A Randomized Waitlist Controlled Trial of Cognitive Behavior Therapy to Improve Emotion Regulation in Children with Autism

Background: Mental health problems are common among individuals with autism spectrum disorder (ASD), and difficulties with emotion regulation processes may underlie these issues. Cognitive behavior therapy (CBT) is considered an efficacious treatment for anxiety in children with ASD specifically; however, additional research is needed to examine the efficacy of a transdiagnostic treatment approach. The intervention in question, Secret Agent Society: Operation Regulation (SAS:OR) is an individually provided spy-themed manualized intervention using cognitive behavioral strategies. Systematic exposures, affect education, and strategies are applied across multiple emotions with a focus on practicing adaptive emotion regulation processes. Sessions progress from teaching basic skills, such as recognizing and labeling emotions in self and others (i.e., affect education) to more complex skills, such as adjusting responses to difficult emotions using relaxation strategies (response modulation), combined with planned systematic exposure to increasingly distressing family-informed situations. A parent is involved throughout each session; they follow along in their own manual, provide support to the child and therapist, and later, help the child transfer skills to school and home environments.

Objectives: The purpose of the present study was to examine the efficacy of SAS:OR with children with ASD, using a randomized waitlist controlled trial.

Methods: Sixty-eight children (M age = 9.75, SD = 1.27) and their parents participated in the study, randomly allocated to either a treatment immediate (n = 35) or waitlist control condition (n = 33). Parent-, child-, and clinician-reported measures of emotion regulation and mental health were administered at baseline, post-intervention, and at 10-week follow-up.

Results: Treatment integrity was high (85.8%) across sessions. Overall, children demonstrated good in-session engagement and program adherence. Results from ANCOVA revealed a significant treatment effect on two primary emotion regulation outcome measures: the parent-report Lability/Negative subscale of the Emotion Regulation Checklist (p = .03), with a medium effect, and the Emotion Regulation and Social Skills Questionnaire, with a large effect. Significant medium to large treatment effects were also found on parent reports of child adaptive behavior (p = .001) and behavioral symptoms (p = .04), overall Anxiety Disorder Interview Schedule Overall Severity (p = .04), and on blind clinician judgement on the Clinical Global Impression Scale-Severity (p = .01), and -Improvement (p = .003). Treatment gains were maintained at follow-up.

Conclusions: This study is the first transdiagnostic CBT efficacy trial for children with ASD. Additional investigations are needed to further establish its relative efficacy compared to more traditional models of CBT for children with ASD and other neurodevelopmental conditions.