Cognitive behavioral treatments for children and adolescents exposed to traumatic events: A meta-analysis examining variables moderating treatment outcomes.

Due to the negative impact of trauma exposure, effective treatments are necessary to prevent and improve negative trauma-related outcomes. Cognitive behavioral therapy (CBT) is considered an efficacious treatment for children and adolescents exposed to traumatic events. Despite the various meta-analyses that have examined trauma treatments, there is a paucity of research on the moderating variables that may impact treatment outcomes. This meta-analytic CBT study addressed those limitations by examining the moderating effects of treatment components on outcomes. A search identified 94 CBT studies with 97 relevant effect sizes for children and adolescents exposed to traumatic events. Consistent with prior meta-analytic studies, CBT was shown to be effective for trauma-exposed youth. CBT subtreatments did not produce significantly different results from one another. Moderators shown to significantly impact CBT treatment outcomes for posttraumatic stress symptom were trauma type, Q = 24.09, p = .004, ds = -0.22 to -1.42, and gender, Q = 10.68, p = .005, ds = -0.53 to -1.36, whereas moderators shown to impact treatment outcomes for depression were study design, Q = 10.95, p = .004, ds = -0.26 to -0.50, and treatment setting, Q = 10.98, p = .004, ds = -0.31 to -0.56. The implications of these findings for research and practice are discussed.

Moderators of School Intervention Outcomes for Children with Autism Spectrum Disorder.

A prior cluster randomized controlled trial (RCT) compared outcomes for a comprehensive school intervention (schoolMAX) to typical educational programming (services-as-usual [SAU]) for 103 children with autism spectrum disorder (ASD) without intellectual disability. The schoolMAX intervention was superior to SAU in improving social-cognitive understanding (emotion-recognition), social/social-communication skills, and ASD-related impairment (symptoms). In the current study, a range of demographic, clinical, and school variables were tested as potential moderators of treatment outcomes from the prior RCT. Moderation effects were not evident in demographics, child IQ, language, or ASD diagnostic symptoms, or school SES. Baseline externalizing symptoms moderated the outcome of social-cognitive understanding and adaptive skills moderated the outcome of ASD-related symptoms (no other comorbid symptoms or adaptive skills ratings moderated outcomes on the three measures). Overall, findings suggest that the main effects of treatment were, with two exceptions, unaffected by third variables.

Exploratory factor analysis of the Adapted Skillstreaming Checklist for children with autism spectrum disorder.

The Adapted Skillstreaming Checklist measures social/social-communication skills and behavioral flexibility/regulation of children with autism spectrum disorder without intellectual disability. Prior studies provided support for the reliability and criterion-related validity of the Adapted Skillstreaming Checklist total score for these children; however, no studies have examined the Adapted Skillstreaming Checklist factor structure. This exploratory factor analysis examined the factor structure and internal consistency of parent ratings on the Adapted Skillstreaming Checklist for a sample of 331 children, ages 6-12 years, with autism spectrum disorder without intellectual disability. Results yielded a correlated three-factor solution. The individual factors and total score demonstrated very good internal consistency reliability. Findings supported the presence and interpretability of three subscales, as well as derivation of a total composite reflecting overall prosocial and adaptive skills and behaviors. Implications for assessment and research are discussed.

Depression, Anxiety, and Hyperactivity in Youth with HFASD: A Replication and Extension of Symptom Level Differences in Self-Report Versus Parent Report.

The present study compared parent ratings to self-report ratings of depression, anxiety, hyperactivity, attention problems, and atypical behaviors in youth with high-functioning autism spectrum disorder (HFASD) and typically developing (TD) controls. Measures included parent and self-report forms from the Behavioral Assessment System for Children-Second Edition (BASC-2), and self-report forms from the Children's Depression Inventory (CDI) and the Multidimensional Anxiety Scale for Children (MASC). Results across all five BASC-2 scales indicated parent ratings for the HFASD condition were significantly higher than HFASD self-ratings, and were significantly higher than parent and self-ratings from the TD condition. In addition, average self-report scores did not differ significantly between HFASD and TD conditions on any of the BASC-2 scales, the CDI, or the MASC.

Psychometric Characteristics of the DANVA-2 in High-Functioning Children with ASD.

This study examined psychometric characteristics of the Diagnostic Analysis of Nonverbal Accuracy-Second Edition (DANVA-2) in 121 children, ages 6 to 13 years, with high-functioning autism spectrum disorder (HFASD). Internal consistency for adult and child faces subtests were .70 and .75, respectively. Immediate test-retest reliability in the total sample (N = 121) ranged from .78 to .84. Reliability for two subsamples for 5- (n = 21) and 12-week (n = 21) intervals ranged from .75 to .90 and from .43 to .68, respectively. DANVA-2 scores strongly converged with two measures of emotion recognition but were unrelated to parent ratings of social functioning and ASD symptoms. Significant correlations (small to medium) were found between DANVA-2 scores and child age, IQ, and language ability.

