People diagnosed with Autism Spectrum Disorders (ASD) find social interaction and communication difficult, and often display rigid and restrictive beliefs and patterns of behaviour. They also have an increased likelihood of experiencing mental health difficulties.

A recent report by the National Institute for Health and Care Excellence (2012) has recommended that individuals with ASD should be offered appropriate psychological treatment for both the core symptoms of ASD and comorbid mental health problems. There is evidence to suggest that intensive behavioural interventions can improve adaptive and communicative behaviour in individuals with ASD. Recent reviews also demonstrate the promising effects of cognitive behavioural therapy (CBT) for young people with ASD and comorbid anxiety disorders.

However, current reviews have not examined the effects of CBT on the primary features of ASD and anxiety disorders, nor have they looked into the effectiveness of such therapy for other mental health problems such as depression. Most of the literature reviewed appears to focus primarily on the benefits of CBT for children and young people with ASD, and not adults. Therefore, the authors aimed to compile a systematic review which examined the effectiveness of CBT across a range of age groups for the core features of ASD and mental health concerns.

Methods

Relevant studies were identified using electronic databases, and were included in the analysis if participants were diagnosed with ASD by a qualified clinician or using a standardised diagnostic assessment.

The studies needed to contain a clinician-led CBT intervention which could either be individual or group based, and included a control group comparison.

Outcomes were measured using validated and standardised measures of either the core features of ASD or mental health symptoms.

The authors also included studies that were non-randomised and which hadn’t been published in a peer reviewed journal.

A total of 48 studies were included in the final analysis.

Results

The authors noted that many included studies failed to specify a primary outcome measure. As such, the authors were left to decide which outcome measure to use within the analysis for each study based on the hypotheses laid out in the analysed studies.

CBT for affective disorder

• Analysis showed a range of conditions and symptoms targeted, with the majority attempting to improve anxiety disorders, whilst others looked at depression or emotional regulation difficulties
• Outcome measures varied across the studies, with the most common being self-reporting, alongside informant-report and clinician ratings
• The majority of studies involved children and adolescents, whilst a small number focused on adults alone or combined adults and children
• There was a combination of group based CBT, individual CBT and mixed sessions, involving a range of treatments including traditional CBT, mindfulness based therapy, and acceptance and commitment therapy.

CBT for Autism Spectrum Disorders features

• The majority of studies analysed targeted social skills, while others sought to improve theory of mind, affectionate communication and the perception of facial emotions
• Again, there was extensive variation in the outcome measures employed within the studies; however a number of papers also employed task-based outcome measures
• There was a notable difference in the number of sessions that made up the interventions; ranging from 5 to 70
• The authors noted that many of the studies included in this part of the analysis did not refer to CBT per se, but instead mentioned the use of both cognitive and behavioural techniques as part of the intervention.

The authors then analysed the studies based on their outcome measures and across age groups to examine the effectiveness of CBT for affective disorders and the features of ASD. They found a small to medium effect size overall when CBT was used to treat affective disorders associated with ASD, but this varied depending on the outcome measure used. Analysis of self-report measures was associated with a small non-significant effect size whilst informant-report and clinician-rating measures demonstrated a medium effect size, with CBT being superior to control conditions.

Similarly, when CBT’s effectiveness for ASD features was examined, it revealed a small to medium effect size which varied according to the outcome measure used. Self-report measures yielded a small non-significant effect size, whereas CBT appeared to be significantly beneficial when the authors compared informant- and clinician-reporting. Task-based measures also demonstrated a small but significant effect size in favour of CBT, however the removal of studies thought to be at higher risk of bias in this area reduced this effect size to non-significant levels.

Conclusions

It appears that in both cases, self-report measures are associated with no significant change in symptoms following treatment. This is in contrast to other forms of report measure. This may be due to the difficulties that individuals with ASD face in identifying and reporting their symptoms. However, the results from informant-report and clinician ratings may be due to the expectations of those observing rather than the CBT producing any real change in symptoms.

Strengths and limitations

Within this analysis there are a number of difficulties that have been identified which will need to be considered when interpreting the above conclusion. The first being the persistently small sample sizes involved in the majority of the studies. As such, the conclusions reached in this analysis are limited in their ability to generalise across the ASD population.

There are also further concerns regarding the validity within the methodology and the increased risk of bias in the studies chosen. The studies themselves lacked good reporting on a number of issues, including participant engagement and missing data. There were also a number of studies that were not randomised and importantly did not report adequate concealment of assessors regarding participant allocation. This leads to a higher risk of bias in these studies and in turn the meta-analysis. There are also difficulties regarding the lack of a primary outcome measure identified in some studies. In a number of cases the authors were forced to pick a primary measure for the analysis at random. However, the authors undertook a quality appraisal of the studies included in the analysis which showed moderate and good agreement for internal and external validity respectively.

The authors also identified a number of strengths with their review. The inclusion of a broader definition of affective disorders aimed to move the conversation away from purely discussing anxiety within this population. The review also benefitted from ensuring that the effects of CBT for a range of age groups were examined.

In conclusion, this review found some evidence for the effectiveness of CBT for both the features of ASD and the comorbid mental health difficulties. However, this effect appears to be dependent on whether you ask those receiving treatment, those supporting treatment or those delivering treatment.

Links

Primary paper

Weston L, Hodgekins J, Langdon PE. (2016) Effectiveness of cognitive behavioural therapy with people who have autistic spectrum disorders: a systematic review and meta-analysis. Clinical Psychology Review, 49:41-54 [PubMed abstract]

Other references

Ho BP, Stephenson J, Carter M. (2014) Cognitive-behavioural approach for children with autism spectrum disorders: A meta-analysis. Review Journal of Autism and Developmental Disorders, 1(1), 18-33

Ho BP, Stephenson J, Carter, M. (2015) Cognitive-behavioural approach for children with autism spectrum disorders: A literature review. Journal of Intellectual and Developmental Disability, 40(2), 213-229

Lugnegård T, Hallerbäck MU, Gillberg C. (2011) Psychiatric comorbidity in young adults with a clinical diagnosis of Asperger syndrome. Research in Developmental Disabilities, 32, 1910-1917 [PubMed abstract]

Matson JL, Adams HL, Williams LW, Rieske RD. (2013) Why are there so many unsubstantiated treatments in autism? Research in Autism Spectrum Disorders, 7(3), 466-474

National Institute for Health and Care Excellence. (2012) Autism: Recognition, referral, diagnosis and management of adults on the autism spectrum, NICE Clinical Guideline 142. London: British Psychological Society & The Royal College of Psychiatrists.

Reichow B, Barton EE, Boyd BA, Hume K. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD009260. DOI: 10.1002/14651858.CD009260.pub2.

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