Cognitive Behavior Therapy for Obsessive-Compulsive Behavior in Children with Autism Spectrum Disorder: A Comparison of Hierarchical Linear Modelling and Visual Analysis

Behavioral researchers commonly use single subject designs to evaluate the effects of a given treatment. Several different methods of data analysis are used, each with their own set of methodological strengths and limitations. Visual inspection is commonly used as a method of analyzing data which assesses the variability, level, and trend both within and between conditions (Cooper, Heron, & Heward, 2007). In an attempt to quantify treatment outcomes, researchers developed two methods for analysing data called Percentage of Non-overlapping Data Points (PND) and Percentage of Data Points Exceeding the Median (PEM). The purpose of the present study is to compare and contrast the use of Hierarchical Linear Modelling (HLM), PND and PEM in single subject research. The present study used 39 behaviours, across 17 participants to compare treatment outcomes of a group cognitive behavioural therapy program, using PND, PEM, and HLM on three response classes of Obsessive Compulsive Behaviour in children with Autism Spectrum Disorder. Findings suggest that PEM and HLM complement each other and both add invaluable information to the overall treatment results. Future research should consider using both PEM and HLM when analysing single subject designs, specifically grouped data with variability.

Exploring the Therapeutic Alliance in Cognitive-Behavior Therapy with Children with Autism Spectrum Disorder: An Interpretative Phenomenological Approach

Abstract The therapeutic alliance (TA) is the most studied process of adult psychotherapeutic change (Zack et al., 2007) and has been found to have a moderate but robust relationship with therapeutic outcome regardless of treatment modality (Horvath, 2001). The TA is loosely described as the extent to which the therapist and the participant connect emotionally and work together towards goals. Conceptualizations of the TA with children have relied on adult models, even though it is widely acknowledged that the pediatric population will rarely willingly commit to therapy, nor readily admit to any challenges that they may be experiencing (Keeley, Geffken, McNamara & Storch, 2011). For children with Autism Spectrum Disorder (ASD) the therapeutic alliance may require an even greater retheorizing considering the communicative and social difficulties of this particular population. Despite this need, research on children with ASD and the therapeutic TA is almost non-existent. In this qualitative study, transcripts from semi-structured interviews with mothers of children with ASD were analyzed using Interpretative Phenomenological Analysis (IPA). IPA closely examines how individual people make sense of their life experiences using a theme-by-theme approach. The three interviewees were mothers whose children were participants in a nine-week Cognitive Behaviour Therapy (CBT) group for obsessive-compulsive behaviours (OCB). A total of four superordinate themes were identified: (i) Centralization and disremembering the TA, (ii) Qualities of the therapist, (iii) TA and the importance of time, and (iv) Signs of a healthy TA. The mothers’ perspectives on the TA suggest that, for them and their children, a strong TA was a required component of the therapy. Implications for clinicians and researchers are discussed.

A school-based cognitive behavior modification intervention strategy for learned helpless mentally retarded students

This study assessed the usefulness of a cognitive behavior modification (CBM) intervention package with mentally retarded students in overcoming learned helplessness and improving learning strategies. It also examined the feasibility of instructing teachers in the use of such a training program for a classroom setting. A modified single subject design across individuals was employed using two groups of three subjects. Three students from each of two segregated schools for the mentally retarded were selected using a teacher questionnaire and pupil checklist of the most learned helpless students enrolled there. Three additional learned helplessness assessments were conducted on each subject before and after the intervention in order to evaluate the usefulness of the program in alleviating learned helplessness. A classroom environment was created with the three students from each school engaged in three twenty minute work sessions a week with the experimenter and a tutor experimenter (TE) as instructors. Baseline measurements were established on seven targeted behaviors for each subject: task-relevant speech, task-irrelevant speech, speech denoting a positive evaluation of performance, speech denoting a negative evaluation of performance, proportion of time on task, non-verbal positive evaluation of performance and non-verbal negative evaluation of performance. The intervention package combined a variety of CBM techniques such as Meichenbaum's (1977) Stop, Look and Listen approach, role rehearsal and feedback. During the intervention each subject met with his TE twice a week for an individual half-hour session and one joint twenty minute session with all three students, the experimentor and one TE. Five weeks after the end of this experiment one follow up probe was conducted. All baseline, post-intervention and probe sessions were videotaped. The seven targeted behaviors were coded and comparisons of baseline, post intervention, and probe testing were presented in graph form. Results showed a reduction in learned helplessness in all subjects. Improvement was noted in each of the seven targeted behaviors for each of the six subjects. This study indicated that mentally retarded children can be taught to reduce learned helplessness with the aid of a CBM intervention package. It also showed that CBM is a viable approach in helping mentally retarded students acquire more effective learning strategies. Because the TEs (Tutor experimenters) had no trouble learning and implementing this program, it was considered feasible for teachers to use similar methods in the classroom.

