Effects of Cognitive Behavioral Therapy on Daily L

Authors: Amy Drahota Jeffrey J Wood Karen M Sze Marilyn Van Dyke

Publish Date: 2010/05/28

Volume: 41, Issue: 3, Pages: 257-265

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Abstract

CBT is a promising treatment for children with autism spectrum disorders ASD and focuses in part on children’s independence and selfhelp skills In a trial of CBT for anxiety in ASD Wood et al in J Child Psychol Psychiatry 50224–234 2009 children’s daily living skills and related parental intrusiveness were assessed Forty children with ASD 7–11 years and their primary caregiver were randomly assigned to an immediate treatment IT n = 17 or 3month waitlist WL n = 23 condition In comparison to WL IT parents reported increases in children’s total and personal daily living skills and reduced involvement in their children’s private daily routines Reductions correlated with reduced anxiety severity These results provide preliminary evidence that CBT may yield increased independence and daily living skills among children with ASDAutism spectrum disorders ASD are pervasive and chronic neurobiological disorders characterized by a pattern of impairments in social reciprocity communication and behavioral flexibility that permeates the individual’s behavior across situations American Psychiatric Association 2000 In addition to these impairments up to 80 of children with highfunctioning ASD have one or more concurrent anxiety disorders de Bruin et al 2007 making high anxiety a common feature in this population Impaired selfhelp skills are common in children with ASD and contribute to overall high levels of morbidity seen in ASD throughout the lifespan Howlin et al 2004 Emerging research also suggests a link between anxiety disorders and impairments in daily living skills Drahota et al 2010 Children with both ASD and anxiety disorders are thus at high risk of poorly developed daily living skills warranting intervention in this domainResearchers have recently proposed that parental overinvolvement in their children’s basic selfcare tasks plays a key role in the maintenance of childhood anxiety Wood 2006 This model suggests that parental overinvolvement in basic selfcare tasks limit their children’s mastery of these tasks facilitating dependence and overreliance on parents which maintains feelings of anxiety Therefore changes in children’s daily living skills should correlate with changes in children’s anxiety symptom severityDevelopment of interventions targeting the daily living skill deficits of children with autism has been of interest for some time Kanner 1943 Various interventions have been developed to ameliorate symptoms of ASD and improve communication and social skills of children with ASD eg applied behavior analysis pivotal response training Yet no interventions currently exist which are considered efficacious for improving daily living skills for children with highfunctioning ASD ie children with ASD having an IQ at or above 70Daily living skills are developmentally appropriate practical skills necessary to care for oneself and meet daily challenges consisting of personal skills ranging from dressing oneself to avoiding sick people in order to remain healthy home or school skills ranging from putting things away with reminders to cleaning with cleaning products and community skills ranging from knowing it is unsafe to accept rides from strangers to telling the time Sparrow et al 1984 Daily living skills are both currently mastered and performed regularly by children yet children with ASD often do not perform skills even if they are capable of doing so A child’s mastery of daily living skills contributes strongly to prognosis Gillham et al 2000 and have been noted as “essential” to an individual’s ability to function successfully and independently in the world Liss et al 2001 However many parents report difficulty teaching daily living skills to children with ASD finding it easier to perform such tasks for their child eg Koegel and Egel 1979 It may be that due to low motivation and limited perspectivetaking eg for social norms regarding developmentally appropriate independent behaviors such as when peers are dressing or bathing without parental assistance children with ASD rarely defy their parents’ efforts to do these tasks for themFamilybased cognitive behavioral therapy CBT is a probably efficacious intervention for the treatment of anxiety disorders in typically developing children and children with ASD eg Wood et al 2009 Wood et al 2006 and may improve daily living skills in typically developing populations as well Flay et al 2005 CBT is a treatment paradigm in which new skills are developed by motivating children and parents with logical and persuasive rationales and Socratic questioning challenging irrational cognitions maintaining maladaptive and avoidant behaviors and practicing these skills hierarchically in reallife in vivo situations Given the importance of daily living skills within the ASD population developing efficacious interventions to improve functioning is a high priority Accordingly this study investigated the effects of the Wood et al 2009 familybased CBT program on parental perceptions of daily living skills of children with ASD and concurrent anxiety disordersThis study utilizes a sample of children with ASD referred by a medical centerbased autism clinic regional centers parent support groups and school personnel for treatment of comorbid anxiety disorders see Wood et al 2009 for a detailed description of the sample the treatment manual and treatment outcome for child anxiety symptoms The intenttotreat sample included 40 children with ASD and an anxiety disorder living in a major metropolitan area of the western United States ranging in age from 7 to 11 years M = 920 SD = 149 and their primary parent defined as parents primarily responsible for overseeing the child’s daily activities Sample size was determined using a power analysis assuming a large effect size ES for group differences at posttreatment/postwaitlist see Wood et al 2009 With an expected sample of 40 children and assuming a treatment effect size of 8 standard deviations for all anxiety measures the power to detect a significant effect for time was 97 p  05Participants met the following inclusion criteria a met research criteria for a diagnosis of autism Asperger syndrome or PDDNOS b met research criteria for one of the following separation anxiety disorder social phobia or obsessive compulsive disorder c were not taking any psychiatric medication at the baseline assessment or were taking a stable dose of psychiatric medication ie at least one month at the same dosage prior to the baseline assessment and d if medication was being used children maintained the same dosage throughout the study Families were excluded if a the child had a verbal IQ less than 70 as assessed in previous testing or if there was any question about the child’s verbal abilities noted by the independent evaluator at baseline on the basis of the Wechsler Intelligence Scale for ChildrenIV administered by the independent evaluator b the child was currently in psychotherapy or social skills training or was receiving behavioral interventions such as applied behavior analysis c the family was currently in family therapy or a parenting class d the child began taking psychiatric medication or changed his/her dosage during the intervention or e for any reason the child or parents appeared unable to participate in the intervention program

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