Doctorate in Educational and Child Psychology
Nikki Collingwood
Case Study 1: An Evidence-Based Practice Review Report
Theme: Interventions for children with Special Educational Needs
What is the effectiveness of CBT-based treatments which involve parents in
treating anxiety in youth with ASD?
1. SUMMARY
There is growing evidence which supports the use of Cognitive Behavioural Therapy
(CBT) in addressing anxiety in youth. CBT examines experiences and addresses the
processing of information around these experiences, in order to change behavioural
responses. This review aims to investigate whether CBT with parental involvement is
effective in treating anxiety in children and adolescent with Autistic Spectrum
Disorders (ASD). Nine studies met the inclusion criteria which excluded studies
which were not controlled trials, did not use standardised measures of anxiety or did
not include a substantial parental element in the treatment. Participants’ age ranged
from 7-17, with various ASD and anxiety subtypes. Treatments were either
specifically designed or adapted, with some including social elements. Specific
parental involvement in terms of supporting anxiety management as well as
approaches to parenting were considered to be important elements. Although the
effect sizes varied from small to large depending on report type, the findings suggest
that with appropriate measures, treatment modification and a range of parental
support, CBT can be considered to be promising in this population.
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Doctorate in Educational and Child Psychology
Nikki Collingwood
2. INTRODUCTION
Anxiety in Youth with Autism Spectrum Disorders (ASD)
Autism Spectrum Disorders (ASD) represent a range of neurodevelopmental
disorders characterised by impairments in the domains of social communication and
repetitive patterns of behaviour and interests (Hazen, McDougle, & Volkmar, 2013).
The co-occurrence of anxiety has been found to be highly prevalent in youth with
ASD. In this population, White, Oswald, Ollendick, & Scahill (2009) found clinically
significant anxiety ranged from 11-84%, while a meta-analysis by van Steensel,
Bögels, & Perrin (2011) found that 39.4% had at least one comorbid DSM-IV anxiety
disorder. van Steensel et al (2011) found that Specific Phobia (SpP), OCD and
Social Anxiety were the most common disorders, however, there was variation
depending on age, IQ and ASD subtype. There is debate regarding behavioural
overlaps, specifically, whether the manifestations of anxiety are separate or innate to
ASD, or whether it arises as a result of ASD symptomology (Kerns & Kendall,2012;
Renno & Wood,2013; Tyson & Cruess,2012). Despite this, it is a condition which
requires attention in order to reduce the debilitating impact in this special population.
Cognitive Behavioural Therapy (CBT)
CBT is an evidence-based psychosocial treatment grounded “on the notion that
cognitions or thoughts mediate our emotional and behavioural responses, implying
that it is not external events (i.e., people, situations) that cause our responses but
rather our thoughts about those events” (Scarpa & Lorenzi, 2013, p.4). Behaviour
therapy is based on the influential work on conditioning (Pavlov and Skinner),
learning theory (Eysenck, 1960); information processing and reciprocal determinism
(Bandura, 1977). Cognitive elements are influenced by work on rational emotive
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Nikki Collingwood
behaviour therapy (Ellis, 1962) and the link between emotional distress, negative
beliefs and schemas (Beck,1967). Modern CBT therapy combines behaviour and
cognitive elements to address psychological problems by examining experiences
and addressing the processing of information around these experiences, in order to
change behavioural responses. The therapy identifies relevant coping skills and
creates opportunities to practice. According to Southam-Gerow & Kendall (2000),
this coping template is a central treatment goal and aims to help individuals develop
new, or modify existing cognitive structures for processing information. Sessions and
homework assignments build on practising these new behavioural and cognitive
strategies and evaluating their success. There are several strategies which can be
included in the treatment: affective education; relaxation training; social problemsolving; cognitive restructuring/attribution retraining; contingent reinforcing; modelling
and role playing. The therapist, as an active collaborator in the process, can flexibly
and selectively use these to address relevant issues (Southam-Gerow & Kendall,
2000).
There is empirical support to suggest that CBT is used effectively in youth to address
anxiety (Southam-Gerow & Kendall, 2000). Its use to address anxiety in youth with
ASD varies widely with respect to type, intensity and duration of intervention, and
characteristics of comorbid problems (Howlin, 2010). Given social communication
difficulties inherent in ASD, there is debate as to whether this talk-based therapy is
appropriate for this population. However there is growing consensus that it can be
effective if adapted in order to make it accessible and relevant, although no specific
guidelines have been agreed upon. These modifications may include the
development of disorder specific hierarchies; use of concrete, visual tactics;
inclusion of child specific interests; incorporation of parents (Moree & Davis, 2010).
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Doctorate in Educational and Child Psychology
Nikki Collingwood
Modes of Delivery
There are several different approaches which are available for treating anxiety in
youth using CBT. Individual Cognitive-Behavioural Therapies (ICBT) involve the
therapist focusing only on the child (e.g. Coping Cat programme by (Kendall,
Aschenbrand, & Hudson, 2003). Group Cognitive-Behavioural Therapies (GCBT) are
increasingly used due to cost effectiveness, as well as the use of peer influence and
support in group processes (Southam-Gerow & Kendall, 2000). Family CognitiveBehavioural Therapies (FCBT) support increased involvement of parents and
address elements such as supporting the reward of positive behaviours; parental
anxiety management skills and problem solving skills. In terms of typically
developing children with anxiety disorders, there are inconsistent and ambiguous
results as to whether ICBT or FCBT is most effective (Breinholst, Esbjørn, ReinholdtDunne, & Stallard, 2012). However, with respect children with ASD, parental
involvement in treatment via reinforcement, practice and support in the home and
other environments is identified as potentially ensuring better generalisation and
therapy outcomes (Moree & Davis, 2010).
Relevance of Review
A recent study based on Millennium cohort, estimated a prevalence of ASD of 1.7 %
in the UK population (Russell, Rodgers, Ukoumunne, & Ford, 2014). The growing
incidence, together with high prevalence of co-occurring anxiety suggests a critical
area for educational psychology practice, particularly given the short term impact of
anxiety on peer relationships and school attendance, as well as potential long term
impact on later adult mood disorders. Previous reviews of CBT in children with ASD
have identified emerging effectiveness, however there were concerns over
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Nikki Collingwood
methodological weaknesses (Danial & Wood, 2013). A recent meta-analysis of
studies of CBT (with and without parent involvement) for treating anxiety in youth
with ASD found that treatment groups had significant effects relative to control
groups (Sukhodolsky, Bloch, Panza, & Reichow, 2013). Furthermore, a review of
modification trends in CBT for anxiety in children diagnosed with ASD (Moree &
Davis, 2010), noted that parental involvement, seemed to increase the longevity and
success rate of CBT in some identified studies. However, according to Reaven &
Blakely-Smith (2013), a clearer delineation of parental role in this population would
be an important contribution to this growing body of literature. This systematic
literature review therefore aims to specifically identify and analyse controlled studies
which directly involve parents in CBT therapy, in order to ascertain treatment
effectiveness with this modification for reducing anxiety in youth with ASD.
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Doctorate in Educational and Child Psychology
Nikki Collingwood
3. CRITICAL REVIEW OF THE EVIDENCE BASE
Literature Search
A final search of databases PsycInfo, ERIC and Medline was carried out on January
25th 2014 using a strategy involving combination of the search terms in the title or
abstract identified in Figure 1. The search yielded a total of 344 results
(171+144+29) after Stage 2 (some of which overlapped between databases). Of
these, 313 could be rejected by introducing the concept of “anxiety”. After full
inspection of the 31 articles, 22 were excluded (Appendix A) based on the
inclusion/exclusion criteria outlined in Table 1. The selected nine studies in this
review are summarised in Appendix B.
Figure 1
Search Terms and Search Procedure
Concept 1
Stage 2
Stage 1