Dyad function-based cognitive behavioural therapy as a treatment for obsessive compulsive disorder in two school aged children with high functioning autism

Children with High-Functioning Autism (HF A) are more vulnerable to developing Obsessive Compulsive Disorder (OCD) than typically developing children and those with Low-Functioning Autism (Gadow et al., 2005). This study used a multiple baseline design across behaviours (Cooper, Heron, & Heward, 2007) to investigate if a two phase function-based Cognitive Behaviour Therapy (CBT) would decrease obsessive compulsive behaviours (OCBs) in two children ages 7 and 9 who met criteria for OCD and HF A. This multimodal treatment package consisted of treatment enhancements to meet the children's cognitive, linguistic, and social challenges associated with their HF A diagnosis, as well as a manual and accompanied children's workbook (Vause, Neil, & Feldman, in progress). In line with previous research conducted on CBT as a treatment for OCD in this population (e.g., Wood et at, 2009), the children in this study experienced clinically significant decreases in their OCBs as a result of receiving the CBT protocol.

Investigating Changes in Parent Knowledge about Obsessive Compulsive Behaviour Following Group Function-Based Cognitive Behavioural Therapy for Children with High Functioning Autism

This study investigated improvements in parent knowledge of effective intervention strategies following participation in a group function-based CBT treatment (GFbCBT) package for children with comorbid OCD and ASD. Nineteen parents of children ages 7-12 years with High Functioning Autism (HFA) participated in the 9-week treatment program. Key components of treatment included psychoeducation and mapping, cognitive-behavioural skills training, function-based interventions and exposure and response prevention (ERP). Treatment sessions also included direct parent education, which followed a behavioural skills training model (Miltenberger, 2008). Parent knowledge (N = 19) was measured pre and post treatment using a vignette about a child demonstrating obsessive-compulsive behaviour. Results of a one-tailed pairwise t-test indicated statistically significant changes (p=.036) in overall parent knowledge following participation in treatment. Statistically significant changes were also found in parents’ ability to generate ERP and function-based intervention strategies. These results provide preliminary evidence that parents benefit from active involvement in the GFbCBT treatment package.

Evaluating Knowledge of a Function-based Cognitive-Behavioural Treatment for Obsessive Compulsive Behaviour in Autism Spectrum Disorder

Children with Autism Spectrum Disorder (ASD) have restricted and repetitive behaviours (RRBs) which may be similar to obsessions and compulsions in Obsessive Compulsive Disorder (OCD). These behaviours can be intrusive and interfere in the lives of the child and their family. Preliminary studies have shown success in using adapted Cognitive Behavioural Therapy (CBT) to treat these behaviors in children with high functioning ASD. Using a hypothetical vignette, this thesis attempted to examine procedural knowledge that the children and their parents gained while participating in a CBT treatment that was evaluated in a Randomized Controlled Trial. For both parents and children, there was a significant increase in number of strategies generated from pre to post-treatment. Further, children in the experimental group generated significantly more strategies than the treatment as usual (TAU) group post-intervention. There was no significant correlation between number of strategies generated and the child’s treatment success, age, or IQ.