Cluster Randomized Trial of a School Intervention for Children with Autism Spectrum Disorder.

There are currently no empirically supported, comprehensive school-based interventions (CSBIs) for children with autism spectrum disorder (ASD) without concomitant intellectual and language disability. This study compared outcomes for a CSBI (schoolMAX) to typical educational programming (services-as-usual [SAU]) for these children. A total of 103 children (6-12 years of age) with ASD (without intellectual and language disability) were randomly assigned by school buildings (clusters) to receive the CSBI (n = 52 completed) or SAU (n = 50 completed). The CSBI was implemented by trained school personnel and targeted social competence and ASD symptoms using social skills groups, emotion recognition instruction, therapeutic activities, behavioral reinforcement, and parent training. Outcome measures tested the effects of the CSBI on social competence and ASD symptoms, as well as potential collateral effects on academic achievement. Outcomes (baseline-to-follow-up) were assessed using tests of social cognition and academic skills and behavioral observations (by masked evaluators) and parent-teacher ratings of ASD symptoms and social/social-communication skills (nonmasked; ClinicalTrials.gov, NCT03338530, https://www.clinicaltrials.gov/). The CSBI group improved significantly more than the SAU group on the test of emotion recognition skills and parent-teacher ratings of ASD symptoms (primary outcomes) and social/social-communication skills (secondary outcome). No differences between groups were detected for recess social interactions or academic skills. The CSBI improved several core areas of functioning for children with ASD compared to usual educational programming. Additional intervention elements may be needed to expand the efficacy of the CSBI so that the observed skills/symptom improvements generalize to recess social interactions and/or academic skills are enhanced.

Psychometric Properties of the Adapted Skillstreaming Checklist for High-functioning Children with ASD.

This study examined the reliability and criterion-related validity of parent ratings on the Adapted Skillstreaming Checklist (ASC) for a sample of 275 high-functioning children, ages 6-12 years, with ASD. Internal consistency for the total sample was 0.92. For two subsamples, test-retest reliability was very good at the 6-week and good at the 9-month intervals. Child age, IQ, and language abilities were unrelated to the ASC score. The ASC total score was inversely and strongly related to parent ratings of ASD symptom severity. Significant positive correlations (moderate-to-high) were found between the ASC and prosocial skills scales and significant negative correlations (low-to-moderate) with problem behavior scales on a broad measure of child functioning. Implications and suggestions for future study are discussed.

Open-trial pilot study of a comprehensive outpatient psychosocial treatment for children with high-functioning autism spectrum disorder.

This study examined the feasibility and initial outcomes of a comprehensive outpatient psychosocial treatment (MAXout) for children aged 7-12 years with high-functioning autism spectrum disorder. The 18-week treatment, two 90-minute sessions per week, included instruction and therapeutic activities targeting social/social communication skills, facial emotion recognition, non-literal language skills, and interest expansion. A behavioral system was implemented to reduce autism spectrum disorder symptoms and problem behaviors and increase skills acquisition and maintenance. Feasibility was supported via high levels of treatment fidelity and parent, child, and staff satisfaction. Significant post-treatment improvements were found for the children's non-literal language skills and facial emotion recognition skills, and parent and staff clinician ratings of targeted social/social communication skills, broad social skills, autism spectrum disorder symptoms, and problem behaviors. Results suggested that MAXout was feasible and may yield positive outcomes for children with high-functioning autism spectrum disorder.

Exploratory Factor Analysis of SRS-2 Teacher Ratings for Youth with ASD.

This study examined the factor structure and internal consistency of special education teaching staff ratings on the Social Responsiveness Scale-2 (SRS-2; Constantino and Gruber 2012), as well as the percentage of ratings falling above pre-established cut scores, for a sample of lower-functioning youth with autism spectrum disorder (ASD; n = 264). Results of the exploratory factor analysis yielded a four-factor correlated solution. The individual factors and total score demonstrated satisfactory internal consistency reliability for screening purposes. When applying the lowest pre-established cut score (T ≥ 60; minimum indication of clinically significant symptoms/impairments), 85 % of the sample had ratings in that range or higher (more severe). Implications for assessment and future research are provided.

Factor Structure, Internal Consistency, and Screening Sensitivity of the GARS-2 in a Developmental Disabilities Sample.