Concept 2
Cognitive Behav*
Cognitive Behav* Therapy
CBT
OR





Concept 3
Autis*
Autis* Spectrum
Austis* Spectrum Disorder*
ASD
Asperger*


OR

Anxiety
Anxiety
disorder
Anx*
Concept 1 and 2 combined with ‘AND’
Stage 3
344 articles
Concept 1, 2 and 3 combined with ‘AND’
Stage 4
31 articles
Review of articles in detail to ascertain if studies met inclusion criteria
9 studies
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Doctorate in Educational and Child Psychology
Nikki Collingwood
Table 1. Inclusion and Exclusion Criteria used during Literature Search, together with Rationale
1.
Intervention
Inclusion Criteria
a) Must be based on
cognitive behavioural
type intervention to
reduce anxiety.
Exclusion Criteria
a) Must not be any other
non-CBT based
intervention which
reduces anxiety
Rationale
This is the type of therapeutic
treatment being considered
effective in the population
b) CBT Based intervention
with some adaptations
for use with children
with ASD with the
intention of reducing
anxiety.
b) No adaptations to CBT
for children/adolescents
with ASD.
Review is interested in treatment to
reduce anxiety, which has been
found to have high prevalence in
this population.
c) Must have sufficient
and direct parent/family
involvement in the
treatment.
c) Does not have any or
sufficient direct
parent/family involvement
in the treatment.
Direct Parental involvement in this
population has been indicated as
an important modification of
treatment.
2.
Setting
Must be implemented in a
school, home or therapist
based setting.
Implemented in settings
outside of school, home or
therapist session.
Settings which can be replicated in
further studies of interest.
3.
Participants
Must be children or young
people between age of 5
and 18 with a confirmed
ASD diagnosis (High
Functioning Autism or
Asperger’s) and moderate
to severe level of anxiety.
Children younger than 5 and
young adults older than 18
without an ASD diagnosis or
moderate to severe level of
anxiety.
This is the population of interest
with respect to current educational
psychology practice.
Children younger than this are not
likely to be able to benefit from
CBT.
4.
Type of
study/
design
a) Must be an
experimental designed
containing primary data
with an experimental
group and a
comparison group
(waitlist, delayed
therapy or treatment as
usual)
b) Must have reported pre
and post treatment
outcome data on
anxiety levels
c) Must use standardised
measure(s) of anxiety.
a) Is a case study design.
Does not have a control
group.
Does not contain primary
empirical data e.g. review
paper, meta-analysis,
and theoretical papers.
Comparison of treatment versus
non-treatment needed in order to
ascertain effectiveness and effect
sizes.
Must be published in a peer
reviewed journal
Must not be in non-peer
reviewed journals or a
dissertation/thesis.
6. Language
Must be published in
English
Not available in English
Required so that information can
be read by reviewer
7. Date
Must be published before
January 31st 2014
Must not be published after
st
January 31 2014.
Final search date before write up of
review
5.
Publication
type
b) Does not contain pre and
post treatment outcome
data on anxiety levels.
c) Does not use
standardised measure(s)
of anxiety
7
Empirical data required in order to
identify and compare effectiveness.
Standardised measurements of
anxiety more likely to present
reliable and valid data.
Peer reviewed journals are
assessed against a set of criteria
measuring its quality.
Doctorate in Educational and Child Psychology
Nikki Collingwood
Weight of Evidence (WoE)
The Gough (2007) framework and a UCL Educational Psychology Literature Review
Coding Protocol, adapted from APA Task Force on Evidence Based Interventions in
School Psychology (Kratochwill, 2003) were used to assess the applicability of each
study to the research question. The WoE criteria were based on categories which
are outlined in Appendix C. WoE A identified methodological quality and made a
generic judgement about the coherence and integrity of the evidence. WoE B
identified methodological relevant and considered the appropriateness of the
research design for answering the review question. WoE C identified the relevant of
evidence to the review question. In order to attain an overall assessment of the
extent to which a study contributes evidence to answer the review question,
weightings are given to the scores of WoE A, B and C and averaged to correspond
to an overall weight of evidence (WoE D). Table 2 summarises the final weighting
summary given to each study included in this review (with detailed evaluation of
weighting criteria, procedures and results in Appendix C). The outcomes analysed
are anxiety measures for the children: self-report; parent reported; or clinician rating.
Table 2. Summary of WoE Judgements (based on Gough, 2007)
Study
WoE A:
WoE B:
WoE C:
WoE D:
Quality of
Relevance of
Relevance of
Overall weight of
methodology
methodology
evidence to the
evidence
review question
Chalfant, Rapee,
Medium
High
Medium - High
High
Low
Medium
Medium
Medium
Medium
High
Medium - High
High
Medium
Medium
High
Medium
Medium
Medium
High
Medium
& Carroll (2007)
Fujii et al., (2012)
McConachie et
al. (2013)
Reaven et al.,
(2009)
Reaven et
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Doctorate in Educational and Child Psychology
Study
Nikki Collingwood
WoE A:
WoE B:
WoE C:
WoE D:
Quality of
Relevance of
Relevance of
Overall weight of
methodology
methodology
evidence to the
evidence
review question
al.,(2012)
Sofronoff,
Medium
High
Medium - High
Medium
Medium
High
High
High
Medium
High
Medium
Medium
Medium
High
High
High
Attwood, &
Hinton (2005)
Storch et al.,
(2013)
(White et al.,
2013)
Wood et al.,
(2009)
Participant Characteristics
Appendix D summarises sample characteristics. The age range across all the
studies was 7–17 years. With the exception of the White et al (2013) study, which
focused on adolescents 12 to 17, the remaining studies had younger age ranges.
Given that ASD is a spectrum disorder, each study stated the participant’s
professionally diagnosed ASD type. All but two studies (Chalfant et al, 2007;
Sofronoff et al, 2005) used measures to verify ASD status at the start of the trial,
which could be seen as limiting the validity of the their study. Each study used a
variety of measures in order to ascertain baseline levels of anxiety. The most
common anxiety types assessed was Social Phobia, which had the highest
prevalence in 6 of the studies, followed by GAD in 2 studies, and SpP and SAD in
one study each. Given that Social Phobia was prevalent in the samples, having a
social element linked to the treatment could be linked to the effectiveness of some
studies (Reaven et al, 2012; Storch et al, 2013; Wood et al, 2013) illustrated in their
high WoE.
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Doctorate in Educational and Child Psychology
Nikki Collingwood
Research Design
Appendix E summaries relevant factors which enable a critical review of each
studies design with respect to sample size, randomisation, control group, group
equivalence, concurrent treatment, and measures utilised.
Sample size. Sample sizes ranged from 12 (Fujii et al, 2013) to 71 (Sofronoff et al
(2005). A previous meta-analysis looking at studies for reducing anxiety in young
people with ASD (Sukholdsky et al, 2013) found that Effect Size (ES) ranged from
small to large dependent on the reporter. According to criteria identified in
Kratochwill (2003), the required group size for a medium ES (based on a 2 group
ANOVA at an alpha level of .05) is 64 or 52 (3 group ANOVA at an alpha level of
.05). None of the studies in this review met this criteria and as such, small sample
sizes reduce the WoE for these studies.
Randomisation. All but one study allocated participants randomly to either the
intervention group or control group. Reaven et al (2009) based allocation on order of
enrolment, with the first groups allocated to the intervention group and latter groups
to the control groups – this lack of randomisation impacted on the WoE B. To ensure
greater group equivalence, two studies used technology to randomly allocate
(Reaven et al, 2012; Storch et al, 2013), while White et al (2013) used a person
unaffiliated to the study. Other studies just stated random assignment without details
of approach.
Control Groups. All studies used control groups either in the form of
Waitlists/Delayed Intervention or Treatment as Usual (TAU) groups. However, one
study, Sofronoff et al (2005) used another comparison group (Individual treatment
only) which further enabled comparison of parental involvement in CBT.
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Nikki Collingwood
Group equivalence. All studies identified a degree of equivalence between
intervention and control groups in terms of demographics and clinical factors. Fujii et
al (2013 and McConachie et al (2013) noted that equivalence was obtained along
some dimensions, but they did not provide any specific statistical analysis.
Furthermore, in the Fujii et al (2013) study, the duration of the waitlist control
condition was not identical to the treatment condition (16 vs 32 weeks)
Measures. All studies used at least one standardised measure to assess baseline
and post-trial anxiety levels, however some of the stronger studies used a
combination of standardised measures (scales and interviews) which not only
identified the primary anxiety type, but also linked to Clinical Severity Ratings (CSR)
or Clinical Global Impressions (CGI) on anxiety improvement or severity
(McConachie et al, 2013;Reaven et al, 2012;Storch et al, 2013;White et al,
2013;Wood et al, 2009). In addition to this, these studies also used a combination of
child, parent and clinician to identify anxiety levels. While Chalfant et al (2013) did
use a combination of measures with multiple informants, it was not linked to a
severity rating. Some of the studies with lower WoE used only one standardised
measure (Fujii et al, 2013;Reaven et al, 2009) but with more than one informant.
Sofronoff et al (2005) used both child and parent reported measures, however the
child measure was unstandardized. A systematic review of available measures for
anxiety in youth with ASD (Lecavalier et al., 2013) examined ten measures. Those
studies which used two or more some of the measures considered more appropriate
(Storch et al,2013;White et al,2013;Wood et al,2009) could be deemed to produce
more acceptable outcome data, compared to studies which relied only potentially
acceptable measures (Reaven et al,2009). The Spence Children Anxiety Scale
(SCAS) and Children’s Automatic Thoughts questionnaire (CATS) were not
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Nikki Collingwood
evaluated in the systematic review, and so it appropriateness is unknown. However,
a report by (Ozsivadjian, Hibberd, & Hollocks,2013) specifically used these
measures to assess ability of young people with ASD to access symptoms of anxiety
and negative thoughts, suggesting that they are valid measures.
Application of intervention
Given that heterogeneity of the CBT interventions, Appendix F summarises key
elements of the treatments.
Treatment duration. The duration of CBT treatment ranged from briefer therapy of 6
or 7weeks (Sofronoff et al, 2005;McConachie et al, 2013) to longer term treatment of
32 weeks (Fujii et al,2013). The remaining five studies had treatments lasting 12 to
16 weeks. The intensity and duration of a treatment may well have impact on both
effectiveness and cost-effectiveness. Results from this review are inconclusive, but
the shorter interventions seemed to have lower effect sizes.
Components of Treatment and Adaptation for ASD. Most of CBT treatments used in
the studies used similar components: an understanding of anxiety; anxiety
management and strategies and graded exposure to situations were common to
almost all treatments. Some treatments were specifically designed for children
and/or adolescents with ASD and anxiety (Reaven et al, 2012;Sofronoff et al,
2005;Storch et al, 2013;White et al, 2013) and so could suggest greater
effectiveness. However, even in those not specifically designed for this population,
relevant adaptations were put in place to a limited degree in some treatments
(e.g.McConachie et al,2013) and to a greater degree in others (eg. Chalfont et
al,2007). The main adaptations include: making materials more concrete and visual;
simplification of exercises; relaxation and the addition of a social skills element.
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Doctorate in Educational and Child Psychology
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Delivery Mode. There was a range of delivery modes across the studies, with some
studies directing sessions at the individual (eg.Fujii et al,2013; Storch et al,2013;
Wood et al,2009), and others at groups – children and parents separately or together
(Chalfant et al,2007; McConachie et al,2013; Reaven et al 2009,2012; Sofronoff et
al, 2005; Wood et al, 2009) or a combination of individual and groups (White et al,
2013). This review found inconsistent results as to which mode was preferable with
respect to outcomes.
Parental intervention elements. All studies included parental involvement in the
treatment (Table 3) supporting high WoE C in most studies. Mode of involvement
ranged from separate to conjoined attendance. Parental elements were somewhat
heterogeneous. McConachie et al(2013) specifies parents went through the same
treatment modules as children, while Sofronoff et al(2005) indicates a more
therapeutic role with parents trained as co-therapists. Parents in White et al’s (2013)
study received coaching which was deemed more appropriate for adolescents.
Table 3. Parental Involvement in CBT Treatments
Study
CBT Intervention
Parent mode of
involvement
Parent Component
Chalfant et al
(2007)
HFA adaptation to the Macquarie
University, ‘‘Cool Kids’’
program (Lyneham, Abbott,
Wignall, & Rapee, 2003)
Separate,
concurrent sessions
Fujii et al (2013)
Building Confidence CBT program
(Wood & McLeod, 2008)
modified for use with children
with ASD (Wood, Drahota,, Sze,
Har, Chiu, & Langer, 2009).
Exploring Feelings (Attwood,
2004)
Sessions divided
into separate and
conjoined elements
Addressed anxiety education, relaxation strategies, cognitive
restructuring exercises, graded exposure, parent management
training and relapse prevention.
Families planned out their weekly exposure tasks (outside of
sessions).
Parents taught social coaching skills to support children at home
and during play dates.
Parents worked with teachers to implement the interventionrelated homework at school.
Coping Group: Fighting Worries
and Facing fears (Reaven,
Hepburn, Nichols, Blakely-Smith,
& Dasari, 2005)
Mixture of separate
parent and child
group meetings, and
parent-child dyads.
McConachie et
al (2013)
Reaven et al
(2009)
Separate,
concurrent sessions
13
Parents worked through the same exercises and materials as
children: being happy, relaxed or anxious, then moved on to
build a toolbox of strategies, including physical, social and
thinking tools.
Psycho-education pf anxiety disorders and introduction to
basic principles of CBT
Identification of child’s specific anxiety symptoms
Identification of target behaviours in preparation for
graded exposure assignments
Discussion of parental anxiety and parenting style
Discussion of social-communication challenges in ASD and
impact on protective parenting style
Doctorate in Educational and Child Psychology
Study
Nikki Collingwood
CBT Intervention
Parent mode of
involvement
Reaven et al
(2012)
Facing Your Fears (Reaven,
Blakely-Smith, Nichols &
Hepburn, 2011)
Mixture of separate
parent and child
group meetings, and
parent-child dyads.
Sofronoff et al
(2005)
Storch et al
(2013)
CBT programme (Sofronoff et al,
2005)
Behavioural Interventions for
Anxiety in Children with Autism
(BIACA; Wood & Drahota, 2005)
White et al
(2013)
Multi Modal Anxiety and Social
Interaction (MASSI; White,
Albano, Johnson, Kasari,
Ollendick, Klin et al (2010)
Parent attendance
at child sessions
Separate sessions
with child and
parent; parents
could attend child
sessions
Parent session after
each child therapy
session.
Wood et al
(2009)
Building Confidence (Wood and
McLeod, 2008)
Parent attendance
at child sessions
Parent Component
-
Psycho-education regarding anxiety symptoms and CBT
strategies
Parent coaching to support child participation
Discussion of parental anxiety, parenting style and anxiety
symptoms
Social and communication challenges in ASD and link to
parenting style (protective)
Parents trained as co-therapists in all components of the
intervention.
Conducting exposure tasks at home; psycho-education; social
skills facilitation; encouraging independence; establishing
reward system; parent/school advocacy; supporting processing
termination.
Parent education and coaching after each of the 13 individual
sessions.
Act as “coaches” for exposure exercise during the week, making
environmental changes; encourage and reinforce
implementation of desired target behaviours
Supporting in vivo exposes, using positive reinforcements and
building communication skills to encourage independence and
autonomy in daily routines.
Elements mainly involved: anxiety education, parenting style support; exposure task
training; and social coaching/support. More effective interventions (e.g. Chalfant et
al, 2007; Storch et al,2013) used a range of these elements, while the therapy in the
Fujii et al (2013) study focused more on social coaching.
Findings: Outcomes and Effect Size (ES)
Effect sizes are identified in Table 4, with main outcomes linked to measures of
anxiety in Appendix G. Given the heterogeneity of outcome measures, effect sizes
were computed when mean and standard deviation data was available for anxiety
measures in both the treatment and control groups. Effect Sizes were calculated by
dividing the differences in the means of each group (pre and post-test) by the pooled
standard deviation (Hedge’s g). The effect sizes were evaluated by comparing them
to Cohen's (1992) interpretation of small (.2), medium (.5) and large (.8) effect sizes.
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When comparing ES within and between studies, a varied picture emerges.
However, some key themes can be identified, indicating effectiveness. Firstly, all the
studies which had Clinician-based measures reported medium to large ES, except
for White et al (2013). However, these results need to be evaluated in the light that
only
some
studies
(McConachie
et
al,2013;Reaven
et
al,2012;Storch
et
al,2013;White et al,2013) mention that evaluators at post-test were blinded to which
group they were evaluating. This adds greater value to the results of these particular
studies.
Secondly, there was an inconsistency between parent and child reports in many
studies, where child reports showed reduction in anxiety, but not the parent reports
(McConachie et al,2013;Storch et al,2013) and vice-versa (Reaven et al,2009;
Wood et al,2009).
Considering the studies as a whole, three studies in particular, Chalfant et al (2007);
Storch et al, (2013) and Wood et al (2012), can be singled out as having a High
WOE overall, a spread of reports and measures, as well at least two large ES and
significant outcomes. While the sample size limited their methodological quality, the
treatments contained various components which may suggest greater effectiveness.
They all included: exposure tasks which were also supported by parents; both
parents and children were educated in anxiety and anxiety management; there was
an element on parenting style and effective parenting skills.
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Table 4. Summary of Study Findings According to Report Type: Anxiety measures, Significance, Effect Size (T1 – T2) and Interpretation, Overall WoE
Study
Sample
Size
Clinician Report
Measure
Sig/
Not
Sig
Sig
Effect
Size
.59
reported
Parent Report
Interpretation
(Cohen, 1992)
Measure
Medium
SCAS-P
Chalfant et
al (2007)
47
ADIS –C/P
Fujii et al
(2013)
12
CSR (based on
ADIS-C/P)
Sig
3.14
Large
McConachie
et al (2013)
Reaven et al
(2009)
Reaven et al
(2012)
32
ADIS-C
Sig
1.25
Large
Sofronoff et
al (2005)
71
33
50
Sig/
Not
Sig
Sig
Sig
.61
Sig
1.03
reported
SCAS-P
White et al
(2013)
Wood et al
(2009)
Measure
Large
CATS (int)
RMAS
SCAS-C
Sig/
Not
Sig
Sig
Sig
Sig
Effect
Size
1.49
2.76
2.57
Interpretation
(Cohen, 1992)
Large
Large
Large
Not
Sig
Sig
.06
Small
SCAS-C
1.00
Large
SCARED -C
Not
Sig
Not
Sig
High
.10
Small
High
.34
Small
Medium
Medium
Medium
Large
SCAS-P *
Sig
.84
Large
SCAS-P*
Sig
.18
Small
MASC-P
Not
Sig
.16
Small
CASI-Anxiety
scale
MASC-P
Not
Sig
Sig
.30
Small
.94
Large
Medium
(FCBT - WL)
(FCBT - ICBT)
Storch et al
(2013)
2.24
Interpretation
(Cohen, 1992)
Overall
WoE (D)
Medium
SCARED-P
ADIS-P Prin.
Anxiety CSR
CGI-I
Effect
Size
Self -Report
45
PARS
ADIS-highest
CSR
CGI-Severity
Sig
30
PARS
40
ADIS-C/P CSR
Not
Sig
Sig
Sig
Sig
1.60
1.61
Large
Large
.59
Medium
.32
Small
3.70
Large
RCMAS –
anx scale
Sig
.25
Small
Medium
MASC-C
Not
Sig
.09
Small
ADIS = Anxiety Disorders Interview Schedule; CATS(int) = Children’s Automatic Thoughts Scale(internalising scale); CASI-Anx= Child and Adolescent Symptom Inventory Anxiety Scale; CGI-I = Clinical Global
Impressions Scale – Improving ratings; CGI-S = Clinical Global Impressions Scale – Severity ratings; C/P: measure completed by Child/Parent; CSR = Clinician’s Severity Rating; MASC= Multidimensional Anxiety Scales
for Children; PARS = Paediatric Anxiety Rating Scale; RCMAS = Revised Children’s Manifest Anxiety Scale; SCARED = Screen for Child Anxiety and Related Emotional Disorders; SCAS = Spence Children’s Anxiety Scale;
SCAS-P *= compared T1 to T3
16
High
High
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Nikki Collingwood
In two of the studies (Storch et al, 2013 and Wood et al, 2012) there was a particular
focus on social skills training, again supported by parents. In terms of adaption for
ASD, both the “Cool Kids“ (Chalfant et al, 2007) and “Building Confidence” (Wood et
al, 2012) treatments were heavily enhanced in the areas of building in concrete,
visual activities in the former, with a heavy focus on addressing social skills relevant
to ASD in the latter treatment. The BIACA treatment used in the Storch et al (2013)
study required not adaptation as it was specifically designed for children with ASD.
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4. CONCLUSIONS
The aim of this review was to identify the effectiveness of various CBT treatments,
which included a substantial parental element, in order to address anxiety in youth
with ASD. ES and outcomes suggest a generally positive impact of the treatment,
however some issues were identified. Conclusions and implications for professional
practice when considering this treatment and recommendations for future research
are outlined below.
Firstly, ES ranged from small to large, with clinician reports mainly on the mediumlarge side, and a higher number of small ES reported by parents and self-reports.
This is line with ES reports in a previous meta-analysis (Sukholdsky et al, 2013).
Similarly, an inconsistency between parent and child reports was reported in many
studies. Research has not been unanimous as to which report is more reliable and
while triangulation and a range of reports is to be encouraged, objective and
accurate reporting ability needs to be further clarified and ensured. Furthermore,
measures of anxiety used in the studies were developed for a non-ASD population.
While some of these measures are considered somewhat more appropriate for the
ASD population (Lecavalier et al., 2013) the complex relationship between anxiety in
ASD and overlap of anxiety symptoms suggests that additional analyses of the
appropriateness of measures needs to be undertaken, perhaps even the
development of a measure which is specifically for this population.
Secondly, there was a reinforcement of the inclusion of parents in treatments. While
this review specifically reviewed treatments which had a substantial parental
element, Sofronoff’s et al (2005) study suggests that family based CBT was possibly
more effective than individual CBT.
Aside from the obvious enhancement in
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Nikki Collingwood
generalisation, a further benefit is suggested by a study by Conner, Maddox, & White
(2013) which found parent’s trait anxiety decreased with the treatment of their
children’s own anxiety. Evidence suggestive of parental behaviour influencing autism
phenotype is also emerging (Baker, Smith, Greenberg, Seltzer, & Taylor, 2011) and
as such “parents may be the untapped yet crucial agents of change their children
need when they support skills development, foster generalisation of new skills, and
even help to prevent the onset of anxiety symptoms” (Reaven & Blakely-Smith,
2013, p.102). A range of parental input such as building knowledge of anxiety
management; parenting skills to support social skills and encourage independence,
