Preliminary Randomized Trial of Function-Based Cognitive-Behavioral Therapy to Treat Obsessive Compulsive Behavior in Children With Autism Spectrum Disorder

Participants

Fifteen children were recruited for this preliminary RCT, but one family dropped out due to work commitments precluding participation. The remaining 14 children were 9 boys and 5 girls, ranging in age between 8 and 12 years (M = 9.74, SD = 1.40) at time of assessment. They were recruited from nonprofit ASD organizations, government-funded agencies, and ASD professionals. Participants had a previous diagnosis of ASD from a pediatrician, psychiatrist, or psychologist who was confirmed by our MA psychometrist who received training to be designated research reliable on the Autism Diagnostic Interview–Revised (ADI-R; Lord, Rutter, & Couteur, 1994). Additional inclusion criteria included (a) presence of OCB as defined by Sameness, Ritualistic, and Compulsive subscales on the RBS-R (Bodfish et al., 1999) and CY-BOCS (Goodman et al., 1986), (b) an estimated Full Scale IQ (Wechsler Intelligence Scale for Children, 4th ed. [WISC-IV]; Wechsler, 2004) ≥ 70, and (c) the parent indicated no planned change in child medication during the study. Exclusion criteria included participating in treatment for anxiety, repetitive behavior, and/or Intensive Behavioral Intervention (IBI) during the study. Participants were able to take part in social skills and physical education/movement groups concurrently with treatment. Families could continue with any services if assigned to the TAU condition. Using a random number generator, participants were assigned to either group Fb-CBT or TAU (see Table 1 for summary of general demographics).

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Table 1.

Demographics and Clinical Information for CBT and TAU groups.

	CBT (n = 7)	TAU (n = 7)
Measure	n (%)	n (%)
Child sex (male)	5 (71)	4 (57)
Child age	9.32 (SD = 1.40)	10.17 (SD = 1.38)
Diagnosis (diagnosis prior to DSM-5)
Autism	3 (42)	3 (42)
PDD-NOS	2 (29)	0
Asperger syndrome	2 (29)	4 (58)
M total score for RBS-R	39.43 (SD = 15)	35.71 (SD = 17.82)
M total score for CY-BOCS compulsions	14.57 (SD = 1.72)	14.67 (SD = 1.51)
M IQ (Child Short Form WISC-IV)	100.14 (SD = 16.09)	94.0 (SD = 13.76)
Parent education
Mother—college or university graduate	7 (100)	5 (71)
Father—college or university graduate	4 (57)	3 (43)
Parent married/remarried	5 (71)	7 (100)
Ethnic background
Caucasian	6 (86)	6 (86)
Asian/Pacific Islander	1 (14)	0
Multi-racial	0	1 (14)
Psychotropic medication use
SSRI	1 (14)	2 (29)
Stimulant, atomoxetine	1 (14)	2 (29)
Family financial status
Less than US$40,000	1 (14)	1 (14)
Between US$40,001 and US$90,000	4 (57)	3 (42)
More than US$90,000	2 (29)	1 (14)
Chose not to say	0	2 (29)

Note. CBT = cognitive-behavior therapy; TAU = treatment as usual; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013); PDD-NOS = pervasive developmental disorder not otherwise specified; RBS-R = Repetitive Behaviors Scale–Revised; CY-BOCS = Children’s Yale–Brown Obsessive-Compulsive Scale; WISC-IV = Wechsler Intelligence Scale for Children (4th ed.); SSRI = selective serotonin reuptake inhibitor.

Of the 14 participants, mean pre-treatment total score for both groups on Sameness, Ritualistic, and Compulsive subscales of the RBS-R (Bodfish et al., 1999) indicated clinically significant levels of ≥ 20, and mean IQ across participants was 97.07 (SD = 14.73). Of the seven children randomly assigned to Fb-CBT, five children attended treatment with their mothers, and two children had consistent involvement of both parents. Children assigned to Fb-CBT did not receive any other psychosocial treatment for anxiety or RRBs; five were medication free, and two children were taking stable doses of psychotropic medication. Children in the TAU condition reported no access to other psychosocial treatment (although allowed), and four children received stable dosages of psychotropic medication. There were no significant group differences on any variable (p > .05).

