Cognitive behaviour therapy for adults with autism spectrum disorders and psychiatric co-morbidity - A review
- Type:#article
- Year read:#read2018
- Subject: CBT ASD
- Bibtex: @spain2015
- Bibliography: Spain, D., Sin, J., Chalder, T., Murphy, D., & Happé, F. (2015). Cognitive behaviour therapy for adults with autism spectrum disorders and psychiatric co-morbidity: A review. Research in Autism Spectrum Disorders, 9, 151–162.
Why and when I was reading this
Key takeaways
They found only six papers (!) to review, of which two were the Russell et al. trials on OCD. Apart from the RCT by Russell et al., there was one RCT on group-based mindfulness vs wait list.
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a systematic review was undertaken to synthesise published data about theeffectiveness of CBT interventions for adults with ASD and psychiatric co-morbidity. Only six studies met pre-determinedreviewinclusioncriteria:twoRCTs; onequasi-experimentalstudy;onecase series; and two case studies.
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Several studies described adaptations to standard CBT including an increase in the number of sessions, or accommodation of core ASD characteristics and associated neuropsychological impairments within thetherapy process.
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First, the average number of sessions offered to treat specific disorders, notably OCD (Russell et al., 2009, 2013) and low mood (Hare, 1997) exceeded UK NHS treatment guidelines (NICE, 2011).
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Second, several studies (Hare, 1997; Russell et al., 2009, 2013) emphasised the deliberate inclusion of materials, from the outset of treatment, to enhance participant understanding of emotions and anxiety. Third, several authors describedmodifying the means through which information was delivered, such as using additional visual cues and written materials, avoidance of colloquialisms, and concerted attempts to identify specific and concrete examples. Fourth, there was some accommodation of core ASD characteristics during and outside of CBT sessions.
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Finally, several studies described that therapists were more directive, i.e. less socratic in their style than would typically be the case in CBT.
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The review findings are broadly consistent with an earlier review (of studies up to 2010) which focused on CBT for the adult ASD population, but not psychiatric co-morbidity specifically (Binnie & Blainey, 2013). We were able to include three additional studies of CBT for co-morbid mental health conditions (Russell et al., 2013; Spek et al., 2013; Weiss & Lunsky, 2010), two of which were RCTs and therefore perhaps provide more robust evidence. Our findings were also consistent with previous reviews of CBT for children and adolescents with ASD (e.g. Danial & Wood, 2013; Lang et al., 2010). Lang, Regester, Lauderdale, Ashbaugh, and Haring (2010), for example, reviewed the effectiveness of CBT for anxiety delivered to a total of 110 participants (only one of whom was reported to be an adult), across nine studies.
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Despite the reported high rates of anxiety, affective and behavioural disorders in the adult ASD population (Hofvander et al., 2009; NICE, 2012), relatively few studies have thus far been undertaken to evaluate the effectiveness of non- pharmacological interventions totreat co-morbid psychiatric symptoms.
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The clinical implicationis that adults with ASD may either fail to be offered formal help, or may be offered sub-optimal treatments that neither have demonstrated efficacy, nor take into account the potential impact of core ASD characteristics or associated impairments on engagement with therapists and the therapy process.
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First, it may be beneficial for CBT clinicians to be aware of the severity of an individual’s core ASD characteristics across the three domains (reciprocal social interaction, communication, and restricted and repetitive behaviours and interests), as well as potential co-occurring alexithymia or impairments in neuropsychological functioning, for example theory of mind ability and information processing styles, and resistance to change. Such information is likely to inform decision-making about how best to undertake the assessment, what interventions to use, and in which order (e.g. behavioural versus cognitive versus skills-based techniques).
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modified therapeutic approach, e.g. a more didactic style, in order to maximise engagement. Similarly, objective assessment of alexithymia and inclusion of emotional literacy sessions may be useful at the outset of a course of CBT, in order to provide individuals with ASD with the requisite knowledgeand language to be able to engage in subsequent conversations about physiological arousal and emotions.
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the clinical implication is that a more flexible style is likely needed when working with individuals who have multiplemental healthsymptoms, andlong-term, entrenched difficulties, as is oftenthecase for adults withASD. Thismay include a longer assessment phase and an increased number of treatment sessions to aid withinitial engagement with the therapist, to enhance emotional literacy, and to practice, consolidate and generalise techniques learnt.
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There are several implications for research. First, there is a small but emerging body of evidence to suggest that psychological interventions, in particular CBT, may have utility in treating co-morbid mental health symptoms in adults with ASD. But there is now a pressing need for larger, more rigorous trials that investigate the effectiveness and acceptability of CBT for (1) specific mental health conditions (e.g. anxiety disorders and depression); (2) transdiagnostic characteristics commonly associated with psychiatric co-morbidity (e.g. anger and sleep difficulties); and (3) using different mediums of delivery (e.g. individual sessions versus group interventions versus self-help approaches). Second, clinical consensus is that the content and structure of CBT require modification to enhance outcomes
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Yet research is needed to better understand mediating and moderating factors for CBT in ASD i.e. what are the essential ingredients of the therapy process and content, and how can interventions be modified to best accommodate inherent ASD traits and associated neuropsychological impairments.