were identified in this review. Furthermore, analysis of these studies have identified a
subtle difference in type of parental support depending on age. There appears a
greater intensity of support for younger children, while for the mainly adolescent
treatment, parental involvement errs more in the direction of coaching (White et al.,
2010). Indeed, training parents as co-coaches may have potential merit (Leong &
Cobham, 2009) for all ages. Overall, Moree & Davis (2010) emphasise parental
involvement
as
increasing
longevity
and
success
rate.
Thirdly, the adaptation of treatment needs to be considered. Including a social skills
element, reinforced in group work seems to have particular merit. Additionally, the
inclusion of school personnel to reinforce social skills and treatment, as in the
approach outlined in the Fujii et al (2013) study, which although was very small
scale, seemed to have very positive impact. While some treatments were specifically
designed for this population, it seems that it adapting existing manuals appropriately
for the ASD population resulted in equally successful outcomes.
Participant characteristics also need to be considered. The use of CBT in this
population needs to recognise certain boundaries with regard to IQ. Intellectual
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ability is important factor to be aware of since CBT places certain demands in the
form of a meta-cognitive and expressive and receptive language. According to
Scarpa, White, & Attwood (2013), under the new DSM-5 (APA, 2013) former labels
of autistic disorder, Asperger’s disorder, PDD are subsumed under the ASD term,
with co-occurring intellectual impairment used as a specifier. Therefore future studies
may not use particular spectrum distinctions, as intellectual specification will become
more important in order to distinguish between High Functioning ASD (HFASD) and
ASD with intellectual impairment. The use of CBT in specifically higher functioning
youth with ASD may provide a greater perspective on effectiveness in a particular
section of this population.
Since CBT involves the modification of maladaptive thoughts, there is also the
cognitive elements to consider with respect to age: concrete to abstract problem
solving; ego-centrism to self-reflection/self-monitoring (Keating, 1990; Kingery et al,
2006). Therefore there are implications regarding mixing younger children with older
children in any group activities, and emphasises the need to differentiate any CBT
program to taken into these developmental issues.
Finally, delivery mode is another area which has some implications for practice. The
studies in this review used either individual or group CBT or a combination of both.
Rationale given for individual included individualisation to meet unique needs, while
group treatment enables practice of social skills and anxiety management (White et
al., 2010). White et al (2013)’s study tried to maximise the benefits of both, by initially
using ICBT and moving to GCBT for reinforcement. Practically and from costeffectiveness point of view , the mode of delivery as well as alternatives need to be
calculated to help inform policy makers decide how best to treat individuals with ASD
and co-occurring anxiety.
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In addition to some issues identified above, the following areas warrant further
research. A few studies have looked at treatments in this population which exclude
parental/family input (Ooi et al., 2008;Ozsivadjian & Knott, 2011;Sung et al., 2011)
and some with limited parental role (e.g.McNally Keehn, Lincoln, Brown, & Chavira,
2013). While research has questioned the value of parental involvement in CBT for
treatment for children with anxiety disorder in non-ASD population (Breinholst et al.,
2012), a study by Puleo & Kendall (2011) found FCBT outperformed ICBT or
children with moderate ASD symptoms. However, there appears to be limited
research which directly studies the value of parental input over child only therapy in
the ASD population.
Regarding design of future studies, beside larger sample sizes, the issue of control
group type needs to be considered. In the studies reviewed, waiting list or TAU
controls were used (with the exception of Sofronoff et al, 2005). In addition, some
studies did not tightly control concomitant treatments due to ethical issues. Utilising
an alternative treatment for comparison purposes as a control group would be a
useful extension to this growing body of research. Finally, there seems to be a
dearth of RCT studies which focus on CBT for adolescents with ASD and anxiety,
despite this being a critical population to serve.
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Appendix A: List of excluded studies
Study
Reason for exclusion
(criterion number)
Bauminger, N. (2007). Brief Report: group social-multimodal intervention for
HFSAD. Journal of Autism and Developmental Disorders, 37 (8), 1605-1615.
CBT not focussed on reducing
anxiety.
Criteria 1a
Cardaciotto, L., & Herbert, J.D. (2004) Cognitive behaviour Therapy for social
anxiety disorder in the context of Asperger’s syndrome: A single-subject report.
Cognitive and Behavioral Practice,11, 74-81.
Single subject case study.
Criteria 4a
Grieg, A., & MacKay, T. (2005). Asperger’s Syndrome and cognitive behaviour
therapy: New applications for educational psychologists. Educational and Child
Psychology, 22, 4-15.
Single subject case study.
Criteria 4a
Helverschou, S.B., Utgaard, K., & Wandaas, P. (2013). The challenges of applying
and assessing cognitive behavioural therapy for individuals on the autism
spectrum in a clinical setting: a case study series. Good Autism practice (GAP), 14
(1), 17 – 27.
Case Study design.
Criteria 4a
McNally Keehn, R.H., Lincoln, A.J., Brown, M.Z., & Chavira, D.A. (2013). The Coping
Cat Program for Children with Anxiety and Autism Spectrum Disorder: A Pilot
Randomised Controlled Trial. Journal of Autism and Developmental Disorders, 43
(1), 57-67.
Not sufficient direct
parent/family involvement in
treatment
Criteria 1c
Nadeau, J.M., Arnold, E.B., Storch, E. A., & Lewin, A.B. (2014). Family CognitiveBehavioral Treatment for a Child with Autism and Comorbid Obsessive Compulsive
Disorder. Clinical Case Studies, 13 (1), 22- 36.
Case Study design.
Criteria 4a
Ooi, Y.P, Lam, C.M, Sung, M., Tan, W.T.S, Goh, T.J., Fung, D.S.S., Pathy, P., Ang,
R.P., & Chua, A. (2008). Effects of cognitive-bheavioural therapy on anxiety for
children with high-functioning autistic spectrum diorders. Singapore Medical
Journal, 49 (3), 214-220.
No control group
Criteria 4a
Ozsivadjian, A., & Knott, F. (2011). Anxiety problems in young people with autism
spectrum disorder: A case series. Clinical Child Psychology and Psychiatry, 16
(2),203 – 214.
No control group
Criteria 4a
Puleo, C.M., &Kendall, P.C. (2011). Anxiety Disorder in Typically Developing Youth:
Autism Spectrum Symptoms as a predictor of Cognitive-Behavioral Treatment.
Journal of Autism and Developmental Disorders, 41, 275-286.
Participants did not have a
diagnosis of ASD and there was
not control group
Criteria 3 and 4
Reaven, J., & Hepburn, S. (2003). Cognitive-behavioral treatment of obsessivecompulsive disorder in a child with Asperger syndrome: A case report. Autism, 7,
145-164.
Single subject case study and
before 2003.
Criteria 4a and 7
Reaven, J., Blakely-Smith, A., Leuthe, E. Moody, E., & Hepburn, S. (2012). Facing
Your Fears in Adolescence: Cognitive-Behavioral Therapy for High-Functioning
Autism Spectrum Disorders and Anxiety. Autism Research and Treatment, 2012,
No Control group
Criteria 4a
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Study
Reason for exclusion
(criterion number)
Rivard, M., Paquet, A., & Mainville, J. (2011). Cognitive-behavioural therapy for
anxiety in children and adolescents with autism spectrum disorders. Journal de
Therapie Comportementale et Cognitive. Vol.21(3), 97-102.
Not available in English.
Criteria 6.
Russell, A.J., Jassi, A., Fullana, M.A., Mack, H., Johnston, K., Heyman, I., Murphy,
D.G., & Mataix-Cols, D. (2013). Cognitive behavior therapy for comorbid obsessivecompulsive disorder in high-functioning autism spectrum disorders: a randomized
controlled trial. Depression & Anxiety, 30(8):697-708.
Adults included in sample
Criteria 3
Scarpa, A., &Reyes, N. (2011). Improving Emotional Regulation with CBT in Young
Children with High Functioning Autism Spectrum Disorders: A Pilot Study.
Behavioural and Cognitive Psychotherapy, 39, 495-500.
Did not use standardised
measure of anxiety.
Criteria 4.
Schleismann, K. D., & Gillis, J. M.(2011). The Treatment of Social Phobia in a Young
Boy with Asperger's Disorder. Cognitive and Behavioral Practice, 18 (4): 515-529.
Single subject case study
Criteria 4a
Sung, M., Ooi, Y.P., Goh, T.J., Pathy, P., Fung, D.S.S., Ang, R.P., Chua, A., & Lam,
C.M. (2011). Efects of Cogntive-Behavioural Therapy on Anxiety in Children with
Autism Spectrum Disorders: A Randomised Controlled Trial. Child Psychiatry and
Human Development, 42, 634-649.
No parent intervention
Criteria 1c.
Sze, K.M., & Wood, J.J. (2007).Cognitive behavioural treatment of comordid
anxiety disorders and social difficulties in children with high-functioning autism: A
case report. Journal of contemporary Psychotherapy, 37, 133-143.
Single subject case study
Criteria 4a
Sze, K.M., & Wood, J.J. (2008).Enhancing CBT for the treatment of comorbid
anxiety disorders and social difficulties in children with high-functioning autism.
Behavioral and Cognitive Psychotherapy, 36, 403-409.
Single subject case study
Criteria 4a
Weiss, J., & Lunsky, Y. (2010). Group Cognitive Behaviour therapy for adults with
Asperger’s and anxiety or mood disorder: A case series. Clinical Psychology and
Psychotherapy, 17, 438-446.
Adults included in sample and
no control group.
Criteria 3 and 4a.
White, S.W., Ollendick, T., Scahill, L., Oswald, D., & Albano, A. (2009). Preliminary
Efficacy of a Cogntive-Behavioral Treatment Program for Anxious Youth with
Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, 39,
1652-1662.
No Control group
Criteria 4a
Wood, J.J., Drahota, A., Sze, K., Van Dyke, M., Decker, K., Fujii, C., Bahng, C. Renno,
p., Hwang, W., & Spiker, M. (2009). Brief Report: Effects of Cogntive Behavioral
Therapy on Parent-Reported Autism Symptoms in School-age children with HighFunctioning Autism. Journal of Autism and Developmental Disorders, 39, 16081612.
Anxiety reduction not focus of
treatment, so no reported pre
and post data on anxiety
levels.
Criteria 1b and 4b
29
Doctorate in Educational and Child Psychology
Nikki Collingwood
Appendix B: Summary of Studies in Review
Study and Aims
Chalfant, Rapee and Caroll
(2007)
Randomised controlled trial
(wait list control) investigating
the effectiveness of CBT for
HFA children who have a
comorbid anxiety disorder.
Study tried to establish
whether active treatment
condition would produce
significantly greater change in
anxiety variables than the Wait
List condition.
Fujii, Renno, McLeod, Enjey
Lin, Decker Zielinski & Wood
(2013)
Pilot study.
An intensive modular CBT
program delivered to address
anxiety, self- regulation and
social engagement in school
and community. Emphasis on
generalising coping skills and
social behaviour by involving
school personnel.
Sample
Intervention
Design
Anxiety Outcome
Measures
47 children with a
professional
diagnosis of ASD
(27.7% HFA, 72.3%
Asperger’s). Use of
ADIS
Participants also had
a primary anxiety
disorder (SAD, GAD,
SP, SpD, PD)
Therapy provided in
groups of children by
2 clinical
psychologists. A
third psychologists
conducted
concurrent parent
discussion sessions.
Randomised
design and
assignment to
either CBT
condition or WL
condition.
Self-report
Children’s Automatic
Thoughts Scale (CATS)
(Schniering & Rapee, 2002)
Post-treatment, 71.4% of children from
the CBT condition no longer met the
DSM-IV criteria for current primary
anxiety disorder
Sig
.59
Revised Children’s Manifest
Anxiety Scale (RCMAS)
(Reynolds, C. R., &
Richmond, 1978)
CATS Internalising Scale:
CBT group reported significantly less
internalising thoughts about self-esteem
and anxiety than WL group in pre- and
post-test.
Sig
1.49
RMAS: significant reduction between
pre- and post-test in self-reported
anxiety in CBT group compared to WL
Sig
2.76
Sig
2.57
Sig
2.24
Sig
3.14
Sample size: 47
Male: 35
Female: 12
Intervention
group:28
Control group:19
Age range: 8 - 13
Mean age: 10.8
12 children who met
research criteria for
ASD (Autism and
PDD-NOS) and at
least one anxiety
disorder
Sample size: 12
Male: 9
Female: 3
Intervention group:7
Control group:5
Age range: 7 - 11
Mean age: 8.8
CBT intervention
designed as an HFA
adaptation to “Cool
Kids” program
(Lyneham, Abbott,
Wignall, & Rapee,
2003).
9 weekly 2 hr
treatment sessions
and three monthly
booster sessions (12
sessions in total)
32 week familybased CBT to
anxiety in youth with
high functioning ASD
and comorbid
anxiety. 90 minutes
sessions (30 min
with child; 30 min
with parent; 30 min
joint child and parent
Spence Children’s Anxiety
Scale (SCAS-C) (Spence,
1998)
Parent-Report
Spence Children’s Anxiety
Scale – Parent scale
(SCAS-P) (Spence, 1998).
Random
assignment to
immediate
treatment (IT) or
a treatment-asusual (TAU)
comparison
group.
Clinician Report
Anxiety Disorders Interview
Schedule (ADISC/P;(Silverman & Albano,
1996)). Generated Clinical
Severity Rating (CSR)
scores ranging from 0 to 8
(higher scores – higher
anxiety)
.
Treatments: Building
Confidence (Wood &
McLeod, 2008)
modified for use with
children with ASD
30
Outcomes
SCAS_C: overall reduction of selfreported anxiety symptoms between
pre-and post-test results in CBT
condition.
SCAS-P: Parents reported significant
reduction in their child’s anxiety
symptoms pre- and post- treatment if
they were in the CBT group.
5 out of 7 (71.4%) in IT condition no
longer met diagnostic criteria for
primary anxiety disorder after treatment,
while all children in TAU still met
diagnostic criteria for primary anxiety
disorder.
Sig/
Not Sig
Effect
Sizes
Doctorate in Educational and Child Psychology
Study and Aims
Sample
Nikki Collingwood
Intervention
Design
Anxiety Outcome
Measures
Outcomes
Sig/
Not Sig
Effect
Sizes
(Wood et al, 2009).
McConachie, McLaughlin,
Grahame, Taylor, Honey,
Tavernor, Rodgers, Freeston,
Hemm, Steen & Couteur
(2013).
To investigate the acceptability
and feasibility of adapted
group therapy fo anxiety with
ASD.
Pilot study.
Reaven, Nichols, Dasari,
Flanigan & Hepburn (2009)
Pilot study.
Aim: to assess the
effectiveness of an original,
manualised, cognitivebehavioural group treatment
with parental involvement, in
the reduction of anxiety
symptoms in children with high
functioning ASD.
Reaven, Blakeley-Smith,
Culhane-Shelburne & Hepburn
(2012)
Aim: to identify if children
receiving active treatment Face Your Fears CBT
32 children aged 9 –
13 who had a
confirmed diagnosis
of ASD and met
criteria for at least
one anxiety disorder.
Sample size: 32
Male: 28
Female: 4
Intervention
group:17
Control group:15
Age range: 9-14
33 children with ASD
(Autistic Disorder =
15; PDD = 4;
Asperger = 14) with
a primary anxiety
diagnosis of GAD,
Sep A, Soc A.
Sample size: 33
Male: 26
Female: 7
Intervention
group:10
Control group:23
Age range: 8-14
Mean age: 11.10
50 children with
diagnosis of ASD
and diagnoses of
anxiety in the
following areas:
Separation Anxiety
(SEP); Social
CBT Intervention:
“Exploring Feelings”
(Attwood, 2004)
involving 7 two hour
sessions with
parents and children
in separate groups,
with different group
leaders.
12 weekly session
(1.5 hours) in large
groups, separate
parent and child
group meetings and
parent-child dyads.
Treatments: Coping
Group: Fighting
Worry and Facing
Fears (Reaven,
Hepburn, Nicholls,
Blakeley-Smith, &
Dasari, 2005) –
original creation
specifically for
children with ASD.
12 weekly session
(1.5 hours) in groups
of 3-6 children and
parents. Sessions
included large group
(children and
parents); small
Randomised
allocation to
immediate
therapy (IT) or
control delayed
therapy (DT)
using random
permuted
blocks.
Clinician Report
ADIS child version
(Silverman and Albano,
1996)
Child and Parent Report
Spence Children’s Anxiety
Scale – C/P (SCAS;
Spence 1998)
Assignment to
Active
Treatment (AT)
or Wait List
Contol based on
order of
enrolment, not
random
assignment.
Child and Parent Report
Screen for Child Anxiety
and Related Emotional
Disorders (SCARED –
P/C;Birmaher et al., 1999)
Random
assignment to
treatment (FYF)
or TAU group
using a
computergenerated
Clinician Report
ADIS-P (Silverman &
Albano, 1996)
Which provided summary
codes of severity and
interference (Clinical
Severity Ratings).
CGI: no significant difference between
IT and DT in the blind rating.
ADIS: 13 out of 17 in the IT reported to
have reduction in severity of primary
anxiety disorder, compared to 5 in DT.
Sig
1.25
Children reported reduction in anxiety
Not Sig
.10
Parents did not report reduction in
anxiety
Not Sig
.06
Sig
1.00
Not Sig
.34
Sig
.61
SCARED-P
Parent report suggests that children in
active treatment group experience
significant decrease in anxiety
symptoms severity over time compared
to WL group.
SCARED-C
Child reports showed no significant
effects of treatment over time
31
CSRs were lower in the intervention
group post-intervention with significant
differences between FYF and TAU
groups in all 4 diagnoses of anxiety.
Significant reduction in number of
principal anxiety disorders (ADIS-P)
Doctorate in Educational and Child Psychology
Study and Aims
Sample
program (FYF) would
demonstrated reduction in
anxiety severity, decreases in
number of pre-treatment
anxiety diagnoses and show
overall improvement in anxiety
symptoms from baseline levels
in comparison to children in
the Treatment as Usual (TAU)
condition.
Anxiety (SOC);
Specific anxiety
(spP) and
Generalised anxiety
(GAD).
Sofronoff, Attwood & Hinton
(2005)
71 children aged 10 12 years with
primary diagnosis of
Asperger’s by a
professional.
Aim: Evaluate the
effectiveness of a brief CBT
intervention for anxiety with
children diagnosed with
Asperger Syndrome and to
evaluate whether more
intensive parent involvement
would increase child’s ability to
manage anxiety.
Storch, Arnold, Lewin,
Nadeau, Jones, De Nadai,
Mutch, Selles, Ung & Murphy
(2013)
Aim: to examine the efficacy of
a modular cognitivebehavioural therapy (CBT)
protocol relative to treatment
as usual (TAU) among
children with high-functioning
autism spectrum disorders
(ASD) and clinically significant
Sample size: 50
Male: 48
Female: 2
Intervention
group:24
Control group:26
Age range: 7-14
Presence of anxiety
established via
parent report.
45 children with
diagnosis of high
functioning ASD and
clinically significant
anxiety.
Sample size: 45
Male: 36
Female: 9
Intervention
group:24
Control group:21
Age range: 7-11
Nikki Collingwood
Intervention
group (children and
parents separate)
and dyadic
parent/child pairs).
Lead by clinical
psychologists and
supported by
trainees.
Treatments: Facing
Your Fears (Reaven,
Blakeley-Smith,
Nicholls, & Hepburn,
2011) – original
creation specifically
for children with
ASD.
6 week intervention.
Treatment: highly
structured CBT
programme
conducted by
therapists.
16 weekly session
(60 – 90 mins) with
child and parent
focused modules.
Treated by
Therapists in a
clinical setting.
Treatment::
Behavioural
Interventions for
Anxiety in Children
with Autism (BIACA)
Design
assignment
system.
Randomly
assigned to
Child only; Child
+ Parent; WaitList.
Anxiety Outcome
Measures
Clinical Global Impressions
Scale – Improvement
ratings (CGISI-; National
Institute of Mental Health,
1970)
Parent Report
Spence Children’s Anxiety
Scale –P (SCAS; Spence,
1995)
Child Report
James and The Maths Test
(Attwood, 2002)
Participants
randomised into
the CBT or TAU
group by
computer
generated
algorithm,
Outcomes
Sig/
Not Sig
Effect
Sizes
was found in the FYF group, not in the
TAU group.
CGIS_I showed a “clinically meaningful
improvement in anxiety severity” for
FYF group sample compared to the
TAU sample.
Both interventions groups significantly
better over time, compared to WL.
Combined Child+Parent group showed
greater improvement than Child only
or Waitlist from T1 to T3 (follow-up)
Sig
1.03
Sig
Sig
.18
.86
Improvement in strategies to deal with
anxiety provoking situations, with Child
+ Parent group generating significantly
more strategies than Child only group.
No data
Clinician Report
Pediatric Anxiety Rating
Scale (PARS;RUPP, 2002)
PARS: 29% reduction after CBT
treatment compared to 9% for TAU.
Sig
1.60
ADIS-C/P (Silverman &
Albano, 1996)
Which provided summary
codes of severity and
interference (Clinical
Severity Ratings).
Clinical Global Impressions
Scale – Severity and Improvement ratings
Large group differences in CBT
compared to TAU group CGIS and
ADIS Highest CSR.
Sig
Sig
1.61
.59
32
Doctorate in Educational and Child Psychology
Study and Aims
Sample
anxiety.
White, Ollendick, Albano,
Oswald, Johnson, SouthamGerow, Kim & Scahill (2013)
Aim: to evaluate the feasibility
and preliminary outcomes of
the Multimodal Anxiety and
Social Skills Intervention
(MASSI) program.
Pilot study.
Wood, Drahota, Sze, Har,
Chiu & Langer (2009)
Aim: to test a modular CBT
program for child with ASD
and comorbid anxiety
disorders.
Nikki Collingwood
Intervention
Design
CBT program (Wood
& Drahota, 2005)
30 adolescents with
ASD and anxiety
symptoms of
moderate or greater
severity.
Sample size: 30
Male: 23
Female: 7
Intervention
group:15
Control group:15
Age range: 12-17
40 children with ASD
and an anxiety
disorder.
Sample size: 40
Male: 27
Female: 13
Intervention
Outcomes
Sig/
Not Sig
Effect
Sizes
(CGIS-I; National Institute
of Global Health, 1970)
20 sessions: 13
individual therapy
(followed by parent
education and
coaching) and 7
group therapy
sessions.
Participants
randomised into
the MASSI or
Wait List (WL)
group by person
unaffiliated to
study.
Treatment: MASSI
(White et al., 2010),
Simultaneous
delivery of individual
and group treatment.
Also worked on
social skills. Content
based on principles
of CBT and applied
behaviour analysis.
16 weekly sessions
lasting 90 minutes
(30 mins with child
and 60 with
parents/family.
Statistical
analysis at
baseline
showed not
significant
differences in
demographic or
clinical variables
between groups
Treatment: Building
Confidence CBT
Anxiety Outcome
Measures
Participants
block
randomised
using computer
randomisation
program either
Immediate
Treatment (IT)
Parent Report
Multidimensional Anxiety
Scale for Children – Parent
version (MASC-P; March,
1998)
No group differences found.
Child Report
Revised Children’s Manifest
Anxiety Scale (RCMAS;
Reynolds, 1978):
(Dysmorphic mood;
Oversensitivity; Worry;
Anxious Arousal)
Parent Report
Child and Adolescent
Symptom Inventory-4 ASD
Anxiety Scale (CASI-Anx,
(Sukhodolsky et al., 2008)
Only Anxious Arousal subscale showed
a difference between groups
No differences between groups on the
PARS
No differences between groups on the
CASI
Not Sig
Sig
.16
.25
Not Sig
.32
Not Sig
.30
Post treatment CSR scores were lower
in the IT group than in the WL group
Sig
3.70
Parent MASC scores were statistically
different post treatment in the IT group
compared to WL group.
Sig
.94
Not Sig
.09
Clinician Report
Pediatric Anxiety Rating
Scale (PARS; RUPP, 2002)
Clinician Report
ADIS-C/P (Silverman &
Albano, 1996). Linked to
CSR.
Child and Parent Report
Multidimensional Anxiety
Scale for Children – Child
33
Child MASC reports showed no
Doctorate in Educational and Child Psychology
Study and Aims
Sample
group:17
Control group:23
Age range: 7-11
Mean age: 9.2
Nikki Collingwood
Intervention
Design
Anxiety Outcome
Measures
program (Wood &
McLeod, 2008).
Modifications made
to an existing family
focused CBT
program to consider
and address deficits
in ASD population.
or waitlist (WL)
Stratified based
on age and
gender.
Statistical tests
show no
difference in
groups based
on anxiety
disorder and
ASD.
and Parent version (MASC;
March, 1998)
34
Outcomes
significant differences between groups
post treatment.
Sig/
Not Sig
Effect
Sizes
Doctorate in Educational and Child Psychology
Nikki Collingwood
Appendix C: Weight of Evidence (WoE)
This appendix contains information about:
1. Procedure for weighting studies: WoE A; WoE B; WoE C; WoE D
2. A summary of application of procedures for WoE with respect to each study
3. Group Coding Protocols and Anxiety Outcome Measures Tables
1. Procedure for weighting studies: based on Gough (2007) and Kratochwill (2003)
Summary of procedusre for weighting studies
WoE A
Methodological quality
WoE B
Methodological relevance
WoE C
Relevance of evidence to
review question
WoE D
Overall weight of
evidence
Generic judgement
about the coherence
and integrity of the
evidence
Appropriateness of the
research design for
answering the review
question
Relevance of the
focus of the evidence
for the review
question
Overall assessment
of the extent to which
a study contributes
evidence to answer
the
review question
To calculate an overall
weighting scores are
attributed to WoE A, B
and C as follows:
High= 3
Medium= 2
Low= 1