Measures

The assessment battery was administered by independent MA graduate students in applied disability studies or education who were kept blind to group assignment. The first author, who has a PhD in clinical psychology and more than 18 years of experience in conducting cognitive and mental health assessments, provided more than 70 hr of assessment training for each student including familiarization with administration, co-rating videotaped and live interviews conducted by the first author, and, finally, conducting independent interviews/assessments and co-rating with 90% reliability.

Research Design

This study received approval from a University Research Ethics Board, and written informed consent and assent were obtained from parents and children, respectively. A RCT design was used with pre- and post-testing. Follow-up RBS-R testing was conducted for the Fb-CBT group at 5 months post-treatment. For the Fb-CBT group, we conducted a treatment component analysis by examining mean parent ratings of OCBs across baseline, treatment, and follow-up.

Treatment Package

Based on level of interference for the child and family members, parents (and their children when possible) chose up to 10 OCBs to address in treatment and discussed post-treatment goals. Several behaviors were treated per participant (M = 6, range = 3– 9). During baseline and treatment, parents completed daily ratings for all OCBs using our OCB Rating Scale. Building on the work of March and Mulle (1998), we created a manualized treatment protocol titled “I Believe in Me Not OCB!” which includes a clinician’s manual (Vause, Neil, Yates, & Feldman, 2013a) and an accompanying children’s workbook (Vause et al., 2013b). Table 2 provides a detailed description of treatment enhancements (e.g., repetitiveness, predictability, use of visuals, immediate reinforcement, incorporating unique interests, and social skills exercises) to optimize treatment for individuals with ASD. Fb-CBT involved nine 2-hr weekly sessions with three to four children in each group and two therapists. Therapy consisted of group activities, individual work in parent–child dyads, group parent training, and social skills exercises. For all treatment components, at least one parent was present with the child to practice and acquire knowledge necessary to assist him or her in implementing the treatment components in the home setting. A lead female therapist (MA student in applied disability studies with a specialization in applied behavior analysis) with a minimum of 2 years’ experience working clinically with children with ASD and mental health issues, and a fourth year undergraduate female student led each group. Therapists administered the treatment jointly, with the exception of group parent training, which was led by the lead therapist, while the other therapist completed a social skills activity with the children. Therapist training consisted of reading and reviewing manual content, role-playing, and at least 2 hr of supervision each week by the first author to review weekly session content, and participants’ individual OCB program plans.

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Table 2.

Treatment Modifications for Individuals With ASD.

Modification	Description
Repetitiveness/predictability of treatment	Provided structure and predictability by following a pre-determined program plan. Treatment components (e.g., group work, individual parent–child dyads) were in the same order each week. Weekly session schedules were presented in the workbook and on a whiteboard. Although predictable, we gradually encouraged work on flexibility through introducing new behaviors with individualized adaptations (e.g., use of visuals, type of cognitive training), and schedules were adjusted (e.g., an activity out of sequence).
Emphasis on visuals, choice of response modality, and concrete exercises	Workbook contained visuals (in addition to text) to illustrate concepts, and child activities included choice in drawing, writing, and/or responding vocally. Activities were tangible (e.g., tracking progress in resisting compulsions with clear visual markers such as numbers).
Within session rules and token system	Session rules pertaining to social-communicative and on-task behavior were reviewed weekly and practiced during individual and group activities. Children earned 10 tokens for following session rules and exchanged them for a back-up reinforcer (e.g., preferred tangible) at the end of session.
Immediate and delayed reinforcers	Preferred items were delivered for completing exposure plus response prevention goals. Items were written in the workbook and earned if the child accomplished his or her goals daily, and response requirements were gradually increased.
Incorporation of child’s interests	Children’s unique interests were incorporated into the therapy components (e.g., using stickers with their favorite character) or including a favorite character as part of their support team.
Social skills exercises	Social skills activities (with and without parents) are incorporated into each session. Social skill components became progressively more difficult (and build on skills learned in previous sessions).