The Gilliam Autism Rating Scale-Second Edition (GARS-2) is a widely used screening instrument that assists in the identification and diagnosis of autism. The purpose of this study was to examine the factor structure, internal consistency, and screening sensitivity of the GARS-2 using ratings from special education teaching staff for a sample of 240 individuals with autism or other significant developmental disabilities. Exploratory factor analysis yielded a correlated three-factor solution similar to that found in 2005 by Lecavalier for the original GARS. Though the three factors appeared to be reasonably consistent with the intended constructs of the three GARS-2 subscales, the analysis indicated that more than a third of the GARS-2 items were assigned to the wrong subscale. Internal consistency estimates met or exceeded standards for screening and were generally higher than those in previous studies. Screening sensitivity was .65 and specificity was .81 for the Autism Index using a cut score of 85. Based on these findings, recommendations are made for instrument revision.

Randomized Controlled Trial of Mind Reading and In Vivo Rehearsal for High-Functioning Children with ASD.

This randomized controlled trial evaluated the efficacy of a computer software (i.e., Mind Reading) and in vivo rehearsal treatment on the emotion decoding and encoding skills, autism symptoms, and social skills of 43 children, ages 7-12 years with high-functioning autism spectrum disorder (HFASD). Children in treatment (n = 22) received the manualized protocol over 12 weeks. Primary analyses indicated significantly better posttest performance for the treatment group (compared to controls) on 3 of the 4 measures of emotion decoding and encoding and these were maintained at 5-week follow-up. Analyses of secondary measures favored the treatment group for 1 of the 2 measures; specifically, ASD symptoms were significantly lower at posttest and follow-up.

Comparison of Adaptive Behavior Measures for Children with HFASDs.

Adaptive behavior rating scales are frequently used to gather information on the adaptive functioning of children with high-functioning autism spectrum disorders (HFASDs), yet little is known about the extent to which these measures yield comparable results. This study was conducted to (a) document the parent-rated VABS-II, BASC-2, and ABAS-II adaptive behavior profiles of 6- to 11-year-olds with HFASDs (including relative strengths and weaknesses); (b) examine the extent to which these measures yielded similar scores on comparable scales; and (c) assess potential discrepancies between cognitive ability and adaptive behavior across the measures. All three adaptive measures revealed significant deficits overall for the sample, with the VABS-II and ABAS-II indicating relative weaknesses in social skills and strengths in academic-related skills. Cross-measure comparisons indicated significant differences in the absolute magnitude of scores. In general, the VABS-II yielded significantly higher scores than the BASC-2 and ABAS-II. However, the VABS-II and ABAS-II yielded scores that did not significantly differ for adaptive social skills which is a critical area to assess for children with HFASDs. Results also indicated significant discrepancies between the children's average IQ score and their scores on the adaptive domains and composites of the three adaptive measures.

Prevalence and Predictors of Psychotropic Use in Children with High-Functioning ASDs.

This study examined (1) the prevalence of psychotropic medication use for a sample of children with high-functioning autism spectrum disorders (HFASDs), (2) the extent to which psychotropic agents were linked to targeted symptoms, and (3) predictors of psychotropic use. A total of 115 children, ages 6-13, with HFASDs who were enrolled in psychosocial treatment trials were included in this study. Parents completed extensive background and rating forms prior to treatment that included data on demographic characteristics, child health, child medication use, and child ASD-related symptoms. Results indicated that 33% (n = 38) of the sample was taking psychotropic medication with the most common being stimulants (25%; n = 29), antidepressants (10%; n = 12), and neuroleptics (6%; n = 7). All children taking stimulants had target symptoms that were appropriate for stimulant medication, whereas 57% of those taking neuroleptics and 42% of those taking antidepressants did not have targeted symptoms consistent with the medication. Logistic regression for the major psychotropic drug categories indicated that lower IQ was a significant predictor of increased antidepressant and neuroleptic use. A higher level of ASD-related symptoms was related to the likelihood of stimulant use.

Comparison of saliva collection methods in children with high-functioning autism spectrum disorders: acceptability and recovery of cortisol.

This study compared cortisol concentrations yielded using three saliva collection methods (passive drool, salivette, and sorbette) in both in vitro and in vivo conditions, as well as method acceptability for a sample of children (n = 39) with High Functioning Autism Spectrum Disorders. No cortisol concentration differences were observed between passive and sorbette samples obtained in vitro or in vivo. The salivette derived concentration was lower than the other two methods for the in vitro derived comparisons but did not differ from the other methods when collected in vivo. Cross-day comparison for the salivettes was also found to differ significantly, whereas the cross-day comparisons did not differ for the passive method or the sorbette method. Overall, passive drool and sorbettes were found to produce similar and stable readings of cortisol, whereas the salivette yielded unstable and variable concentrations. Ratings suggested that the children generally perceived all methods as acceptable.

Atypical categorization in children with high-functioning autism spectrum disorder.