Measures are reliable,
valid and multisourced

Active control/waitlist
group, with group
equivalence
established

Appropriate analysis,
including correction
for family-wise error if
required, with
sufficiently large N

Random or
Random Block
assignment to
conditions

Studies evaluate a
CBT based treatment
for anxiety in children
and adolescents

Used an
intervention/
treatment group
and control to
conduct
betweenparticipant
analysis.

CBT treatment
includes parental/
family direct
involvement



Studies collect
outcome on
measures of
anxiety pre and
post intervention
Used an active
comparison
group
Identification of
alternative
treatment sought
which may have
reduced anxiety
sought during
wait list period.

CBT specifically
designed or adapted
for the ASD
population

Treatment focused on
children and young
people with a
diagnosis of ASD and
co-occurring Anxiety.

Took empirical
measures to ascertain
change in anxiety
levels

Fidelity to treatment
assessed
35
These scores are
averaged to
correspond to an
overall weight (WoE D)
for each study:
Av. >2.4=High
Av. 1.5-2.4=Medium
Av. <1.5=Low
Doctorate in Educational and Child Psychology
Nikki Collingwood
WoE A: Methodological quality
Based on Kratochwill et al.’s (2003) criteria studies were given weightings for measures used, comparison group and
appropriateness of statistical analysis. These weightings have numerical values and so overall methodological
quality can be appraised via the total points awarded. Descriptors are outlined below.
Measures
Weighting
Description
High (3)




Used multiple measures
Used multiple sources
Used measures with reliability of at least 0.85 for study population
Presented a case for the validity of these measures
Medium (2)



Either used either multiple measures or sources and used measures with a
reliability of at least 0.70 for the study population
Or used measures commonly used in the literature with reported reliability of
above 0.70 in the general population plus frequency measures
Low (1)


Either used measures with a reliability of at least 0.50 for study population
Or used measures commonly used in the literature with reported reliability of
0.50 in the general population)
Comparison Group
Weighting
High (3)
Medium (2)
Description
 Used an active comparison group
 Demonstrated group equivalence
 Demonstrated equivalent mortality or low attrition at post-test



Low (1)



Used at least a ‘no intervention’ comparison group, and demonstrated one of
the following:
group equivalence
equivalent mortality with low attrition at post (if no equivalent mortality was
demonstrated an ‘intention-to-treat’ analysis must have been conducted,
finding no significant between-group differences)
Used at least a ‘no intervention’ comparison group, and demonstrated none of
the following:
group equivalence
equivalent mortality with low attrition at post (if no equivalent mortality was
demonstrated an ‘intention-to-treat’ analysis must have been conducted).
36
Doctorate in Educational and Child Psychology
Weighting
High (3)
Nikki Collingwood
Description



Medium (2)



Low (1)



Appropriate unit of analysis
Accounted for family wise error if necessary
A sufficiently large sample size*
Demonstrated two of the following:
Appropriate unit of analysis
accounted for family wise error if necessary
had a sufficiently large sample size*
Demonstrated one of the following:
Appropriate unit of analysis
accounted for family wise error if necessary
had a sufficiently large sample size*
Analysis



High methodological quality: Studies accumulating 8 out of 9 points or more (strong in at least two areas)
Medium methodological quality: Those accumulating 5-7 points out of 9
Low methodological quality: Those accumulating 4 points or fewer (weak in at least 2 areas or failing to meet
criteria for weak in some cases)
* Sufficiently large sample size based on a power analysis calculation, where a medium effect size was expected
based on previous research in the area (see page 12). At an .05 alpha level and when using ANOVA for 2 groups, a
group size greater than 64 was required or when using an ANOVA for 3 groups, a group size greater than 52 was
required.
WoE B: Methodological Relevance
To inspect if the methodological design of studies were suitable for evaluating the effectiveness of CBT with
family/parent intervention for reducing anxiety in children with ASD, the following criteria was applied:
Weighting Description
High (3)





Medium
(2)




Low (1)



Randomly assigned participants to control and experimental/CBT Treatment
conditions
Used an active comparison group: Waitlist or Treatment as Usual group
Collected pre- and post-measures on anxiety for both groups
Demonstrated group equivalence for group differences statistically
No alternative treatment sought during the study period which may reduce anxiety
in either groups
Used a comparison group: Waitlist or Treatment as Usual group
Demonstrated group equivalence or modelled for group differences statistically
Collected pre- and post-measures from both groups
Some indication that alternative treatment may be sought during the study which
may reduce anxiety in either groups
Collected pre- and post-measures from both groups
Used a comparison group
Alternative treatment was available during the period which may have reduced
anxiety
37
Doctorate in Educational and Child Psychology
Nikki Collingwood
38
Doctorate in Educational and Child Psychology
Nikki Collingwood
WoE C: Relevance to the review question
Weight of Evidence investigated whether the study contributing to answering the Review Question.
Weighting Description




High


Medium
Low

Studies evaluate a CBT based treatment for anxiety in children and adolescents
CBT treatment includes parental/ family direct involvement
CBT designed or adapted specifically for individuals with ASD
Sample focused on children and young people with a diagnosis of ASD and co-occurring
Anxiety
Empirical measures to ascertain change in anxiety levels
Fidelity to treatment assessed



Studies evaluate a CBT based treatment on impact on anxiety and other difficulties or to
promote other skills for children and young people
Parent/family involvement in some of the CBT treatment
Some adaptions made to existing CBT for individuals with ASD
Sample focused on children and young people with a diagnosis of ASD



Studies evaluate a CBT based treatment for anxiety in children and adolescents
Limited or indirect parent/family involvement in CBT treatment
No adaptations made to existing CBT treatment for individuals with ASD
WoE D: Overall weight of evidence
The overall weight of evidence was calculated as followed:




Studies were given scores of 3 (high), 2 (medium), or 1 (low) for their weightings in WoE A, B and C
High overall weight of evidence: Average score of at least 2.5
Medium overall weight of evidence: Average score of between 1.5 and 2.4
Low overall weight of evidence: Average score of less than 1.4
39
Doctorate in Educational and Child Psychology
Collingwood
Nikki
2. Summary of Application of WoE to Studies:
Methodological quality
(WoE A)
Methodological
Relevance
(WoE B)
Relevance of
evidence to
Review Question
Overall weight
of evidence (D)
(WoE C)
Chalfant
et al
(2007)
Measurement: 2



Multiple measures: CATS, RMAS,
SCAS
Multiple source: Teachers,
Parents, Children.
No specific measures of reliability
for this study, based on previous
reports of demonstrated validity
and reliability
Comparison Grp: 3



Used CBT group (n=28) and wait
list control group (n=19)
Demonstrated group equivalence
in terms of age, school type, ASD
type, family, intellectual
functioning. SES, primary anxiety
type, pre-treatment dependent
measures
Low attrition (less than 20%)





Participants
randomly assigned
to conditions
Use of active group
(CBT) and WL
group
Collected pre- and
post- measures on
anxiety in both
groups
Group Equivalence
demonstrated
statistically
No alternative
treatment sought
during treatment or
waiting period.
HIGH (3)




Statistical Analysis: 1



Unit of analysis: post treatment
Chi Squared group difference;
ANOVA used to compare anxiety
measure pre and post treatment
(Group x Time interaction)
Family-wise error: none indicated
for multiple outcome measures.
Insufficiently large N size: 28/19
(not sufficient in groups to yield
enough statistical power for
detecting medium effects of
interest – identified that needed
64


Evaluated a
CBT
intervention for
anxiety in
children and
adolescents
CBT included
parental/family
direct
involvement
Adaptation to
the Macquarie
University,
‘‘Cool
Kids’’CBT
Program for
children with
HFA
Sample was
children and
young people
with diagnosis
of ASD (not
validated in
study) and cooccurring
anxiety
Empirical
measures to
ascertain
change in
anxiety levels
No indication of
therapy fidelity
Average
score: 2.5
HIGH
MEDIUM-HIGH
(2.5)
TOTAL: 6 MEDIUM (2)
Fujji et al
(2013)
Measurement: 1



One measures: ADIS – C/P
linked to CSR measures
Multiple source: Parents,
Children.
No specific measures of reliability
for this study, based on previous
reports of favourable
psychometric properties.
Comparison Grp: 2

Used Treatment As Usual (10)




Participants block
randomised by sex
and age
Use of active group
(Intervention) and
TAU group
Collected pre- and
post- measures on
anxiety in both
groups
No Group
Equivalence
demonstrated
40



Evaluated a
CBT
intervention for
anxiety in
children and
adolescents
CBT included
parental/family
direct
involvement
Building
Confidence
CBT program
Average
score: 1.6
MEDIUM
Doctorate in Educational and Child Psychology
Collingwood
Methodological quality
(WoE A)
Nikki
Methodological
Relevance
(WoE B)
Relevance of
evidence to
Review Question
Overall weight
of evidence (D)
(WoE C)


control group (6)
No statistical analysis of group
equivalence – gave numerical
differences for demographic and
primary anxiety diagnosis and
ASD type. Difference in time for
treatment and TAU
No attrition

MEDIUM (2)
Statistical Analysis: 1



statistically.
Families in TAU free
to seek any kind of
treatment they chose
during waiting period
- not identified if
relevant to anxiety
reduction.
Unit of analysis: post treatment
Chi Squared diagnostic status in
both groups; ANCOVA used to
test group differences on highest
anxiety severity scores post test.
Family-wise error: none indicated.
Insufficient Sample size: 10/6 (not
sufficient to yield enough
statistical power for detecting
effects of interest


TOTAL: 4 LOW (1)

(Wood &
McLeod, 2008)
modified for
use with
children with
ASD (Wood,
Drahota,, Sze,
Har, Chiu, &
Langer, 2009).
Sample was
children and
young people
with diagnosis
of ASD and cooccurring
anxiety
Empirical
measure (only
one) to
ascertain
change in
anxiety levels
No indication of
therapy fidelity
MEDIUM (2)
McConac
hie et al
(2013)
Measurement: 3



Multiple measures:ADIS,SCASC/P
Multiple source: Parents,
Children.
Inter-rater reliability and
instrument reliability for this study
reported (high)


Comparison Grp: 3



Used Immediate Therapy (n=15)
and Delayed Therapy group
(n=14)
Baseline equivalence
demonstrated for Autism type; IQ;
demographics; anxiety disorder.
Low attrition (less than 20%)
Statistical Analysis: 1


Unit of analysis: post treatment
Chi Squared group difference;
ANOVA used to compare anxiety
measure pre and post treatment
(Group x Time interaction)
Family-wise error: none indicated
for multiple outcome measures.



Participants
randomised in a 1:1
ratio to condition
using random
permuted blocks of
variable length.
Use of active group
(Immediate Therapy)
and Delayed
Therapy control
group
Collected pre- and
post- measures on
anxiety in both
groups
Group Equivalence
demonstrated
statistically
All children
continued with other
services and
interventions as
usual – not identified
if relevant to anxiety
reduction.
HIGH (3)
41





Evaluated a
CBT
intervention for
anxiety in
children and
adolescents
CBT included
parental/family
direct
involvement
Minor
adjustments
made to
“Exploring
Feelings”
manual with an
introductory on
CBT session
added.
Sample was
children and
young people
with diagnosis
of ASD and cooccurring
anxiety
Empirical
measures to
Average
Score: 2.5
HIGH
Doctorate in Educational and Child Psychology
Collingwood
Methodological quality
(WoE A)
Nikki
Methodological
Relevance
(WoE B)
Relevance of
evidence to
Review Question
Overall weight
of evidence (D)
(WoE C)

Insufficiently large N size: 15/14
(not sufficient in groups to yield
enough statistical power for
detecting medium effects of
interest – identified that needed
64

MEDIUM HIGH (2.5)
TOTAL: 7 MEDIUM (2)
Reaven
et al
(2009)
Measurement: 2



One measure: SCARED – C/P
Multiple source: Parents,
Children.
Internal consistency for domains
of SCARED is seen to “adequate
and ranged from .66 to .82 for
both parent and child report”



Comparison Grp: 2



Used Active group (n=10) and
Wait List control group (n=23).
Demonstrated group equivalence
in terms of age, IQ, gender,
parent education or parent report
of anxiety symptoms in child;
medications taken pre-treatment.
Not very equivalent in number in
each group.
Low attrition (less than 20%)


Not randomly
assigned – based on
initial entrance into
test.
Use of active group
(Active Group) and
Wait list control
group
Collected pre- and
post- measures on
anxiety in both
groups
Group Equivalence
identified
ongoing
interventions during
trial – not identified





MEDIUM (2)
Statistical Analysis: 1

ascertain
change in
anxiety levels
Indication of
therapy fidelity

Unit of analysis: post treatment
Chi Squared group difference;
ANOVA repeated measures used
to compare anxiety measure pre
and post treatment (Group x Time
interaction)
Family-wise error: none indicated
for multiple outcome measures.
Insufficiently large N size: 10/23
(not sufficient in groups to yield
enough statistical power for
detecting medium effects of
interest – identified that needed
64


Evaluated a
CBT
intervention for
anxiety in
children and
adolescents
CBT included
parental/family
direct
involvement
Original
manualised
programme,
based on mainstream
cognitivebehavioural
approaches,
modified to
meet cognitive,
linguistic and
social needs of
children with
ASD
Sample was
children and
young people
with diagnosis
of ASD and cooccurring
anxiety
Empirical
measures to
ascertain
change in
anxiety levels
Indication of
therapy fidelity
Average
score: 2.3
MEDIUM
HIGH (3)
TOTAL: 5 MEDIUM (2)
Reaven
et al
(2012)
Measurement: 2

Multiple measures: ADIS – C/P
linked to CSR; CGIS- I; SCARED
C-P (for treatment group only)


Randomly assigned
to condition using
computer generated
system
Use of active group
42

Evaluated a
CBT
intervention for
anxiety in
children and
Average
score: 2.3
Doctorate in Educational and Child Psychology
Collingwood
Methodological quality
(WoE A)
Nikki
Methodological
Relevance
(WoE B)
Relevance of
evidence to
Review Question
Overall weight
of evidence (D)
(WoE C)


Multiple source: Parents, not clear
if Children provided data.
Inter-rater reliability reported as
adequate CSR: .82 - .88)

Comparison Grp: 3



Used Face Your Fears Treatment
group (n=20) and Treatment as
usual control group (n=23).
Demonstrated group equivalence
in demographic and diagnostic
variables
Low attrition (less than 20%)




ongoing
interventions during
trial in the TAU



MEDIUM (2)
Statistical Analysis: 1

(Active Group) and
Treatment As usual
control group
Collected pre- and
post- measures on
anxiety in both
groups (for some of
the measures – not
SCARED)
Group Equivalence
identified
Unit of analysis: post treatment
Chi Squared group difference;
ANCOVA to test group differences
in anxiety severity
Family-wise error: none indicated
for multiple outcome measures.
Insufficiently large N size: 20/23
(not sufficient in groups to yield
enough statistical power for
detecting medium effects of
interest – identified that needed
64


adolescents
CBT included
parental/family
direct
involvement
CBT
programme
developed
specifically for
children with
ASD and
clinical anxiety.
Sample was
children and
young people
with diagnosis
of ASD and cooccurring
anxiety
Empirical
measures to
ascertain
change in
anxiety levels
Indication of
therapy fidelity
MEDIUM
HIGH (3)
TOTAL: 6 MEDIUM (2)
Sofronoff
et al
(2005)
Measurement: 1



Multiple measures: SCAS-P;
James and The Maths Test (not a
standardised test)
Multiple source: Parents only
SCAS-P: Total scale
demonstrated high validity with
population (Cronbach’s alpha .92)
and internal reliability coefficients
for subscales ranged from
adequate to excellent (.62 - .81
Comparison Grp: 3



Used intervention group with parents
(n=25); intervention groups- child only
(23) and TAU control group (n=23)
No significant differences between
groups.
Low attrition (less than 20%)
Statistical Analysis: 2






Participants
randomly assigned
to conditions
Use of active groups
(CBT) and WL
group
Collected pre- and
post- measure on
anxiety in both
groups
Group Equivalence
demonstrated
statistically
No comment on
whether alternative
treatment sought
during treatment or
waiting period.
MEDIUM -HIGH
(2.5)
Unit of analysis: ANOVA used to
identify Time X group interaction.
43




Evaluated a
CBT
intervention for
anxiety in
children and
adolescents
CBT included
parental/family
direct
involvement
(for one
intervention
group)
CBT
specifically
designed for
this population
Sample was
children and
young people
with diagnosis
of ASD (Not
verified in
Study) and co-
Average
Score: 2.3
MEDIUM
Doctorate in Educational and Child Psychology
Collingwood
Methodological quality
(WoE A)
Nikki
Methodological
Relevance
(WoE B)
Relevance of
evidence to
Review Question
Overall weight
of evidence (D)
(WoE C)


Family-wise error: Bonferroni
adjustments used to take into
account number of analyses
conducted
Insufficient size: 23/25/23 (not
sufficient in groups to yield
enough statistical power for
detecting medium effects of
interest – identified that needed
52 PER GROUP


MEDIUM HIGH (2.5)
TOTAL: 6 MEDIUM (2)
Storch et
al (2013)
Measurement: 2



Multiple measures: PARS; ADISC/P; CGIS; RMAS; MASC-P
Multiple source: Parents,
Children.
No specific measures of reliability
for this study, based on previous
reports of demonstrated validity
and reliability. Inter-rater reliability
excellent.




Comparison Grp: 2



Used CBT group (n=24) and TAU
control group (n=21)
demonstrated group equivalence in
terms demographic and diagnostic
variables, although difference in ASD
diagnosis type.
Low attrition (less than 20%)

Participants
randomly assigned
to conditions
Use of active group
(CBT) and TAU
group
Collected pre- and
post- measures on
anxiety in both
groups
Group Equivalence
demonstrated
statistically (mostly)
Limited alternative
treatment sought in
TAU as long as not
concurrent
psychosocial
treatments




HIGH (3)
Statistical Analysis: 1



occurring
anxiety
Empirical
measures to
ascertain
change in
anxiety levels
Indication of
therapy fidelity

Unit of analysis: ANCOVA where
post treatment scorees were
predicted by treatment condition
while co-varying for baseline
scores
Family-wise error: none indicated
for multiple outcome measures.
Insufficiently large N size: 28/19
(not sufficient in groups to yield
enough statistical power for
detecting medium effects of
interest – identified that needed
64

Evaluated a
CBT
intervention for
anxiety in
children and
adolescents
CBT included
parental/family
direct
involvement
CBT
specifically
designed for
children with
ASD
Sample was
children and
young people
with diagnosis
of ASD and cooccurring
anxiety
Empirical
measures to
ascertain
change in
anxiety levels
Indication of
therapy fidelity
Average
Score: 2.6
HIGH
HIGH (3)
TOTAL: 5 MEDIUM (2)
White et
al (2013)
Measurement: 2


Multiple measures: PARS; CASIAnx
Multiple source: Parents,

Participants
randomly assigned
in group (ie. 3
subjects randomly
assigned to sctive
44

Evaluated a
CBT
intervention
for anxiety but
Average
score: 2.3
Doctorate in Educational and Child Psychology
Collingwood
Methodological quality
(WoE A)
Nikki
Methodological
Relevance
(WoE B)
Relevance of
evidence to
Review Question
Overall weight
of evidence (D)
(WoE C)

Clinician.
Internal consistency CASIAnx:.85; PARS: .77

Comparison Grp: 2



Used CBT MASSI group (n=15) and
Wait List control group (n=15)
No statistical differences in groups
identified.
Low attrition (less than 20%)


Statistical Analysis: 1



Unit of analysis: t- test between
groups change
Family-wise error: none indicated
for multiple outcome measures.
Insufficiently large N size: 15/15
(not sufficient in groups to yield
enough statistical power for
detecting medium effects of
interest – identified that needed
64

treatment; 3 to
waitlist)
Use of active group
(CBT) and Wait List
group
Collected pre- and
post- measures on
anxiety in both
groups
Group Equivalence
demonstrated
statistically
Only medication
permitted as long as
does was stable for
at least 4 weeks with
no planned changes
for the duration of
the trial.