Note. ASD = autism spectrum disorder.

Phase 2: Individualized treatment for OCBs using functional assessment and cognitive and behavioral treatment components

Function-based assessment and intervention

Prior to working on each individual OCB, the QABF was administered to a parent to determine perceived functions (beyond anxiety reduction). Based on resources available, a variety of methods were used to collect descriptive data. Researchers observed child behavior in contrived and naturally occurring situations at home and during therapy sessions. Parents also recorded video of child behavior at home that was later analyzed by researchers. Analysis of antecedents and consequences and possible functions was conducted by researchers trained in applied behavior analysis. Based on QABF and descriptive analyses of 38 behaviors, the top two functions were automatic reinforcement and attention, with percentage of behaviors maintained by these variables being 84% and 74%, respectively (note that many behaviors had multiple functions that were all treated).

Perceived functions of individual OCBs were addressed in a written function-based assessment and intervention (FBAI) plan. Parents were trained to implement function-based interventions using verbal prompting, modeling, role-playing, and performance feedback. Functions were addressed using extinction and differential reinforcement of alternative or low rates of behaviors (Cooper, Heron, & Heward, 2007). For example, if perceived functions of frequent hand washing were parental attention and escaping a demand (e.g., meals), we addressed both functions in the FBAI. For parental attention, we advised the parent to minimize attention and prompt the child (in a neutral voice) back to the table and provide positive attention when eating. For escape, we gradually reduced the number of minutes the child engaged in hand washing and redirected him back to the meal (see Table 3 for an example of one representative behavior per participant, one perceived function, and how that function was addressed).

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Table 3.

Compulsions, Perceived Functions, and Intervention.

Target compulsions	One perceived function	Intervention to address function
Counting by touching fingers to thumb in rapid succession	Attention	Withhold attention when counting fingers. Provide attention when engaging in activities other than counting fingers (e.g., playing on computer).
Sitting in the same seat at dinner table	Nonsocial	When sitting in a seat other than “his” seat (similar sensory experience), provide positive reinforcement (e.g., verbal praise, tangibles).
Repetitive asking for reassurance about scars/discolorations or minor marks on body	Tangible	Withhold using cream and/or bandages unless deemed medically necessary. Provide a tangible contingent on the absence of this behavior.
Need to tell on sister and dad	Attention	Withhold attention when “telling” on sister or dad, and redirect to coping strategies (e.g., social stories) providing as minimal attention as possible. Provide attention for appropriate conversation.
Visual checking that possessions are in the same place	Escape	When leaving an activity to engage in checking, redirect back to the activity and provide praise for appropriate engagement.
Insistence on being picked up at exactly 5:00 p.m.	Attention	Withhold attention when child makes comments about being picked up at a time other than 5:00 p.m., and redirect to coping strategies providing as minimal attention as possible. Provide attention for engaging in coping strategies or other appropriate activities.
Ordering and straightening of objects	Nonsocial	When tolerating the gradual movement of objects out of order, provide positive reinforcement (e.g., verbal praise, tangibles).

Cognitive and behavioral strategies

OCBs were targeted one to two at a time throughout the remaining weeks. CBT skills training involved continued work on externalizing OCB. For each individual OCB, we reviewed the pros and cons of engaging in obsessions/compulsions, and taught children to generate coping statements, which often consisted of (a) externalizing statements (e.g., “I don’t have to listen to you OCB!”), (b) positive self-statements (e.g., “I can do it. I’m not going to let OCB beat me”), and/or (c) challenging faulty assumptions and deriving concrete coping statements—for example, “brushing my teeth for 3 minutes (rather than 20 minutes) is enough to get them clean.” Extent of cognitive restructuring was individualized to the participant. If there was not a distinguishable thought, we focused strictly on treatment of compulsions. Children were taught replacement behaviors (e.g., talking about and/or doing other things) to cope with the physical reactions of anxiety and/or urge to complete compulsions.

