The Relationship Between Treatment Acceptability and Child Outcome in Group CBT for Youth with ASD and Anxiety

Background: Children with ASD are at increased risk for developing anxiety and modified cognitive-behavioral therapy (CBT) interventions can be effective in reducing anxiety in this population (Lang et al., 2010). CBT for anxiety consists of psychoeducation (e.g., somatic management, attention to automatic negative thoughts) and graded exposure (facing fears a little at time) (Velting et al., 2004). However, client resistance is typically highest during exposure practice compared to psychoeducation (Abramowitz et al., 2002). Little is known about how children with ASD (and their parents) perceive the acceptability of treatment and in particular, exposure. In fact, it is important to understand whether clients must consider a treatment helpful (or acceptable) in order to improve. Currently, the relationship between treatment acceptability (e.g., perceptions about a treatment and whether it is deemed helpful; Kazdin et al., 2005) and treatment outcomes in CBT for youth with ASD is unknown. Gaining a better understanding of this relationship may allow researchers to refine intervention content and delivery. Objectives: (1) To examine overall ratings of acceptability for parents and children completing the Facing Your Fears (FYF) intervention (Reaven et al., 2011) (a group CBT treatment for youth with anxiety/ASD); and (2) To compare acceptability ratings for psychoeducation (sessions 1-6) and exposure (sessions 7-13) among parents and children; and (3) To determine the association between acceptability and child outcome (child and parent report on the SCARED). Methods: This study was part of a larger, multi-site study, investigating the impact of clinician training on treatment fidelity and youth anxiety treatment outcome. A three group parallel design was used to randomize eight clinician cohorts to one of the three training conditions. Acceptability ratings were collected from parents and children who participated in the 14-week FYF intervention at four outpatient clinics across the US. Acceptability was rated for each activity across sessions and rated on a 5-point-Likert scale (1=Not helpful; 5=Very helpful). A sub-sample of 63 children with ASD ages 8-14 (and their parents) were included in the analyses. Results: Mean acceptability ratings for children and parents were high for the overall treatment (Parent Overall: M=4.4, SD=.42; Child Overall: M=4.12, SD=.64) Children and parents did not differ on their ratings for psychoeducation (Parent: M=4.39, SD=.40; Child: M=4.07, SD=.63) and exposure (Parent: M=4.46, SD=.48; Child: M=4.19, SD=.76) sessions. However, ratings of child acceptability of the overall treatment were significantly related to child outcome (child report on the SCARED), r=.292, p<.05. More specifically, higher child acceptability ratings of exposure sessions were significantly related to a reduction in child anxiety symptoms, r=.355, p<.05. Conclusions: Overall, parents and children rated the FYF treatment as helpful in treating anxiety. However, children who rate exposure sessions as helpful were more likely to report a reduction in anxiety symptoms. Given that exposure is considered an “active ingredient” in anxiety treatment, acceptability of exposure may in fact be important for change to occur. Implications for the importance of measuring acceptability in treatment research will be discussed.