatment gains.

Originality/value

– This is one of the first reviews to focus specifically on psychological interventions for adults with HF-ASD.

INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD): development and validation

OBJECTIVE

To develop and validate INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD).

DESIGN

Diagnostic test evaluation by cross sectional design.

SETTING

Four tertiary pediatric neurology centers in Delhi and Thiruvanthapuram, India.

METHODS

Children aged 2-9 years were enrolled in the study. INDT-ASD and Childhood Autism Rating Scale (CARS) were administered in a randomly decided sequence by trained psychologist, followed by an expert evaluation by DSM-IV TR diagnostic criteria (gold standard).

MAIN OUTCOME MEASURES

Psychometric parameters of diagnostic accuracy, validity (construct, criterion and convergent) and internal consistency.

RESULTS

154 children (110 boys, mean age 64.2 mo) were enrolled. The overall diagnostic accuracy (AUC=0.97, 95% CI 0.93, 0.99; P<0.001) and validity (sensitivity 98%, specificity 95%, positive predictive value 91%, negative predictive value 99%) of INDT-ASD for Autism spectrum disorder were high, taking expert diagnosis using DSM-IV-TR as gold standard. The concordance rate between the INDT-ASD and expert diagnosis for 'ASD group' was 82.52% [Cohen's k=0.89; 95% CI (0.82, 0.97); P=0.001]. The internal consistency of INDT-ASD was 0.96. The convergent validity with CARS (r = 0.73, P= 0.001) and divergent validity with Binet-Kamat Test of intelligence (r = -0.37; P=0.004) were significantly high. INDT-ASD has a 4-factor structure explaining 85.3% of the variance.

CONCLUSIONS

INDT-ASD has high diagnostic accuracy, adequate content validity, good internal consistency high criterion validity and high to moderate convergent validity and 4-factor construct validity for diagnosis of Autistm spectrum disorder.

Cognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trial

BACKGROUND

High rates of anxiety disorders, particularly obsessive compulsive disorder (OCD) are reported in people with Autism spectrum disorders (ASD). Group cognitive behavioral treatment (CBT) has been found effective for anxiety in young people with ASD but not been OCD specific. One uncontrolled pilot study of individual CBT for OCD for adults with ASD showed good treatment efficacy.

METHODS

Forty-six adolescents and adults (mean age 26.9 years, 35 Males) with ASD and comorbid OCD were randomized to CBT for OCD or anxiety management (AM), a plausible control treatment. Treatments were matched in duration (mean of 17.4 sessions CBT; 14.4 sessions AM), the Yale-Brown Obsessive Compulsive Severity Scale (YBOCS) as primary outcome measure and evaluations blind to treatment group. Treatment response was defined as > 25% reduction in YBOCS total severity scores.

RESULTS

Both treatments produced a significant reduction in OCD symptoms, within-group effect sizes of 1.01 CBT group and 0.6 for the AM group. There were no statistically significant differences between the two groups at end of treatment, although more responders in the CBT group (45 versus 20%). Effect sizes for self-rated improvement were small (0.33 CBT group; -0.05 AM group). Mild symptom severity was associated with improvement in the AM but not the CBT group. Family/carer factors were important for both groups, in that increased family accommodation was associated with poorer outcome.

CONCLUSIONS

Evidence-based psychological interventions, both AM and CBT, were effective in treating comorbid OCD in young people and adults with ASD.

Treatment-resistant Obsessive-compulsive Disorder in Young People: Assessment and Treatment Strategies

Cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitors have both been established as effective interventions for paediatric obsessive-compulsive disorder (OCD), with CBT being the recommended first-line treatment in most cases. While the majority of young people respond well to these treatments, a significant proportion remain symptomatic. Although the research on treatment-resistant OCD remains limited, increasing empirical attention is being paid to predictors of treatment outcome in young people with OCD, and efforts are being made to identify the factors that hinder recovery. This article outlines potential barriers in treatment and highlights strategies for optimising outcome, with particular focus on cognitive behavioural techniques.