HIGH (3)

TOTAL: 5 MEDIUM (2)

also looked at
social skill
changes in
children and
adolescents
CBT included
parental/famil
y direct
involvement
Specifically
designed for
young people
with ASD.
Sample was
children and
young people
with diagnosis
of ASD and
co-occurring
anxiety
Empirical
measures to
ascertain
change in
anxiety levels
and SRS
levels
Indication of
therapy
fidelity
MEDIUM
MEDIUM (2)
Wood et
al (2009)
Measurement: 2



Multiple measures: ADIS- CSR;
MASC-C/P
Multiple source: Parents, Child.
Internal consistency MASC-C: .85
MASC-P: ,88
Comparison Grp: 2



Used Immediate Treatment group
(n=17) and Wait List control group
(n=23)
No statistical differences in groups
identified through chi-squared and ttests – except for 3 with dysthymia in
IT group and none in WL group.
Low attrition (less than 20%)





Block randomised
using computer
randomisation
programme.
Use of Immediate
Treatment and Wait
List group
Collected pre- and
post- measures on
anxiety in both
groups
Group Equivalence
demonstrated
statistically
Only medication
permitted as long not
changed during
study.
HIGH (3)
45




Evaluated a
CBT
intervention for
anxiety in
children and
adolescents
CBT included
parental/family
direct
involvement
Building
Confidence
(Wood and
McLeod, 2008)
enhanced and
adapted for
ASD
population.
Sample was
Average
Score: 2.6
HIGH
Doctorate in Educational and Child Psychology
Collingwood
Methodological quality
(WoE A)
Nikki
Methodological
Relevance
(WoE B)
Relevance of
evidence to
Review Question
(WoE C)
Statistical Analysis: 1



Unit of analysis: ANCOVA used to test
group differences at post-treatment
/post-waitlist on continuous outcome
variables.
Family-wise error: none indicated for
multiple outcome measures.
Insufficiently large N size: 17/23 (not
sufficient in groups to yield enough
statistical power for detecting medium
effects of interest – identified that
needed 64