Evaluation of a treatment program for individuals with an intellectual disability who have high risk behaviours

In the past two decades numerous programs have emerged to treat individuals with developmental disabilities who have sexual offending behaviours. There has, however been very few studies that systematically examine the effectiveness of long term treatment with this population. The present research examines the therapeutic outcomes of a multi-modal behaviour approach with six individuals with intellectual disabilities previously charged with sexual assault. The participants also exhibited severe behavioural challenges that included verbal aggression, physical aggression, destruction and self-injury. These six participants (5 males, 1 female) were admitted to a Long Term Residential Treatment Program (LTRTP), due to the severity of their behaviours and due to their lack of treatment success in other programs. Individualized treatment plans focused on the reduction of maladaptive behaviours and the enhancing of skills such as positive coping strategies, socio-sexual knowledge, life skills, recreation and leisure skills. The treatment program also included psychiatric, psychological, medical, behavioural and educational interventions. The participants remained in the Long Term Residential Treatment Program (LTRTP) program from 181 to 932 days (average of 1.5 years). Pre and post treatment evaluations were conducted using the following tools: frequency of target behaviours, Psychopathology Inventory for Mentally Retarded Adults (PIMRA), Emotional Problems Scale (EPS), Socio-Sexual Knowledge and Attitudes Assessment Tool (SSKAAT-R) and Quality of Life Questionnaire (QOL-Q). Recidivism rates and the need for re-hospitalization were also noted for each participant. By offering high levels of individualized interventions, all six participants showed a 37 % rate of reduction in maladaptive behaviours with zero to low rates of inappropriate sexualbehaviour, there were no psychiatric hospitalizations, and there was no recidivism for 5 of 6 participants. In addition, medication was reduced. Mental health scores on the PIMRA were reduced across all participants by 25 % and scores on the Quality of Life Questionnaire increased for all participants by an average of 72 %. These findings add to and build upon the existing literature on long term treatment benefits for individuals with a intellectual disability who sexually offend. By utilizing an individualized and multimodal treatment approach to reduce severe behavioural challenges, not only can the maladaptive behaviours be reduced, but adaptive behaviours can be increased, mental health concerns can be managed, and overall quality of life can be improved.

Using fuction-based CBT with parent involvement to treat OCD in two school-age children with high-functioning autism

Obsessive Compulsive Disorder (OCD) involves excessive worry coupled with engaging in rituals that are believed to help alleviate the worry. Pervasive Developmental Disorders (PODs) are characterized by impairments in social interaction, communication, and the presence of repetitive and/or restrictive behaviours (American Psychiatric Association, 2000). Research suggests that as many as 81% of children with a POD also meet criteria for a diagnosis ofOCD. Currently, only a handful of studies have investigated the use of Cognitive Behavioural Therapy (CBT) in treating OCD in children with autism (Reaven & Hepburn, 2003 ; Sze & Wood, 2007; Lehmkuhl, Storch, Bodtish & Geflken, 2008). In these case studies. the use of a multi-modal CBT treatment package was successful in alleviating OCD behaviours. The current study used function-based CBT with parent involvement and behavioural supplements to treat 2 children with POD and OCD. Using a multiple baseline design across behaviours and participants, parents reported that their child 's anxiety was alleviated and these gains were maintained at 6-month follow-up. According to results of the Children 's Yale-Brown Obsessive Compulsive Scale (Goodman, Price, Rasmussen, Riddle, & Rapoport, 1986) from preto post-test, OCD behaviours of the children decreased II"om the severe to the mild range. In addition, the parents rated the family's level of interference related to their child 's OCD as substantially lower. Last, the CBT treatment received high ratings of consumer satisfaction.

Promoting parent-therapist collaboration in intensive behavioural intervention programs : exploring estrategies to improve teamwork

This qualitative study investigated senior level staff (Senior Therapists), front-line staff (Instructor Therapists), and parent perspectives on parent-therapist collaboration within Intensive Behavioural Intervention settings. Two senior staff interviews, two parent interviews, and a focus group with therapists were conducted to examine how parents and therapists currently interact within IBI settings, parent and therapist expectations of each other, factors that promote and barriers that impede parent-therapist collaboration, and how parent-therapist collaboration might be improved. A constant comparative analysis by question within and across cases revealed five prominent themes of 'Role Definition', 'Perspective-taking/Empathy', 'Trust', 'Open Communication', and 'Consistency'. Additional similarities and differences were discovered between parent and therapist perspectives such as the need for clear parentprofessional boundaries, the importance of maintaining client privacy, and respect. Implications of the findings and suggestions for future research are discussed.