Children with autism spectrum disorder process many perceptual and social events differently from typically developing children, suggesting that they may also form and recognize categories differently. We used a dot pattern categorization task and prototype comparison modeling to compare categorical processing in children with high-functioning autism spectrum disorder and matched typical controls. We were interested in whether there were differences in how children with autism use average similarity information about a category to make decisions. During testing, the group with autism spectrum disorder endorsed prototypes less and was seemingly less sensitive to differences between to-be-categorized items and the prototype. The findings suggest that individuals with high-functioning autism spectrum disorder are less likely to use overall average similarity when forming categories or making categorical decisions. Such differences in category formation and use may negatively impact processing of socially relevant information, such as facial expressions. A supplemental appendix for this article may be downloaded from http://pbr.psychonomic-journals.org/content/supplemental.

Anxiety and depression in children with HFASDs: symptom levels and source differences.

The purpose of this study was to: (1) examine symptom levels of anxiety and depression in children with high-functioning autism spectrum disorders (HFASDs) compared with matched control children using child self-reports and parent ratings; and (2) examine source differences within the two condition groups. An overall multivariate effect indicated significantly elevated depression and anxiety symptoms for children with HFASDs based on parent reports; however no significant between-group differences based on child self-reports. Within-condition source comparisons (parent vs. child) revealed a significant multivariate effect indicating a significant difference in symptoms of depression and anxiety for the HFASD group but none for the control. Correlations between parent and child reports for the HFASD group suggested some positive association between child-reports and parent-reports for depressive symptoms only; however, the difference in average scores reflected a substantial discrepancy in the magnitude of symptoms by rater. Implications for clinical assessment and future research are provided.

RCT of a manualized social treatment for high-functioning autism spectrum disorders.

This RCT examined the efficacy of a manualized social intervention for children with HFASDs. Participants were randomly assigned to treatment or wait-list conditions. Treatment included instruction and therapeutic activities targeting social skills, face-emotion recognition, interest expansion, and interpretation of non-literal language. A response-cost program was applied to reduce problem behaviors and foster skills acquisition. Significant treatment effects were found for five of seven primary outcome measures (parent ratings and direct child measures). Secondary measures based on staff ratings (treatment group only) corroborated gains reported by parents. High levels of parent, child and staff satisfaction were reported, along with high levels of treatment fidelity. Standardized effect size estimates were primarily in the medium and large ranges and favored the treatment group.

BASC-2 PRS profiles for students with high-functioning autism spectrum disorders.

BASC-2 PRS profiles of 62 children with high-functioning autism spectrum disorders (HFASDs) were compared with those of 62 typically-developing children matched by age, gender, and ethnicity. Results indicated that, except for the Somatization, Conduct Problems, and Aggression scales, significant differences were found between the HFASD and typically-developing groups on all PRS scores. Mean HFASD scores were in the clinically significant range on the Behavioral Symptoms Index, Atypicality, Withdrawal, and Developmental Social Disorders scales. At-risk range HFASD means were obtained on the Adaptive Skills composite, all adaptive scales, remaining content scales (except Bullying), and Hyperactivity, Attention Problems, and Depression clinical scales. Screening indices suggested that the Developmental Social Disorders scale was highly effective in differentiating between the two groups.

Effect of social familiarity on salivary cortisol and self-reports of social anxiety and stress in children with high functioning autism spectrum disorders.

This study examined the effect of social familiarity on salivary cortisol and social anxiety/stress for a sample of children with high-functioning autism spectrum disorders. The relationship between self-reported social anxiety/stress and salivary cortisol was also examined. Participants interacted with a familiar peer on one occasion and an unfamiliar peer on another occasion. Data were collected using salivary cortisol and a scale measuring subjective stress. Results indicated a significant condition by order interaction for salivary cortisol levels, while self-rated stress did not differ significantly across situations. A mild-moderate correlation was found between self-reported distress and salivary cortisol within each condition. Examination of self-rated distress vs. cortisol scatter plots suggested a more complex relationship than the correlation coefficient could adequately convey.

Effectiveness of a manualized summer social treatment program for high-functioning children with autism spectrum disorders.

This paper presents findings from the final two years of a four-year study investigating a manualized social treatment program for high-functioning children with autism spectrum disorders. The study sought to (1) replicate and expand findings from years one and two; (2) compare outcomes of participants who received response-cost feedback versus non-categorical feedback; and (3) provide further evidence of program feasibility. Results indicated significant improvements in social skills and problem behaviors, however no significant differences for face emotion recognition. Measures of several socially-related behaviors yielded mixed results based on rater. While parent ratings did not appear to favor one feedback format, staff ratings appeared to favor the response-cost format on some measures. Results also provided support for program feasibility.