TOTAL: 5 MEDIUM (2)
children and
young people
with diagnosis
of ASD and cooccurring
anxiety
Empirical
measures to
ascertain
change in
anxiety levels
Indication of
therapy fidelity
HIGH (3)
46
Overall weight
of evidence (D)
Doctorate in Educational and Child Psychology
Collingwood
Nikki
3. Group Experiment Coding Protocols
Name of Coder:
Date: December 2013
Full Study Reference in proper format:
Chalfant, A. M., Rapee, R., & Carroll, L. (2007). Treating anxiety disorder in children with high
functioning autism spectrum disorders: a controlled trial. Journal of autism and developmental
disorders, 37 (10), 1842 – 52.
Intervention Name (description of study):
A family based, Cognitive-behavioural treatment (Cool Kids – adapted for ASD) for anxiety in
children with comorbid anxiety disorders and High Functioning Autism.
Type of Publication:
Book/Monograph
Journal Article
Book Chapter
Other (specify):
1.General Characteristics
A. General Design Characteristics
A1. Random assignment designs (if random assignment design, select one of the following)
Completely randomized design
Randomized block design (between participants, e.g., matched classrooms)
Randomized block design (within participants)
Randomized hierarchical design (nested treatments
A2. Nonrandomized designs (if non-random assignment design, select one of the following)
Nonrandomized design
Nonrandomized block design (between participants)
Nonrandomized block design (within participants)
Nonrandomized hierarchical design
Optional coding for Quasi-experimental designs
A3. Overall confidence of judgment on how participants were assigned (select one of the
following)
Very low (little basis)
Low (guess)
Moderate (weak inference)
High (strong inference)
47
Doctorate in Educational and Child Psychology
Collingwood
Nikki
Very high (explicitly stated)
N/A
Unknown/unable to code
B Participants
Total size of sample (start of study): 47
Intervention group sample size: 28
Control group sample size: 19
C. Type of Program
Universal prevention program
Selective prevention program
Targeted prevention program
Intervention/Treatment
Unknown
D. Stage of Program
Model/demonstration programs (adaption of “Cool Kids” CBT program for HFA children)
Early stage programs
Established/institutionalized programs
Unknown
E. Concurrent or Historical Intervention Exposure
Current exposure
Prior exposure
Unknown
48
Doctorate in Educational and Child Psychology
Collingwood
Section 2
Nikki
Key Features for Coding Studies and Rating Level of Evidence/Support
A Measurement (Estimating the quality of the measures used to establish effects)
A1 The use of the outcome measures produce reliable scores for the majority of the primary
outcomes (see following table for a detailed breakdown on the outcomes)
Yes
No
Unknown/unable to code
A2 Multi-method (at least two assessment methods used)
Yes
No
N/A
Unknown/unable to code
A3 Multi-source (at least two sources used self-reports, teachers etc.)
Yes
No
N/A
Unknown/unable to code
A4 Validity of measures reported (well-known or standardized or norm-referenced are
considered good, consider any cultural considerations)
Yes validated with specific target group
In part, validated for general population only
No
Unknown/unable to code
Overall Rating of Measurement:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
49
Doctorate in Educational and Child Psychology
Nikki Collingwood
B Comparison Group
B1 Type of Comparison group
Typical intervention
Attention placebo
Intervention element placebo
Alternative intervention
Pharmacotherapy
No intervention
Wait list/delayed intervention
Minimal contact
Unable to identify type of comparison
B2 Overall rating of judgment of type of comparison group
Very low
Low
Moderate
High
Very high
Unable to identify comparison group
B3 Counterbalancing of change agent (participants who receive intervention from a single therapist/teacher etc
were counter-balanced across intervention)
By change agent
Statistical (analyse includes a test for intervention)
Other
Not reported/None
B4 Group equivalence established
Random assignment
Posthoc matched set (as repeated measures design)
Statistical matching
Post hoc test for group equivalence
B5 Equivalent mortality
Low attrition (less than 20 % for post)
Low attrition (less than 30% for follow-up)
Intent to intervene analysis carried out?
Findings_____________
Overall Rating of Comparison Group:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
C Appropriate Statistical Analysis
50
Doctorate in Educational and Child Psychology
Nikki Collingwood
Analysis 1___________CATS______________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Analysis 2_______RCMAS________________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Analysis 3___________SCAS-C_________________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Analysis 4______________SCAS-P______________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Overall Rating of Analysis:
3
2
1
0
51
Doctorate in Educational and Child Psychology
Nikki Collingwood
Chalfant, Rapee and Caroll (2007)
Significant
Outcomes
Outcome 1
Anxiety
symptoms
Outcome 2
Anxiety
symptoms
Outcome 3
Anxiety
symptoms
Primary vs
Secondary
Who Changed
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
What Changed
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Source
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other
Unknown
Self Report
Parent Rpt.
Teacher Rpt.
Observation
Test
Other
Unknown
Self Report
Parent Rpt.
Teacher Rpt.
Observation
Test
Other
Unknown
Treatment
Information
12 sessions of CBT
intervention
designed as an HFA
adaptation to “Cool
Kids” program
Outcome
Measure
Used
CATS –
Internalising
Thoughts
scale
12 sessions of CBT
intervention
designed as an HFA
adaptation to “Cool
Kids” program
Revised
Children’s
Manifest
Anxiety
Scale
(RCMAS
12 sessions of CBT
intervention
designed as an HFA
adaptation to “Cool
Kids” program
Spence
Children’s
Anxiety
Scale (SCASC)
Reported
Reliability
Reported to be
“psychometrically
sound”.
Items have
“demonstrated
developmental
sensitivity”
Scale has
“demonstrated
validity and
reliability”
(Reynolds &
Richmond, 1978)
Scale has “sound
validity and
reliability and is
considered to be
significantly
correlated with
RCMAS (Spence,
Effect Size
(Cohen,
1992)
1.49
(LARGE)
2.76
(LARGE)
2.57
(MEDIUM)
1998; Spence, Barrett
& Turner, 2003)
Outcome 4
Anxiety
symptoms
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Behaviour
Attitude
Knowledge
Other –
internalised
Self Report
Parent Rpt.
Teacher Rpt.
Observation
Test
12 sessions of CBT
intervention
designed as an HFA
adaptation to “Cool
Kids” program
52
Spence
Children’s
Anxiety
Scale (SCASP)
Not reported
3.14
(LARGE)
Doctorate in Educational and Child Psychology
Unknown
Outcome 5
Anxiety
symptoms
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Nikki Collingwood
symptoms
Unknown
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Other
Unknown
Self Report
Parent Rpt.
Teacher Rpt.
Observation
Test
Other –
Clinician rating
Unknown
12 sessions of CBT
intervention
designed as an HFA
adaptation to “Cool
Kids” program
53
ADIS-C/P
ADIS is a
structured
interview
schedule that is
consistent with
the DSM-IV
criteria for
diagnosis of
childhood anxiety
disorders and has
sound reliability
(Silverman,
Saavedra & Pina,
2001)
.59
(MEDIUM)
Doctorate in Educational and Child Psychology
Collingwood
Nikki
Group Experiment Coding Protocol
Name of Coder:
Date: December 2013
Full Study Reference in proper format:
Fujii, C., Renno, P., McLeod, B. D., Lin, C. E., Decker, K., Zielinski, K., & Wood, J. J. (2012).
Intensive Cognitive Behavioral Therapy for Anxiety Disorders in School-aged Children with
Autism: A Preliminary Comparison with Treatment-as-Usual. School Mental Health, 5(1),
25–37. doi:10.1007/s12310-012-9090-0
Intervention Name (description of study):
An intensive, modular family-based CBT program (Building Confidence) for children with ADS to
address anxiety, self-regulation, and social engagement in school and in the community
Type of Publication:
Book/Monograph
Journal Article
Book Chapter
Other (specify):
1.General Characteristics
A. General Design Characteristics
A1. Random assignment designs (if random assignment design, select one of the following)
Completely randomized design
Randomized block design (between participants, e.g., matched classrooms)
Randomized block design (within participants)
Randomized hierarchical design (nested treatments
A2. Nonrandomized designs (if non-random assignment design, select one of the following)
Nonrandomized design
Nonrandomized block design (between participants)
Nonrandomized block design (within participants)
Nonrandomized hierarchical design
Optional coding for Quasi-experimental designs
A3. Overall confidence of judgment on how participants were assigned (select one of the
following)
54
Doctorate in Educational and Child Psychology
Collingwood
Very low (little basis)
Low (guess)
Moderate (weak inference)
High (strong inference)
Very high (explicitly stated)
N/A
Unknown/unable to code
B Participants
Total size of sample (start of study): 12
Intervention group sample size: 7
Control group sample size: 5
C. Type of Program
Universal prevention program
Selective prevention program
Targeted prevention program
Intervention/Treatment
Unknown
D. Stage of Program
Model/demonstration programs
Early stage programs
Established/institutionalized programs
Unknown
E. Concurrent or Historical Intervention Exposure
Current exposure
Prior exposure
Unknown
55
Nikki
Doctorate in Educational and Child Psychology
Collingwood
Section 2
Nikki
Key Features for Coding Studies and Rating Level of Evidence/Support
A Measurement (Estimating the quality of the measures used to establish effects)
A1 The use of the outcome measures produce reliable scores for the majority of the primary
outcomes (see following table for a detailed breakdown on the outcomes)
Yes
No
Unknown/unable to code
A2 Multi-method (at least two assessment methods used)
Yes
No
N/A
Unknown/unable to code
A3 Multi-source (at least two sources used self-reports, teachers etc.)
Yes
No
N/A
Unknown/unable to code
A4 Validity of measures reported (well-known or standardized or norm-referenced are
considered good, consider any cultural considerations)
Yes validated with specific target group
In part, validated for general population only
No
Unknown/unable to code
Overall Rating of Measurement:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
56
Doctorate in Educational and Child Psychology
Collingwood
Nikki
B Comparison Group
B1 Type of Comparison group
Typical intervention
Attention placebo
Intervention element placebo
Alternative intervention
Pharmacotherapy
No intervention
Wait list/delayed intervention
Minimal contact
Unable to identify type of comparison
B2 Overall rating of judgment of type of comparison group
Very low
Low
Moderate
High
Very high
Unable to identify comparison group
B3 Counterbalancing of change agent (participants who receive intervention from a single
therapist/teacher etc were counter-balanced across intervention)
By change agent
Statistical (analyse includes a test for intervention)
Other
Not reported/None
B4 Group equivalence established
Random assignment
Posthoc matched set (as repeated measures design)
Statistical matching ( not identical duration between control and treatment)
Post hoc test for group equivalence
B5 Equivalent mortality
Low attrition (less than 20 % for post)
Low attrition (less than 30% for follow-up)
Intent to intervene analysis carried out?
Findings_____________
Overall Rating of Comparison Group:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
57
Doctorate in Educational and Child Psychology
Nikki Collingwood
C Appropriate Statistical Analysis
Analysis 1___________ADIS-CP_(CSR)_____________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Overall Rating of Analysis:
3
2
1
0
58
Doctorate in Educational and Child Psychology
Nikki Collingwood
Fujii, Renno, McLeod, Enjey Lin, Decker Zielinski & Wood (2013)
Significant
Outcomes
Outcome 1
Anxiety
symptoms
Primary vs
Secondary
Primary
Secondary
Unknown
Who Changed
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
What Changed
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Source
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other
Unknown
Treatment
Information
32 week family-based
CBT to anxiety in youth
with high functioning
ASD and comorbid
anxiety.
Treatments: Building
Confidence (Wood &
McLeod, 2008) modified
for use with children
with ASD (Wood et al,
2009
59
Outcome
Measure
Used
ADIS –
C/P(semidiagnostic
interview)
linked to
CSR ratings
Reported
Reliability
“shown to have
favourable
psychometric
properties in this
population”
Effect Size
(Cohen,
1992)
3.14
(LARGE)
Doctorate in Educational and Child Psychology
Collingwood
Nikki
Group Experiment Coding Protocol
Name of Coder:
Date: December 2013
Full Study Reference in proper format:
McConachie, H., McLaughlin, E., Grahame, V., Taylor, H., Honey, E., Tavenrnor,
L., Rodgers, J., Freeston, M. Hemm, C., Steen, N., and Le Couteur, A. (2013).
Group Therapy for anxiety in children with autism spectrum disorder. Autism, On
Line version, October 7th 2013.
Intervention Name (description of study):
CBT based Group therapy (Exploring Feelings) for reducing anxiety in children with ASD.
Type of Publication:
Book/Monograph
Journal Article
Book Chapter
Other (specify):
1.General Characteristics
A. General Design Characteristics
A1. Random assignment designs (if random assignment design, select one of the following)
Completely randomized design
Randomized block design (between participants, e.g., matched classrooms)
Randomized block design (within participants)
Randomized hierarchical design (nested treatments
A2. Nonrandomized designs (if non-random assignment design, select one of the following)
Nonrandomized design
Nonrandomized block design (between participants)
Nonrandomized block design (within participants)
Nonrandomized hierarchical design
Optional coding for Quasi-experimental designs
A3. Overall confidence of judgment on how participants were assigned (select one of the
following)
60
Doctorate in Educational and Child Psychology
Collingwood
Very low (little basis)
Low (guess)
Moderate (weak inference)
High (strong inference)
Very high (explicitly stated)
N/A
Unknown/unable to code
B Participants
Total size of sample (start of study): 32
Intervention group sample size: 17
Control group sample size: 15
C. Type of Program
Universal prevention program
Selective prevention program
Targeted prevention program
Intervention/Treatment
Unknown
D. Stage of Program
Model/demonstration programs
Early stage programs
Established/institutionalized programs
Unknown
E. Concurrent or Historical Intervention Exposure
Current exposure
Prior exposure
Unknown
61
Nikki
Doctorate in Educational and Child Psychology
Collingwood
Section 2
Nikki
Key Features for Coding Studies and Rating Level of Evidence/Support
A Measurement (Estimating the quality of the measures used to establish effects)
A1 The use of the outcome measures produce reliable scores for the majority of the primary
outcomes (see following table for a detailed breakdown on the outcomes)
Yes
No
Unknown/unable to code
A2 Multi-method (at least two assessment methods used)
Yes
No
N/A
Unknown/unable to code
A3 Multi-source (at least two sources used self-reports, teachers etc.)
Yes
No
N/A
Unknown/unable to code
A4 Validity of measures reported (well-known or standardized or norm-referenced are
considered good, consider any cultural considerations)
Yes validated with specific target group
In part, validated for general population only
No
Unknown/unable to code
Overall Rating of Measurement:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
62
Doctorate in Educational and Child Psychology
Collingwood
Nikki
B Comparison Group
B1 Type of Comparison group
Typical intervention
Attention placebo
Intervention element placebo
Alternative intervention
Pharmacotherapy
No intervention
Wait list/delayed intervention
Minimal contact
Unable to identify type of comparison
B2 Overall rating of judgment of type of comparison group
Very low
Low
Moderate
High
Very high
Unable to identify comparison group
B3 Counterbalancing of change agent (participants who receive intervention from a single
therapist/teacher etc were counter-balanced across intervention)
By change agent
Statistical (analyse includes a test for intervention)
Other
Not reported/None
B4 Group equivalence established
Random assignment
Posthoc matched set (as repeated measures design)
Statistical matching
Post hoc test for group equivalence
B5 Equivalent mortality
Low attrition (less than 20 % for post)
Low attrition (less than 30% for follow-up)
Intent to intervene analysis carried out?
Findings_____________
Overall Rating of Comparison Group:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
63
Doctorate in Educational and Child Psychology
Nikki Collingwood
C Appropriate Statistical Analysis
Analysis 1___________ADIS______________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Analysis 2_______SCAS – C________________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Analysis 3_______SCAS – P________________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Overall Rating of Analysis:
3
2
1
0
64
Doctorate in Educational and Child Psychology
Nikki Collingwood
McConachie, McLaughlin, Grahame, Taylor, Honey, Tavernor, Rodgers, Freeston, Hemm, Steen & Couteur (2013).
Significant
Outcomes
Outcome 1
Anxiety
symptoms
Not
Significant
Outcomes
Outcome 2
Anxiety
symptoms
Outcome 3
Anxiety
symptoms
Primary vs
Secondary
Primary
Secondary
Unknown
Primary vs
Secondary
Who Changed
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Who Changed
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
What Changed
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
What
Changed
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Source
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other
Unknown
Source
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other
Unknown
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other
Unknown
Treatment
Information
CBT Intervention:
“Exploring Feelings”
(Attwood, 2004)
involving 7 two hour
sessions with parents
and children in separate
groups
Treatment
Information
CBT Intervention:
“Exploring Feelings”
(Attwood, 2004)
involving 7 two hour
sessions with parents
and children in
separate groups
CBT Intervention:
“Exploring Feelings”
(Attwood, 2004)
involving 7 two hour
sessions with parents
and children in
separate groups
65
Outcome
Measure
Used
ADIS
Outcome
Measure
Used
SCAS-C
SCAS-P
Reported
Reliability
Effect Size
(Cohen,
1992)
“has good interrater reliability
(Lyneham et al,
1.25
2007) and
(LARGE)
concurrent validity
(Wood et al, 2002)
in typically anxiety
children.
Inter-rater
reliability in this
study was high.
Reported
Effect Size
Reliability
(Cohen, 1992)
SCAS-C:
Cronbachs alpha
= .94
.10
(SMALL)
SCAS-P:
Cronbach’s alpha:
.92
.06
(SMALL)
Doctorate in Educational and Child Psychology
Nikki Collingwood
66
Doctorate in Educational and Child Psychology
Collingwood
Nikki
Group Experiment Coding Protocol
Name of Coder:
Date: December 2013
Full Study Reference in proper format:
Reaven, J.A., Nichols, S., Dasari, M., Flanigan, E., & Hepburn, S. (2009). Cognitive Behavioral
Group Treatment for Anxiety Symptoms in Children With High Functioning Autism Spectrum
Disorders. Focus on Autism and Other Developmental Disabilities, 24 (1), 27 – 37.
Intervention Name (description of study):
Children with High Functioning ASD and their parents participated in an original, manualised
cognitive behavioural group (Fighting Worry and Facing Fears) aimed at reducing severity of
anxiety symptoms.
Type of Publication:
Book/Monograph
Journal Article
Book Chapter
Other (specify):
1.General Characteristics
A. General Design Characteristics
A1. Random assignment designs (if random assignment design, select one of the following)
Completely randomized design
Randomized block design (between participants, e.g., matched classrooms)
Randomized block design (within participants)
Randomized hierarchical design (nested treatments
A2. Nonrandomized designs (if non-random assignment design, select one of the following)
Nonrandomized design
Nonrandomized block design (between participants)
Nonrandomized block design (within participants)
Nonrandomized hierarchical design
Optional coding for Quasi-experimental designs
67
Doctorate in Educational and Child Psychology
Collingwood
Nikki
A3. Overall confidence of judgment on how participants were assigned (select one of the
following)
Very low (little basis)
Low (guess)
Moderate (weak inference)
High (strong inference)
Very high (explicitly stated)
N/A
Unknown/unable to code
B Participants
Total size of sample (start of study): 33
Intervention group sample size: 10
Control group sample size: 23
C. Type of Program
Universal prevention program
Selective prevention program
Targeted prevention program
Intervention/Treatment
Unknown
D. Stage of Program
Model/demonstration programs
Early stage programs
Established/institutionalized programs
Unknown
E. Concurrent or Historical Intervention Exposure
Current exposure
Prior exposure
Unknown
68
Doctorate in Educational and Child Psychology
Collingwood
Section 2
Nikki
Key Features for Coding Studies and Rating Level of Evidence/Support
A Measurement (Estimating the quality of the measures used to establish effects)
A1 The use of the outcome measures produce reliable scores for the majority of the primary
outcomes (see following table for a detailed breakdown on the outcomes)
Yes
No
Unknown/unable to code
A2 Multi-method (at least two assessment methods used)
Yes
No
N/A
Unknown/unable to code
A3 Multi-source (at least two sources used self-reports, teachers etc.)
Yes
No
N/A
Unknown/unable to code
A4 Validity of measures reported (well-known or standardized or norm-referenced are
considered good, consider any cultural considerations)
Yes validated with specific target group
In part, validated for general population only
No
Unknown/unable to code
Overall Rating of Measurement:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
69
Doctorate in Educational and Child Psychology
Collingwood
Nikki
B Comparison Group
B1 Type of Comparison group
Typical intervention
Attention placebo
Intervention element placebo
Alternative intervention
Pharmacotherapy
No intervention
Wait list/delayed intervention
Minimal contact
Unable to identify type of comparison
B2 Overall rating of judgment of type of comparison group
Very low
Low
Moderate
High
Very high
Unable to identify comparison group
B3 Counterbalancing of change agent (participants who receive intervention from a single
therapist/teacher etc were counter-balanced across intervention)
By change agent
Statistical (analyse includes a test for intervention)
Other
Not reported/None
B4 Group equivalence established
Random assignment
Posthoc matched set (as repeated measures design)
Statistical matching (fewer in active treatment compared to control)
Post hoc test for group equivalence
B5 Equivalent mortality
Low attrition (less than 20 % for post)
Low attrition (less than 30% for follow-up)
Intent to intervene analysis carried out?
Findings_____________
Overall Rating of Comparison Group:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
70
Doctorate in Educational and Child Psychology
Nikki Collingwood
C Appropriate Statistical Analysis
Analysis 1___________SCARED – C______________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Analysis 2___________SCARED – P______________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Overall Rating of Analysis:
3
2
1
0
71
Doctorate in Educational and Child Psychology
Nikki Collingwood
Reaven, Nichols, Dasari, Flanigan & Hepburn (2009)
Significant
Outcomes
Outcome 1
Anxiety
symptoms
Not
Significant
Outcomes
Outcome 2
Anxiety
symptoms
Primary vs
Secondary
Primary
Secondary
Unknown
Primary vs
Secondary
Primary
Secondary
Unknown
Who Changed
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Who Changed
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
What Changed
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
What
Changed
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Source
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other
Unknown
Source
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other
Unknown
Treatment
Information
Treatments: Coping
Group: Fighting Worry
and Facing Fears
(Reaven et al, 2005) –
original creation
specifically for children
with ASD 12 weekly
session (1.5 hours) in
large groups, separate
parent and child group
meetings and parentchild dyads.
Treatment
Information
Treatments: Coping
Group: Fighting Worry
and Facing Fears
(Reaven et al, 2005) –
original creation
specifically for children
with ASD 12 weekly
session (1.5 hours) in
large groups, separate
parent and child group
meetings and parentchild dyads.
72
Outcome
Measure
Used
SCARED-P
Outcome
Measure
Used
SCARED-C
Reported
Reliability
Effect Size
(Cohen,
1992))
Internal
consistency for
domains of
SCARED is seen to
“adequate and
ranged from .66 to
.82 for both
parent and child
report”
Reported
Reliability
Internal
consistency for
domains of
SCARED is seen
to “adequate and
ranged from .66
to .82 for both
parent and child
report”
1.00
(LARGE)
Effect Size
.34
(SMALL)
Doctorate in Educational and Child Psychology
Collingwood
Nikki
Group Experiment Coding Protocol
Name of Coder:
Date: December 2013
Full Study Reference in proper format:
Reaven, J., Blakeley-Smith, A., Culhane-Shelburne, K., & Hepburn, S. (2012). Group cognitive
behavior therapy for children with high-functioning autism spectrum disorders and
anxiety: a randomized trial. Journal of Child Psychology and Psychiatry, 53(4), 410–419.
doi:10.1111/j.1469-7610.2011.02486.x
Intervention Name (description of study):
Modified group CBT Intervention (Facing your Fears) used specifically with children with ASD to
reduce anxiety symptoms.
Type of Publication:
Book/Monograph
Journal Article
Book Chapter
Other (specify):
1.General Characteristics
A. General Design Characteristics
A1. Random assignment designs (if random assignment design, select one of the following)
Completely randomized design
Randomized block design (between participants, e.g., matched classrooms)