"Weathering a hidden storm" : an application of Andersen's behavioral model of health, and health services use for those with diagnosable anxiety disorder

"Weathering a Hidden Storm": An App~ication of Andersen's Behaviora~ Mode~ of Hea~th, and Hea~th Services Use for Those With Diagnosab~e Anxiety Disorder Research has primarily focused on depression and mood disorders, but little research has been devoted to an examination of mental health services use amongst those with diagnosable anxiety disorder (Wittchen et al., 2002; Bergeron et al., 2005). This study examined the possible predicting factors for mental health services utilization amongst those with identifiable anxiety disorder in the Canadian population. The methods used for this study was the application of Andersen's Behavioral Model of Health Services Use, where predisposing, need and enabling 111 characteristics were regressed on the dependent variable of mental health services use. This study used the Canadian Community Health Survey (cycle 1.2: Mental Health and Well- Being) in a secondary data analysis. Several multiple logistics models predicted the likelihood to seek and use mental health services. Predisposing characteristics of gender and age, Enabling characteristics of education and geographical location, and those with co-occurring mood disorders were at the greatest increased likelihood to seek and use mental health services.

I Believe in me, not OCB: Evaluation of Group Function-Based CBT as a Treatment for Obsessive Compulsive Behaviour in Four Children with HFA

Researchers have conceptualized repetitive behaviours in individuals with Autism Spectrum Disorder (ASD) on a continuum oflower-Ievel, motoric, repetitive behaviours and higher-order, repetitive behaviours that include symptoms ofOCD (Hollander, Wang, Braun, & Marsh, 2009). Although obsessional, ritualistic, and stereotyped behaviours are a core feature of ASD, individuals with ASD frequently experience obsessions and compulsions that meet DSM-IV-TR (American Psychiatric Association, 2000) criteria for Obsessive-Compulsive Disorder (OCD). Given the acknowledged difficulty in differentiating between OCD and Autism-related obsessive-compulsive phenomena, the present study uses the term Obsessive Compulsive Behaviour (OCB) to represent both phenomena. This study used a multiple baseline design across behaviours and ABC designs (Cooper, Heron, & Heward, 2007) to investigate if a 9-week Group Function-Based Cognitive Behavioural Therapy (CBT) decreased OCB in four children (ages 7 - 11 years) with High Functioning Autism (HFA). Key treatment components included traditional CBT components (awareness training, cognitive-behavioural skills training, exposure and response prevention) as well as function-based assessment and intervention. Time series data indicated significant decreases in OCBs. Standardized assessments showed decreases in symptom severity, and increases in quality of life for the participants and their families. Issues regarding symptom presentation, assessment, and treatment of a dually diagnosed child are discussed.

The relation of attentional, emotional, and social regulation to cognitive competence, from infancy to school entry

Recent research on the sources of cognitive competence in infancy and early childhood has highlighted the role of social and emotional factors (for example, Lewis, 1993b). Exploring the roots of competence requires a longitudinal and multivariate approach. To deal with the resulting complexity, potentially integrative theoretical constructs are required. One logical candidate is self-regulation. Three key developmental questions were the focus of this investigation. 1) Does infant self-regulation (attentional, emotional, and social) predict preschool cognitive competence? 2) Does infant self-regulation predict preschool self-regulation? 3) Does preschool self-regulation predict concurrent preschool cognitive competence? One hundred preschoolers (46 females, 54 males; mean age = 5 years, 11 months) who had participated at 9- and/ or 12-months of age in an object permanence task were recruited to participate in this longitudinal investigation. Each subject completed four scales of the WPPSI-R and two social cognitive tasks. Parents completed questionnaires about their preschoolers' regulatory behaviours (Achenbach's Child Behavior Checklist [1991] and selected items from Eisenberg et ale [1993] and Derryberry & Rothbart [1988]). Separate behavioural coding systems were developed to capture regulatory capabilities in infancy (from the object permanence task) and preschool (from the WPPSIR Block Design). Overall, correlational and multiple regression results offered strong affirmative answers to the three key questions (R's = .30 to .38), using the behavioural observations of self-regulation. Behavioural regulation at preschool substantially predicted parental reports of regulation, but the latter variables did not predict preschool competence. Infant selfregulation and preschool regulation made statistically independent contributions to competence, even though regulation at Time 1 and Time 2 ii were substantially related. The results are interpreted as supporting a developmental pathway in which well-regulated infants more readily acquire both expertise and more sophisticated regulatory skills. Future research should address the origins of these skills earlier in infancy, and the social contexts that generate them and support them during the intervening years.