Randomized block design (within participants)
Randomized hierarchical design (nested treatments
A2. Nonrandomized designs (if non-random assignment design, select one of the following)
Nonrandomized design
Nonrandomized block design (between participants)
Nonrandomized block design (within participants)
Nonrandomized hierarchical design
Optional coding for Quasi-experimental designs
73
Doctorate in Educational and Child Psychology
Collingwood
Nikki
A3. Overall confidence of judgment on how participants were assigned (select one of the
following)
Very low (little basis)
Low (guess)
Moderate (weak inference)
High (strong inference)
Very high (explicitly stated)
N/A
Unknown/unable to code
B Participants
Total size of sample (start of study): 50
Intervention group sample size: 24
Control group sample size: 26
C. Type of Program
Universal prevention program
Selective prevention program
Targeted prevention program
Intervention/Treatment
Unknown
D. Stage of Program
Model/demonstration programs
Early stage programs
Established/institutionalized programs
Unknown
E. Concurrent or Historical Intervention Exposure
Current exposure
Prior exposure
Unknown
74
Doctorate in Educational and Child Psychology
Collingwood
Section 2
Nikki
Key Features for Coding Studies and Rating Level of Evidence/Support
A Measurement (Estimating the quality of the measures used to establish effects)
A1 The use of the outcome measures produce reliable scores for the majority of the primary
outcomes (see following table for a detailed breakdown on the outcomes)
Yes
No
Unknown/unable to code
A2 Multi-method (at least two assessment methods used)
Yes
No
N/A
Unknown/unable to code
A3 Multi-source (at least two sources used self-reports, teachers etc.)
Yes
No
N/A
Unknown/unable to code
A4 Validity of measures reported (well-known or standardized or norm-referenced are
considered good, consider any cultural considerations)
Yes validated with specific target group
In part, validated for general population only
No
Unknown/unable to code
Overall Rating of Measurement:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
75
Doctorate in Educational and Child Psychology
Collingwood
Nikki
B Comparison Group
B1 Type of Comparison group
Typical intervention
Attention placebo
Intervention element placebo
Alternative intervention
Pharmacotherapy
No intervention
Wait list/delayed intervention
Minimal contact
Unable to identify type of comparison
B2 Overall rating of judgment of type of comparison group
Very low
Low
Moderate
High
Very high
Unable to identify comparison group
B3 Counterbalancing of change agent (participants who receive intervention from a single
therapist/teacher etc were counter-balanced across intervention)
By change agent
Statistical (analyse includes a test for intervention)
Other
Not reported/None
B4 Group equivalence established
Random assignment
Posthoc matched set (as repeated measures design)
Statistical matching
Post hoc test for group equivalence
B5 Equivalent mortality
Low attrition (less than 20 % for post)
Low attrition (less than 30% for follow-up)
Intent to intervene analysis carried out?
Findings_____________
Overall Rating of Comparison Group:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
76
Doctorate in Educational and Child Psychology
Nikki Collingwood
C Appropriate Statistical Analysis
Analysis 1___________ADIS – P- CSR_____________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Analysis 2_____________________CGIS-I_______________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Overall Rating of Analysis:
3
2
1
0
77
Doctorate in Educational and Child Psychology
Nikki Collingwood
Reaven, Blakeley-Smith, Culhane-Shelburne & Hepburn (2012)
Significant
Outcomes
Outcome 1
Anxiety
symptoms
Outcome 2
Anxiety
symptoms
Primary vs
Secondary
Primary
Secondary
Unknown
Primary
Secondary
Unknown
Who Changed
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
What
Changed
Source
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other CLINICIAN
Unknown
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other CLINICIAN
Unknown
Treatment
Information
Outcome
Measure
Used
Reported
Reliability
Treatments: Coping
Group: Fighting Worry
and Facing Fears
(Reaven et al, 2005) –
original creation
specifically for children
with ASD 12 weekly
session (1.5 hours) in
large groups, separate
parent and child group
meetings and parentchild dyads.
ADIS – C/P CSR
generated for
4 anxiety
types by ICE
blind to
condition
Treatments: Coping
Group: Fighting Worry
and Facing Fears
(Reaven et al, 2005) –
original creation
specifically for children
with ASD 12 weekly
session (1.5 hours) in
large groups, separate
parent and child group
meetings and parentchild dyads.
CGIS-I
Agreement of
CSRs with
consensus ratings
was adequate for
all anxiety
disorders –
ranging from .82 .88
80% reliability on
clinical diagnoses
and CSRs
Agreement
between the ICE
and the
consensus
improvement
ratings was .86.
78
Principal
Anxiety
diagnosis
Effect Size (Cohen, 1992)
.61
(MEDIUM)
Cohen’s d reported: 1.03
(reported in study - no
data available to calculate)
(LARGE)
Doctorate in Educational and Child Psychology
Collingwood
Nikki
Group Experiment Coding Protocol
Name of Coder:
Date: December 2013
Full Study Reference in proper format:
Storch, E.A., Arnold, E.B., Lewin, A.B., Nadeau, J.M., Jones, A.M., De Nadai, A.S., Mutch, P.J.,
Selles, R.R., Ung, D., & Murphy, T.K. (2013). The Effect of Cognitive-Behavioral Therapy Verus
Treatment as Usual for Anxiety in Children with Autism Spectrum Disorders: A Randomised,
Controlled Trial. Journal of the American Academy of Child & Adolescent Psychiatry, 52 (2), 132
– 142.
Intervention Name (description of study):
Modular Cognitive-Behavioral therapy (BIANCA) used with children with High functioning
autism spectrum disorders and who have clinically significant anxiety.
Type of Publication:
Book/Monograph
Journal Article
Book Chapter
Other (specify):
1.General Characteristics
A. General Design Characteristics
A1. Random assignment designs (if random assignment design, select one of the following)
Completely randomized design
Randomized block design (between participants, e.g., matched classrooms)
Randomized block design (within participants)
Randomized hierarchical design (nested treatments
A2. Nonrandomized designs (if non-random assignment design, select one of the following)
Nonrandomized design
Nonrandomized block design (between participants)
Nonrandomized block design (within participants)
Nonrandomized hierarchical design
Optional coding for Quasi-experimental designs
79
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Nikki
A3. Overall confidence of judgment on how participants were assigned (select one of the
following)
Very low (little basis)
Low (guess)
Moderate (weak inference)
High (strong inference)
Very high (explicitly stated)
N/A
Unknown/unable to code
B Participants
Total size of sample (start of study): 45
Intervention group sample size: 24
Control group sample size: 21
C. Type of Program
Universal prevention program
Selective prevention program
Targeted prevention program
Intervention/Treatment
Unknown
D. Stage of Program
Model/demonstration programs
Early stage programs
Established/institutionalized programs
Unknown
E. Concurrent or Historical Intervention Exposure
Current exposure
Prior exposure
Unknown
80
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Collingwood
Section 2
Nikki
Key Features for Coding Studies and Rating Level of Evidence/Support
A Measurement (Estimating the quality of the measures used to establish effects)
A1 The use of the outcome measures produce reliable scores for the majority of the primary
outcomes (see following table for a detailed breakdown on the outcomes)
Yes
No
Unknown/unable to code
A2 Multi-method (at least two assessment methods used)
Yes
No
N/A
Unknown/unable to code
A3 Multi-source (at least two sources used self-reports, teachers etc.)
Yes
No
N/A
Unknown/unable to code
A4 Validity of measures reported (well-known or standardized or norm-referenced are
considered good, consider any cultural considerations)
Yes validated with specific target group
In part, validated for general population only
No
Unknown/unable to code
Overall Rating of Measurement:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
81
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Nikki
B Comparison Group
B1 Type of Comparison group
Typical intervention
Attention placebo
Intervention element placebo
Alternative intervention
Pharmacotherapy
No intervention
Wait list/delayed intervention
Minimal contact
Unable to identify type of comparison
B2 Overall rating of judgment of type of comparison group
Very low
Low
Moderate
High
Very high
Unable to identify comparison group
B3 Counterbalancing of change agent (participants who receive intervention from a single
therapist/teacher etc were counter-balanced across intervention)
By change agent
Statistical (analyse includes a test for intervention)
Other
Not reported/None
B4 Group equivalence established
Random assignment
Posthoc matched set (as repeated measures design)
Statistical matching
Post hoc test for group equivalence
B5 Equivalent mortality
Low attrition (less than 20 % for post)
Low attrition (less than 30% for follow-up)
Intent to intervene analysis carried out?
Findings_____________
Overall Rating of Comparison Group:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
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C Appropriate Statistical Analysis
Analysis 1___________PARS______________________________________________________________
Appropriate unit of analysis
Familywise/expeirmenter wise error rate controlled when applicable
Sufficiently large N
Analysis 2_______ADIS- CSR________________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Analysis 3____________MASC_P________________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Analysis 4____________RMAS________________________________________________________________
Appropriate unit of analysis
Familywise/expermenter wise error rate controlled when applicable
Sufficiently large N
Analysis 5____________CGIS-S______________________________________________________________
Appropriate unit of analysis
Familywise/expermenter wise error rate controlled when applicable
Sufficiently large N
Overall Rating of Analysis:
3
2
1
0
83
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84
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Storch, Arnold, Lewin, Nadeau, Jones, De Nadai, Mutch, Selles, Ung & Murphy (2013)
Significant
Outcomes
Outcome 1
Anxiety
symptoms
Outcome 2
Anxiety
symptoms
Outcome 3
Anxiety
symptoms
Outcome 4
Anxiety
Primary vs
Secondary
Who Changed
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
What
Changed
Source
Treatment
Information
Outcome
Measure
Used
Reported
Reliability
Effect Size
(Cohen, 1992)
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other – Clinicia
Unknown
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other – Clinician
Unknown
Behavioural
Interventions for Anxiety
in Children with Autism
(BIANCA) CBT program
(Wood and Drahota,
2005).
Pediatric
Anxiety
Rating Scale
(PARS;
RUPP, 2002)
The intraclass
correlation
coefficient (ICC) for
20% of randomly
selected
assessments was
.79
1.60
(LARGE)
Behavioural
Interventions for Anxiety
in Children with Autism
(BIANCA) CBT program
(Wood and Drahota,
2005).
ADIS-C/P
1.61
(LARGE)
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Behaviour
Attitude
Knowledge
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other – Clinician
Unknown
Self Report
Parent Rpt
Teacher Rpt.
Behavioural
Interventions for Anxiety
in Children with Autism
(BIANCA) CBT program
(Wood and Drahota,
2005).
CGIS-I
“demonstrated
adequate inter-rater
agreement and
treatment sensitivity
in you with ASD”
Inter-rater reliability
for sample found to
be excellent for
primary diagnosis
(kappa = 1.0)
Not reported
Behavioural
Interventions for Anxiety
in Children with Autism
(BIANCA) CBT program
RMAS –
Anxiety
Arousal
Scale
“psychometrically
sound”(Reynolds,
1978)
85
.59
(MEDIUM)
.25
(SMALL)
Doctorate in Educational and Child Psychology
symptoms
Not
Significant
Outcomes
Outcome 1
Anxiety
symptoms
Ecology
Other
Unknown
Primary vs
Secondary
Primary
Secondary
Unknown
Who Changed
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Nikki Collingwood
Other –
internalised
symptoms
Unknown
What
Changed
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Observation
Test
Other
Unknown
Source
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other
Unknown
86
(Wood and Drahota,
2005).
Treatment
Information
Behavioural
Interventions for
Anxiety in Children
with Autism (BIANCA)
CBT program (Wood
and Drahota, 2005
Outcome
Measure
Used
MASC-P
Reported
Reliability
“demonstrates
psychometric
support in youth
with ASD” (Wood
et al 2009)
Effect Size
(Cohen, 1992)
.16
(SMALL)
Doctorate in Educational and Child Psychology
Collingwood
Nikki
Group Experiment Coding Protocol
Name of Coder:
Date: December 2013
Full Study Reference in proper format:
Sofronoff, K. Attwood, T. and Hinton, S. (2005). A randomised controlled trial of a CBT
intervention for anxiety in children with Asperger syndrome. Journal of Child Pyschiology and
Psychiatry, 46 (11), 1152 – 1160.
Intervention Name (description of study):
Brief CBT intervention with children diagnosed with Asperger syndrome.
Type of Publication:
Book/Monograph
Journal Article
Book Chapter
Other (specify):
1.General Characteristics
A. General Design Characteristics
A1. Random assignment designs (if random assignment design, select one of the following)
Completely randomized design
Randomized block design (between participants, e.g., matched classrooms)
Randomized block design (within participants)
Randomized hierarchical design (nested treatments
A2. Nonrandomized designs (if non-random assignment design, select one of the following)
Nonrandomized design
Nonrandomized block design (between participants)
Nonrandomized block design (within participants)
Nonrandomized hierarchical design
Optional coding for Quasi-experimental designs
A3. Overall confidence of judgment on how participants were assigned (select one of the
following)
Very low (little basis)
Low (guess)
87
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Moderate (weak inference)
High (strong inference)
Very high (explicitly stated)
N/A
Unknown/unable to code
B Participants
Total size of sample (start of study): 71
Intervention group 1 (child only) sample size: 23
Intervention group 2 (child + Parent) sample size: 25
Control group sample size: 23
C. Type of Program
Universal prevention program
Selective prevention program
Targeted prevention program
Intervention/Treatment
Unknown
D. Stage of Program
Model/demonstration programs
Early stage programs
Established/institutionalized programs
Unknown
E. Concurrent or Historical Intervention Exposure
Current exposure
Prior exposure
Unknown
88
Nikki
Doctorate in Educational and Child Psychology
Collingwood
Section 2
Nikki
Key Features for Coding Studies and Rating Level of Evidence/Support
A Measurement (Estimating the quality of the measures used to establish effects)
A1 The use of the outcome measures produce reliable scores for the majority of the primary
outcomes (see following table for a detailed breakdown on the outcomes)
Yes
No
Unknown/unable to code
A2 Multi-method (at least two assessment methods used)
Yes – although only one was standardised
No
N/A
Unknown/unable to code
A3 Multi-source (at least two sources used self-reports, teachers etc.)
Yes – although only parents completed standardised instrument
No
N/A
Unknown/unable to code
A4 Validity of measures reported (well-known or standardized or norm-referenced are
considered good, consider any cultural considerations)
Yes validated with specific target group
In part, validated for general population only
No
Unknown/unable to code
Overall Rating of Measurement:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
89
Doctorate in Educational and Child Psychology
Collingwood
Nikki
B Comparison Group
B1 Type of Comparison group
Typical intervention
Attention placebo
Intervention element placebo
Alternative intervention – CBT with Child only
Pharmacotherapy
No intervention
Wait list/delayed intervention
Minimal contact
Unable to identify type of comparison
B2 Overall rating of judgment of type of comparison group
Very low
Low
Moderate
High
Very high
Unable to identify comparison group
B3 Counterbalancing of change agent (participants who receive intervention from a single
therapist/teacher etc were counter-balanced across intervention)
By change agent
Statistical (analyse includes a test for intervention)
Other
Not reported/None
B4 Group equivalence established
Random assignment
Posthoc matched set (as repeated measures design)
Statistical matching
Post hoc test for group equivalence
B5 Equivalent mortality
Low attrition (less than 20 % for post)
Low attrition (less than 30% for follow-up)
Intent to intervene analysis carried out?
Findings_____________
Overall Rating of Comparison Group:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
90
Doctorate in Educational and Child Psychology
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C Appropriate Statistical Analysis
Analysis 1___________SCAS-P______________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Analysis 2_______James and the Maths Test________________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Overall Rating of Analysis:
3
2
1
0
91
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Sofronoff, Attwood & Hinton (2005)
Significant
Outcomes
Outcome 1
Anxiety
symptoms
Outcome 2
Strategies
generated to
deal with
Anxiety
provoking
situations
Primary vs
Secondary
Who Changed
What Changed
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Source
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other –
Clinician rated
Unknown
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other –
Clinician rated
Unknown
Treatment
Information
CBT intervention
(Sofronoff et al,
2005)
CBT intervention
(Sofronoff et al,
2005)
92
Outcome
Measure
Used
Reported
Reliability
Effect Size
Spence
Children’s
Anxiety Scale
– Parent
(SCAS-P;
Spence,
2005)
Total scale
demonstrated high
validity with
population
(Cronbach’s alpha
.92) and internal
reliability coefficients
for subscales ranged
from adequate to
excellent (.62 - .81)
.12
James and
the Maths
test
(Attwood,
2002)
Scenario based
assessment.
No data available
to assess this.
(Cohen, 1992)
Administration
standardised.
(SMALL)
Doctorate in Educational and Child Psychology
Collingwood
Nikki
Group Experiment Coding Protocol
Name of Coder:
Date: December 2013
Full Study Reference in proper format:
White, S.W., Ollendick, T., Albano, A.M., Oswald, D., Johnson, C., Southam-Gerow, M.A. Kim, I.,
& Scahill, L. (2013). Randomized Controlled Trial: Multimodal Anxiety and Social Skill
Intervention for Adolescents with Autism Spectrum Disorder. Journal of Autism and
Developmental Disorders, 43 (2), 382 – 394.
Intervention Name (description of study):
Use of Multimodal Anxiety and Social Skills Interventions (MASSI) program (combined
individual, group and parent) with adolescents with ASD and anxiety symptoms of moderate or
greater severity.
Type of Publication:
Book/Monograph
Journal Article
Book Chapter
Other (specify):
1.General Characteristics
A. General Design Characteristics
A1. Random assignment designs (if random assignment design, select one of the following)
Completely randomized design
Randomized block design (between participants, e.g., matched classrooms)
Randomized block design (within participants)
Randomized hierarchical design (nested treatments
A2. Nonrandomized designs (if non-random assignment design, select one of the following)
Nonrandomized design
Nonrandomized block design (between participants)
Nonrandomized block design (within participants)
Nonrandomized hierarchical design
Optional coding for Quasi-experimental designs
93
Doctorate in Educational and Child Psychology
Collingwood
Nikki
A3. Overall confidence of judgment on how participants were assigned (select one of the
following)
Very low (little basis)
Low (guess)
Moderate (weak inference)
High (strong inference)
Very high (explicitly stated)
N/A
Unknown/unable to code
B Participants
Total size of sample (start of study): 30
Intervention group sample size: 15
Control group sample size: 15
C. Type of Program
Universal prevention program
Selective prevention program
Targeted prevention program
Intervention/Treatment
Unknown
D. Stage of Program
Model/demonstration programs
Early stage programs
Established/institutionalized programs
Unknown
E. Concurrent or Historical Intervention Exposure
Current exposure
Prior exposure
Unknown
94
Doctorate in Educational and Child Psychology
Collingwood
Section 2
Nikki
Key Features for Coding Studies and Rating Level of Evidence/Support
A Measurement (Estimating the quality of the measures used to establish effects)
A1 The use of the outcome measures produce reliable scores for the majority of the primary
outcomes (see following table for a detailed breakdown on the outcomes)
Yes
No
Unknown/unable to code
A2 Multi-method (at least two assessment methods used)
Yes
No
N/A
Unknown/unable to code
A3 Multi-source (at least two sources used self-reports, teachers etc.)
Yes
No
N/A
Unknown/unable to code
A4 Validity of measures reported (well-known or standardized or norm-referenced are
considered good, consider any cultural considerations)
Yes validated with specific target group
In part, validated for general population only
No
Unknown/unable to code
Overall Rating of Measurement:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
95
Doctorate in Educational and Child Psychology
Collingwood
Nikki
B Comparison Group
B1 Type of Comparison group
Typical intervention
Attention placebo
Intervention element placebo
Alternative intervention
Pharmacotherapy
No intervention
Wait list/delayed intervention
Minimal contact
Unable to identify type of comparison
B2 Overall rating of judgment of type of comparison group
Very low
Low
Moderate
High
Very high
Unable to identify comparison group
B3 Counterbalancing of change agent (participants who receive intervention from a single
therapist/teacher etc were counter-balanced across intervention)
By change agent
Statistical (analyse includes a test for intervention)
Other
Not reported/None
B4 Group equivalence established
Random assignment
Posthoc matched set (as repeated measures design)
Statistical matching
Post hoc test for group equivalence
B5 Equivalent mortality
Low attrition (less than 20 % for post)
Low attrition (less than 30% for follow-up)
Intent to intervene analysis carried out?
Findings_____________
Overall Rating of Comparison Group:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
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C Appropriate Statistical Analysis
Analysis 1___________CASI______________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Analysis 2_________________PARS______________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Overall Rating of Analysis:
3
2
1
0
97
Doctorate in Educational and Child Psychology
Nikki Collingwood
White, Ollendick, Albano, Oswald, Johnson, Southam-Gerow, Kim & Scahill (2013)
Not
Significant
Outcomes
Outcome 1
Anxiety
symptoms
Outcome 2
Anxiety
symptoms
Primary vs
Secondary
Primary
Secondary
Unknown
Primary
Secondary
Unknown
Who Changed
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
What Changed
Source
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other
Unknown
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
OtherClinician rated
Unknown
Treatment
Information
Multimodal Anxiety and
Social Skills
Intervention (MASSI)
program.
Multimodal Anxiety and
Social Skills
Intervention (MASSI)
program.
98
Outcome
Measure
Used
CASI-Anx
Reported
Reliability
Internal
consistency of .85.
Effect Size
(Cohen, 1992)
.30
(SMALL)
PARS
Contains DSM-IV
based items
across a range of
anxiety disorders
Internal
consistency .77
.32
(SMALL)
Doctorate in Educational and Child Psychology
Collingwood
Nikki
Group Experiment Coding Protocol
Name of Coder:
Date: December 2013
Full Study Reference in proper format:
Wood, J.J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D.A. (2009). Cognitive behavioural
therapy for anxiety in children with autism spectrum disorders: a randomized, controlled trial.
The Journal of Child Psychology and Psychiatry, 50 (3), 224 – 234.
Intervention Name (description of study):
Modular cognitive behavioural therapy program (Building Confidence) for children with
comorbid anxiety disorders. The treatment emphasised behavioural experimentation parenttraining and school consultation.
Type of Publication:
Book/Monograph
Journal Article
Book Chapter
Other (specify):
1.General Characteristics
A. General Design Characteristics
A1. Random assignment designs (if random assignment design, select one of the following)
Completely randomized design
Randomized block design (between participants, e.g., matched classrooms)
Randomized block design (within participants)
Randomized hierarchical design (nested treatments
A2. Nonrandomized designs (if non-random assignment design, select one of the following)
Nonrandomized design
Nonrandomized block design (between participants)
Nonrandomized block design (within participants)
Nonrandomized hierarchical design
Optional coding for Quasi-experimental designs
A3. Overall confidence of judgment on how participants were assigned (select one of the
following)
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Doctorate in Educational and Child Psychology
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Very low (little basis)
Low (guess)
Moderate (weak inference)
High (strong inference)
Very high (explicitly stated)
N/A
Unknown/unable to code
B Participants
Total size of sample (start of study): 40
Intervention group sample size: 17
Control group sample size: 23
C. Type of Program
Universal prevention program
Selective prevention program
Targeted prevention program
Intervention/Treatment
Unknown
D. Stage of Program
Model/demonstration programs
Early stage programs
Established/institutionalized programs
Unknown
E. Concurrent or Historical Intervention Exposure
Current exposure
Prior exposure
Unknown
100
Nikki
Doctorate in Educational and Child Psychology
Collingwood
Section 2
Nikki
Key Features for Coding Studies and Rating Level of Evidence/Support
A Measurement (Estimating the quality of the measures used to establish effects)
A1 The use of the outcome measures produce reliable scores for the majority of the primary
outcomes (see following table for a detailed breakdown on the outcomes)
Yes
No
Unknown/unable to code
A2 Multi-method (at least two assessment methods used)
Yes
No
N/A
Unknown/unable to code
A3 Multi-source (at least two sources used self-reports, teachers etc.)
Yes
No
N/A
Unknown/unable to code
A4 Validity of measures reported (well-known or standardized or norm-referenced are
considered good, consider any cultural considerations)
Yes validated with specific target group
In part, validated for general population only
No
Unknown/unable to code
Overall Rating of Measurement:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
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Nikki
B Comparison Group
B1 Type of Comparison group
Typical intervention
Attention placebo
Intervention element placebo
Alternative intervention
Pharmacotherapy
No intervention
Wait list/delayed intervention
Minimal contact
Unable to identify type of comparison
B2 Overall rating of judgment of type of comparison group
Very low
Low
Moderate
High
Very high
Unable to identify comparison group
B3 Counterbalancing of change agent (participants who receive intervention from a single
therapist/teacher etc were counter-balanced across intervention)
By change agent
Statistical (analyse includes a test for intervention)
Other
Not reported/None
B4 Group equivalence established
Random assignment
Posthoc matched set (as repeated measures design)
Statistical matching
Post hoc test for group equivalence
B5 Equivalent mortality
Low attrition (less than 20 % for post)
Low attrition (less than 30% for follow-up)
Intent to intervene analysis carried out?
Findings_____________
Overall Rating of Comparison Group:
3
2
1
0
(Rating Scale: 3= Strong Evidence, 2=Promising Evidence, 1=Weak Evidence, 0=No Evidence)
102
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C Appropriate Statistical Analysis
Analysis 1___________ADIS______________________________________________________________
Appropriate unit of analysis
Familywise/expermenter wise error rate controlled when applicable
Sufficiently large N
Analysis 2______________MASC – P/C_________________________________________________________
Appropriate unit of analysis
Familywise/experimenter wise error rate controlled when applicable
Sufficiently large N
Overall Rating of Analysis:
3
2
1
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Wood, Drahota, Sze, Har, Chiu & Langer (2009)
Significant
Outcomes
Outcome 1
Anxiety
symptoms
Outcome 2
Anxiety
symptoms
Not
Significant
Outcomes
Outcome 1
Anxiety
symptoms
Primary vs
Secondary
Who Changed
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Primary
Secondary
Unknown
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
Primary vs
Secondary
Primary
Secondary
Unknown
Who Changed
Child
Teacher
Parent/Sig.A
Ecology
Other
Unknown
What Changed
Source
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other:
therapist
Unknown
Behaviour
Self Report
Attitude
Parent Rpt
Knowledge
Teacher Rpt.
Other –
Observation
internalised
Test
symptoms
Other
Unknown
Unknown
What Changed Source
Behaviour
Attitude
Knowledge
Other –
internalised
symptoms
Unknown
Self Report
Parent Rpt
Teacher Rpt.
Observation
Test
Other
Unknown
Treatment
Information
Building Confidence
CBT program (Wood &
McLeod, 2008) modified
for ASD
Building Confidence
CBT program (Wood &
McLeod, 2008) modified
for ASD
Treatment
Information
Building Confidence
CBT program (Wood &
McLeod, 2008) modified
for ASD
104
Outcome
Measure
Used
ADIS-CSR
Reported
Reliability
MASC-P
Alpha= .88
Agreement between
clinician and consist
severity ratings and
diagnoses was
adequate
Outcome
Measure
Used
Reported
Reliability
MASC-C
Alpha= .85
Effect Size
(Cohen,
1992)
3.7
(LARGE)
.94
(LARGE)
Effect
Size
(Cohen,
1992)
.09
(SMALL)
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105
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Appendix D: Participant Characteristics
Study
Sample
Size
Gender type
(approx.
male:female
ratio)
Chalfant et
al (2007)
47
35 males
12 females
Age
range/
Mean age
(if
available)
8-13
Mean age:
10.8
Intellectual Functioning
ASD type (if specified)
Use of Instrument to
ASD verify diagnosis
Numbers with Primary
Anxieties
(pre-trial/baseline)
Age appropriate language skills
and intellectual functioning
ranged between borderline to
every superior.
HFAD: 13 (27.7%)
Asperger’s: 34 (72.3%)
None
Only pre-trial diagnosis
via paediatrician
7 – 11
mean age:
8.8
Exclusion criteria
IQ < 70
Autism: 11
PDD-NOS: 1
ADI-R; ADOS
9 – 13.11
Mean age:
11.8
Inclusion criteria
IQ > 69
ASD = 32
ADOS
8 – 14
Mean age:
11.10
7 – 14
Mean age:
10.5
70 – 138
Mean = 102.65, SD = 16.22)
AD: 15
PDD-NOS = 4
Asperger’s = 14
AD= 31
PDD-NOS: 3
Asperger’s: 16
ADOS
10 – 12
Mean age:
10.6
90 - 137
Mean = 104.7
SD= 25.2
AS = 71.
None
Only pre-trial diagnosis
via paediatrician
7 – 11
Mean age:
Exclusion criteria
IQ < 70
AD = 13
PDD -NOS= 18
ADOS; ADI-R
SP: 20
GAD: 14
SAD: 8
SpP: 3
PD: 2
SAD: 5
SP: 5
OCD: 1
GAD: 1
SpP=14
GAD= 13
SP= 11
SAD =7
OCD=3
GAD = 22
SAD = 6
SA = 5
Mean CSR in each:
GAD:4.46
SOC: 3.85
SpP:3.45
SEP:2.45
Primary diagnoses (mean scores)
SP:8.1
SAD: 7.3
GAD:7.1
Panic:5.4
PI: 5.4
OCD:5.1
SP = 18
GAD = 14
3:1
Fujii et al
(2013)
12
McConachie
et al (2013)
32
9 males
3 females
3:1
28 males
4 females
7:1
Reaven et al
(2009)
33
Reaven et al
(2012)
50
26 males
7 females
4:1
48 males
2 females
70 – 139
Mean = 104.7
SD = 17.09)
ADOS
24:1
Sofronoff et
al (2005)
71
62 males
9 females
7:1
Storch et al
(2013)
45
36 males
9 females
106
Doctorate in Educational and Child Psychology
Study
Sample
Size
Gender type
(approx.
male:female
ratio)
Nikki Collingwood
Age
range/
Mean age
(if
available)
8.9
Intellectual Functioning
ASD type (if specified)
Use of Instrument to
ASD verify diagnosis
12-17
mean age:
15
Verbal IQ mean: 97.07
SD: 14.46
Autism: 10
Asperger’s: 16
PDD-NOS= 4
ADOS; ADI-R
7-11
mean age:
9.2
Exclusion criteria
IQ < 70
AD= 20
PDD-NOS= 17
AS= 3
ADOS; ADI-R
AS = 14
SAD = 9
OCD= 4
4:1
White et al
(2013)
30
23 males
7 females
3:1
Wood et al
(2009)
40
27 males
13 females
2:1
Numbers with Primary
Anxieties
(pre-trial/baseline)
SP=23
GAD=19
SpP= 16
OCD=4
SAD=1
PD=1
PTSD=1
SP=25
SAD= 24
GAD=19
OCD=17
AD = Autistic Disorder; ADIS = Anxiety Disorders Interview Schedule; AS = Asperger’s Syndrome; ASD = Autism Spectrum Disorder; HFAD = High Functioning Autistic Disorder; GAD =
Generalised Anxiety Disorder; PI= Personal Injury; PD = Panic Disorder; PDD-NOS = Pervasive Developmental Disorder Not otherwise specified; PTSD= Post Traumatic Stress Disorder; ; SA =
Social Anxiety; SAD = Separation Anxiety Disorder;; SOC = Social Phobia; SP = Social Phobia; SpP = Specific Phobia
107
Doctorate in Educational and Child Psychology
Nikki Collingwood
Appendix E: Summary of Design elements of the studies
Study
Sample
Size
Design
Type/Control
Group
Group Equivalence
Concomitant Treatments during
the trial
Anxiety Outcome
measures/ approach
Chalfant et al
(2007)
47
12
Chi squared analysis showed that groups did not
differ in ages, gender, school grade, intellectual
functions, family make-up; siblings; socioeconomic status; primary anxiety type; type of
ASD
Authors note that groups did not differ
significantly on child gender, age, ethnic
background, and parent demographics
No alternative treatment sought
during treatment or waiting period.
Fujii et al
(2013)
ADIS-C/P (Interview) – no blind
rating
RMAS (Scale - Child)
SCAS – C/P (scale)
CATS (scale – Child)
ADIS – C/P (interview) linked to
a CSR rating
(no mention of blind rating)
McConachie
et al (2013)
32
Authors note that randomisation resulted in
groups which did not differ on ASD diagnosis; full
scale IQ, and demographics.
There was a slight difference in parent
occupations.
All children continued with other
services and interventions as usual –
not identified if relevant to anxiety
reduction
ADIS –C (interview)
CGI (interview and
questionnaire assessed “blind”)
SCAS – C/P (scale)
Reaven et al
(2009)
33
Chi squared and t-tests analyses found no
differences on demographic variables (age, IQ,
gender, mother’s education, parental report of
overall anxiety symptoms on SCARED, number of
medication taken by child pre-treatment.
Parents were asked not change
medications during the course of the
treatment, however, clinical need
superseded research protocol. Not
allowed therapy directed toward
anxiety reduction.
SCARED –C/P (scale)
Reaven et al
(2012)
50
Chi squared and t-tests analyses found no
differences on demographic and diagnostic
variables
Ongoing interventions during trial in
the TAU
Sofronoff et
al (2005)
71
Randomised design
and assignment to
either CBT condition
or Wait List
condition.
Random assignment
to immediate
treatment (IT) or a
treatment-as-usual
(TAU) comparison
group.
Randomised
allocation to
immediate therapy
(IT) or control
delayed therapy
(DT) using random
permuted blocks.
Assignment to
Active Treatment
(AT) or Wait List
Control based on
order of enrolment,
not random
assignment.
Random assignment
to treatment (FYF)
or TAU group using
a computergenerated
assignment system.
Randomly assigned
to Child only; Child +
Authors noted that there was no significant
differences in the group pre-intervention
No comment on whether alternative
treatment sought during treatment
ADIS-P (interview) linked to CSR
(blind rating)
CGI (bases on interview and
scaled) blind to treatment type
SCARED – C/P (used for
screening only)
SCAS-P (scale)
108
Families in TAU free to seek any kind
of treatment they chose during
waiting period - not identified if
relevant to anxiety reduction
Doctorate in Educational and Child Psychology
Study
Sample
Size
Design
Type/Control
Group
Nikki Collingwood
Group Equivalence
Parent; Wait-List.
Concomitant Treatments during
the trial
Anxiety Outcome
measures/ approach
or waiting period
James and the Maths Test –
Child generates strategies
PARS-(Clinician rated) – blind
rating except at 3 month follow
up.)
ADIS- C/P (interview)
CGI–I (Clinician rated)
CGI-S (Clinician rated)
MASC – P (scale)
RCMAS – C (scale)
CASI-Anx – P (scale)
ADIS – C/P (interview) linked to
CSR ratings
PARS – (clinician rated)
Storch et al
(2013)
45
Participants
randomised into the
CBT or TAU group
by computer
generated algorithm
Chi squared and t-tests analyses found no
differences on demographic and clinical variables,
except in the case of Autistic Disorder, where
there were significantly more children with this
ASD type in the CBT group
Limited alternative treatment sought
in TAU as long as not concurrent
psychosocial treatments
White et al
(2013)
30
Participants
randomised into the
MASSI or Wait List
(WL) group by
person unaffiliated
to study.
Chi squared and t-tests analyses found no
differences on demographic and clinical variables
at baseline
Only medication permitted as long as
does was stable for at least 4 weeks
with no planned changes for the
duration of the trial
Wood et al
(2009)
Blinded Independent
evaluations
40
Participants were
Chi squared and t-tests analyses found no
Only medication permitted as long
ADIS-C/P (interview)
block randomised
differences on demographic and clinical variables, not changed during study.
linked to CSRs (Clinician rated)
using computer
except in the case of other comorbid diagnoses,
CGI-I (Clinician rated)
randomisation
where there were more cases of children with
(no mention of blind rating)
program either
Dysthymia in the intervention group.
Immediate
MASC-C/P (scale)
Treatment (IT) or
waitlist (WL)
ADIS = Anxiety Disorders Interview Schedule; CATS = Children’s Automatic Thoughts Scale; CASI-Anx= Child and Adolescent Symptom Inventory Anxiety Scale; CGI-I = Clinical Global
Impressions Scale – Improving ratings; CGI-S = Clinical Global Impressions Scale – Severity ratings; C/P: measure completed by Child/Parent; CSR = Clinician’s Severity Rating; MASC=
Multidimensional Anxiety Scales for Children; PARS = Paediatric Anxiety Rating Scale; RCMAS = Revised Children’s Manifest Anxiety Scale; SCARED = Screen for Child Anxiety and Related
Emotional Disorders; SCAS = Spence Children’s Anxiety Scale
109
Doctorate in Educational and Child Psychology
Nikki Collingwood
Appendix F: Summary of CBT Treatment dimensions
Author
CBT
Intervention
Duration
Chalfant et
al (2007)
HFA adaptation to
the Macquarie
University, ‘‘Cool
Kids’’
program
(Lyneham,
Abbott, Wignall,
& Rapee, 2003)
12 weekly
sessions for 2
hours
Building
Confidence CBT
program (Wood &
McLeod, 2008)
modified for use
with children with
ASD (Wood,
Drahota,, Sze,
Har, Chiu, &
Langer, 2009).
32 weekly
sessions
lasting 90
mins (30 mins
with child; 30
mins with
parents; 30
mins parents
and child)
Fujii et al
(2013
)
Main components for
Child
-
Introduction to and roleplaying of anxiety
management procedures.
Consolidation newly
learned skills and planning
out their weekly exposure
tasks
-Coping skills training
-In vivo exposure to feared
situations,
-social skills Skills for dealing
with relationships and
interactions with peers at
school and in community.
Adaption for ASD
Delivery
Mode
Sessions involved more concrete
exercises and placed less emphasis
on the children’s communication
skills.
Material covered the recognition of
anxious feelings and somatic
reactions to anxiety, relaxation,
simplified cognitive restructuring
exercises, coping self-talk, exposure
to feared stimuli and relapse
prevention.
3 monthly booster sessions.
Specific treatment modules were
included to teach social and
friendship skills to children in school
and community situations,
supported by teachers and their
parents.
Group of 68 children/
Family
treatment
Individual/
Family
treatment
Large school based/teacher
involvement in teaching and
integrating social skills.
Facilitation/
setting/ Fidelity
to intervention
Parent Component
Therapists:
Registered Clinical
Psychologists.
Setting: Clinic
Addressed anxiety education,
relaxation strategies, cognitive
restructuring exercises, graded
exposure, parent management
training and relapse prevention.
No indication of
therapy fidelity
Families planned out their weekly
exposure tasks (outside of
sessions).
Therapists: graduate
students in clinical or
educational
psychology; doctoral
students in
psychology and
psychiatry.
Received initial
training and weekly
supervision.
Setting: Clinic, with
transition of skills
into school setting
Parents taught social coaching skills
to support children at home and
during play dates.
Parents worked with teachers to
implement the intervention-related
homework at school.
No indication of
therapy fidelity
McConachi
e et al
(2013)
Exploring Feelings
(Attwood, 2004)
Seven 2-h
early evening
sessions
-
Sessions on identified
feelings of being happy,
relaxed or anxious, then
moved on to build a
toolbox of strategies
appropriate for each child,
including physical, social
Minor adjustments made to manual
with an introductory on CBT session
added.
110
Parents and
children in
separate
groups,
each with
two group
leaders.
Therapists: Trainee
Psychologists
Received initial
training and weekly
supervision.
Setting: Clinic
Parents worked through the same
exercises and materials as children.
Doctorate in Educational and Child Psychology
Author
CBT
Intervention
Duration
Nikki Collingwood
Main components for
Child
Adaption for ASD
Delivery
Mode
Facilitation/
setting/ Fidelity
to intervention
Parent Component
and thinking tools.
Indication of therapy
fidelity
Reaven et
al (2009)
Reaven et
al (2012)
Sofronoff et
al (2005)
Coping Group:
Fighting Worries
and Facing fears
(Reaven,
Hepburn, Nichols,
Blakely-Smith, &
Dasari, 2005)
Facing Your Fears
(Reaven, BlakelySmith, Nichols &
Hepburn, 2011)
CBT programme
(Sofronoff et al,
2005)
12 weekly
sessions each
lasting
1½ hours
-
-
12 multifamily groups
sessions, 1.5
hours.
Six 2 hour
sessions.
-
-
Introduction to anxiety
symptoms and an
introduction to common
CBT strategies
Implementation and
generalization of specific
tools and strategies to
treat the anxiety
symptoms.
Original manualised programme,
based on main-stream cognitivebehavioural approaches, modified
to meet cognitive, linguistic and
social needs of children with ASD.
Introduction to anxiety
symptoms and CBT
Implementation of
strategies for anxiety
Graded exposure
Social Skills development
CBT programme developed
specifically for children with ASD
and clinical anxiety.
Positive emotions and
relaxation
Exploration of anxiety and
impact; tool box for
dealing with anxiety
social tools; thinking tools;
Emotional understanding
Pacing of session taken into
account, token reinforcement
programme for in-group behaviour;
video-modelling; opportunities for
repetition; visual structure and
predictable routine. Adapted
worksheets.
Specifically designed for this
population
Mixture of
group time,
separate
parent and
child group
meetings,
and parentchild dyads.
Therapists: Group
Facilitators
supervised by
Research
psychologist
Setting: Clinic
Groups
children and
parents;
mixture of
large group;
small group
and dyadic
work
(parent/chil
d pairs)
Therapists: Clinical
Psychologist led
groups, supported by
two co-therapists.
Received initial
training and ongoing
supervision
Setting: Clinic
Child
groups or
child and
parent
groups
Therapists – post
graduate students.
Training available and
weekly supervision
Setting: clinic
Indication of therapy
fidelity
Indication of therapy
fidelity
Indication of therapy
111
Modules covered:
Psycho-education pf anxiety
disorders and introduction to
basic principles of CBT
Identification of child’s specific
anxiety symptoms
Identification of target
behaviours in preparation for
graded exposure assignments
Discussion of parental anxiety
and parenting style
Discussion of socialcommunication challenges in
ASD and impact on protective
parenting style
Psycho-education regarding
anxiety symptoms and CBT
strategies
Parent coaching to support
child participation
Discussion of parental anxiety,
parenting style and anxiety
symptoms
Social and communication
challenges in ASD and link to
parenting style (protective)
Parents trained as cotherapists in all components
of the intervention.
Doctorate in Educational and Child Psychology
Author
CBT
Intervention
Duration
Storch et al
(2013)
Behavioural
Interventions for
Anxiety in
Children with
Autism (BIACA;
Wood & Drahota,
2005)
16 weekly 60
– 90 minute
sessions
White et al
(2013)
Wood et al
(2009)
Multi Modal
Anxiety and Social
Interaction
(MASSI; White,
Albano, Johnson,
Kasari, Ollendick,
Klin et al (2010)
Building
Confidence
(Wood and
McLeod, 2008)
Main components for
Child
Emotion management.
Core CBT modules , but
additional modules flexibly
followed based on child’s
clinical needs.
Nikki Collingwood
Adaption for ASD
Specifically designed for children
with ASD.
Considers issues for working with
this population such as low
motivation and co-morbidity.
Child modules included: coping
skills; exposure therapy; social
skills; relaxation; processing
termination.
13 Individual
sessions: 60 –
70 mins
Parents
sessions: 15
mins
7 Group
meetings: 75
mins
Individual sessions to address
subject-specific anxiety
symptoms and social skill
deficits – modules selected by
therapists.
Group sessions covered social
skills related activities.
16 weekly
sessions (90
mns): 30 mins
with child and
60 mins with
parents/famil
y
Coping skills training
In Vivo exposure to a hierarchy
of feared situations, with the
practise of coping skills learned.
Social skills training.
Specifically designed for young
people with ASD.
Manual enhanced by addressing:
poor social skills; adaptive skills
deficits; poor attention and
motivation; common comorbidities
of ASD; and school based problems.
Specific modules on friendship skills
and building independence.
112
Delivery
Mode
Individual/
Family
based –
modules
completed
by child and
parent
Individual
therapy (13
sessions)
Group
therapy (7
sessions)
Parent
education
and
coaching
after each
individual
therapy
session.
Individual/
Family
sessions
Facilitation/
setting/ Fidelity
to intervention
fidelity
Therapists: doctoral
students or postdoctoral students
with at least 1 year of
therapeutic
experience for
anxiety in youth with
ASD, and 2 or more
years of experience
working clinically
with youth with ASD.
Training provided
and supervision
Indication of therapy
fidelity
Principal investigator
and 4 doctoral
students in clinical
psychology.
Training and
supervision provided.
Setting: Clinic
Indication of therapy
fidelity
Therapists: doctoral
students in clinical or
educational
psychology and
doctoral level
psychologists.
Training and
Parent Component
Conducting exposure tasks at
home; psycho-education;
social skills facilitation;
encouraging independence;
establishing reward system;
parent/school advocacy;
supporting processing
termination.
Parent education and coaching
after each of the 13 individual
sessions.
Act as “coaches” for exposure
exercise during the week,
making environmental
changes; encourage and
reinforce implementation of
desired target behaviours
Supporting in vivo exposes, using
positive reinforcements and
building communication skills to
encourage independence and
autonomy in daily routines.
Doctorate in Educational and Child Psychology
Author
CBT
Intervention
Duration
Nikki Collingwood
Main components for
Child
Adaption for ASD
Delivery
Mode
Link with school to set up “peer
buddies” and to teach the social
intervention techniques to relevant
adults.
Facilitation/
setting/ Fidelity
to intervention
Parent Component
supervision provided.
Setting: Clinic, with
transference support
in schools
Indication of therapy
fidelity
Appendix G: Summaries of Outcomes of studies with respect to Report type
Study
Chalfant et al
(2007)
Sampl
e Size
47
Clinician Report
Measure
ADIS –C/P
Outcomes
Post-treatment, 71.4% of children
from the CBT condition no longer
met the DSM-IV criteria for current
primary anxiety disorder
Parent Report
Measure
SCAS-P
Outcome
SCAS-P: Parents reported
significant reduction in their
child’s anxiety symptoms preand post- treatment if they were
in the CBT group.
Self -Report
Measure
CATS
(internalising)
RMAS
SCAS-C
Fujii et al
(2013)
12
CSR (based
on ADISC/P)
McConachie
32
ADIS-C
5 out of 7 (71.4%) in IT condition no
longer met diagnostic criteria for
primary anxiety disorder after
treatment, while all children in TAU
still met diagnostic criteria for
primary anxiety disorder.
13 out of 17 in the IT reported to
have reduction in severity of primary
SCAS-P
No significant reduction in
anxiety
113
SCAS-C
Outcome
CATS Internalising Scale:
CBT group reported
significantly less internalising
thoughts about self-esteem
and anxiety than WL group in
pre- and post-test.
RMAS: significant reduction
between pre- and post-test in
self-reported anxiety in CBT
group compared to WL
SCAS_C: overall reduction of
self-reported anxiety
symptoms between pre-and
post-test results in CBT
condition.
Children reported reduction in
anxiety (not significant
Doctorate in Educational and Child Psychology
Study
Sampl
e Size
Nikki Collingwood
Clinician Report
Measure
et al (2013)
Outcomes
Parent Report
Measure
Outcome
Self -Report
Measure
Outcome
anxiety disorder, compared to 5 in
DT.
CGI-I
Reaven et al
(2009)
33
Reaven et al
(2012)
50
ADIS-C/P
Principal
Anxiety CSR
CGI: no significant difference
between IT and DT in the blind
rating, however frequency shows a
trend for more improvement in IT
SCARED-P
SCARED-P
Parent report suggests that
children in active treatment
group experience significant
decrease in anxiety symptoms
severity over time compared to
WL group.
SCARED -C
SCARED-C
Child reports showed no
significant effects of treatment
over time
SCAS-P
Both interventions groups
significantly better over time,
compared to WL.
Combined Child+Parent group
showed greater improvement
than Child only or Waitlist.
No group differences found.
James and the
Maths Test
Improvement in strategies to
deal with anxiety provoking
situations, with Child + Parent
group generating significantly
more strategies than Child
only group.
Anxious Arousal subscale
showed a difference between
groups
CSRs were lower in the intervention
group post-intervention with
significant differences between FYF
and TAU groups in all 4 diagnoses
of anxiety.
Significant reduction in number of
principal anxiety disorders (ADIS-P)
was found in the FYF group, not in
the TAU group.
CGI-I
Sofronoff et
al (2005)
71
Storch et al
(2013)
45
PARS
ADIShighest CSR
CGIS_I showed a “clinically
meaningful improvement in anxiety
severity” for FYF group sample
compared to the TAU sample
PARS: 29% reduction after CBT
treatment compared to 9% for TAU.
Large group differences in CBT
compared to TAU group
MASC-P
114
RCMAS –
anxious arousal
subscale
Doctorate in Educational and Child Psychology
Study
Sampl
e Size
Clinician Report
Measure
Outcomes
30
PARS
Large group differences in CBT
compared to TAU group
38% of children in CBT group
achieved clinical remission at posttreatment compared to 5% in TAU.
No differences between groups
40
ADIS-C/P
CSR
Post treatment CSR scores were
lower in the IT group than in the WL
group
CGISeverity
White et al
(2013)
Wood et al
(2009)
Nikki Collingwood
Parent Report
Measure
Outcome
CASI-Anxiety
scale
MASC-P
Self -Report
Measure
Outcome
No differences between
groups
Parent MASC scores
were statistically different
post treatment in the IT
group compared to WL
group.
MASC-C
Child MASC reports showed no
significant differences between
groups post treatment.
ADIS = Anxiety Disorders Interview Schedule; CATS = Children’s Automatic Thoughts Scale; CASI-Anx= Child and Adolescent Symptom Inventory Anxiety Scale; CGI-I = Clinical Global Impressions Scale – Improving ratings; CGI-S = Clinical
Global Impressions Scale – Severity ratings; C/P: measure completed by Child/Parent; CSR = Clinician’s Severity Rating; MASC= Multidimensional Anxiety Scales for Children; PARS = Paediatric Anxiety Rating Scale; RCMAS = Revised
Children’s Manifest Anxiety Scale; SCARED = Screen for Child Anxiety and Related Emotional Disorders; SCAS = Spence Children’s Anxiety Scale
115