ERP and positive reinforcement

For ERP, therapists and parents assisted the child in creating a written plan for exposure to environmental stimuli associated with anxiety and refraining from performing the compulsion. For some OCBs, in attempt to ensure success, gradual exposure was used where specific criteria were set for reduced engagement in compulsions. If the child met his or her goal, child-initiated positive reinforcement (e.g., access to a preferred tangible item) was provided by the parent and faded accordingly. For example, a child may have developed a plan that limited the number of times he or she could erase and rewrite letters during homework each day, gradually decreasing the amount of times throughout the week. When possible, parents brought associated stimuli from home, and exposures were contrived in session (e.g., when objects were lined up, the child practiced moving one object out of place).

Parent training

Fb-CBT was family-based (Barrett, Farrell, Pina, Peris, & Piacentini, 2008) with parent training being an integral part of the treatment. Parent training occurred simultaneously with children working on specific treatment components. Parent training included discussions of OCB etiology, maintenance, impact of stressors, functions, various treatments of OCBs, positive reinforcement, and relapse prevention. Following discussion of treatment components, parents received hands-on training using modeling, role-playing, practice, and feedback in implementing individualized function-based and reinforcement interventions, cognitive strategies, and exposure plus response prevention. Parents received information on generalization of strategies to other child behavior problems and referral sources for other issues (e.g., fine motor problems).

Treatment Integrity

Trained observers followed a treatment checklist derived from the Vause et al. (2013a) manual to conduct treatment integrity (TI) checks on both therapist and parent behaviors on 97% of sessions across all components of the intervention. TI was calculated as percentage of checklist items completed correctly. Interobserver agreement on TI was calculated by dividing the number of agreements on delivery of treatment components by the number of agreements plus disagreements and converting to a percentage. Mean TI and TI interobserver agreement (25% of sessions) were both 100%.

Reliability on Parent Ratings of Target Behaviors

For three of the seven participants, observational probe data were collected by digital recordings of participants in their home environments. Interobserver agreement was calculated as the average percentage agreement between the lead therapist and the parent’s rated scores for each recording (Cooper et al., 2007). Agreement between the therapist and parents’ Likert-type scale ratings on six behaviors over 19% of randomly selected observations was 86% (range = 76%–91%).

Group Comparisons on RBS-R and CY-BOCS

Figure 1 shows between-group pre–post differences on behaviors included in the Compulsive, Ritualistic, and Sameness RBS-R subscales. A mixed-design ANOVA shows a significant Time × Group interaction, F(1, 12) = 6.98, p = .02 (η² = .58), indicating a significantly greater reduction between pre- and post-treatment RBS-R ratings of child OCBs in the Fb-CBT group. Figure 2 shows between-group pre–post differences on the CY-BOCS. A mixed-design ANOVA shows a significant Time × Group interaction, F(1, 11) = 27.77, p < .001 (η² = .51), indicating a significantly greater reduction between pre- and post-treatment in the severity of compulsions for participants in Fb-CBT versus TAU.

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Figure 1.

Changes in mean severity ratings on the Compulsive, Ritualistic, and Sameness subscales of the RBS-R for Fb-CBT and TAU groups.

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Figure 2.

Changes in mean compulsion severity ratings for the CY-BOCS for FB-CBT and TAU groups.

Treatment Component Analysis for Fb-CBT Group

Figure 3 shows grand means for daily parent ratings (using a Likert-type scale) of target behaviors across baseline (M = 24 days, SD = 7 days), PM, individualized OCB treatment, and follow-up (M = 5 months, 13 days; SD = 5 days). Across 7 participants in the Fb-CBT group, we treated 42 behaviors (M = 6, range = 3–9). Using the last three data points in each phase (for two behaviors, only one or two data points were available for use in the analysis), grand mean parent ratings were calculated for participants’ treated behaviors. Individual behaviors missing data in one or more phases were excluded from grand mean calculations; there were a total of 37 behaviors with data across all phases. Follow-up parent rating data were unavailable for two of the seven participants; therefore, we used the Last Observation Carry Forward (LOCF; Hamer & Simpson, 2009). A one-way repeated-measures ANOVA revealed a significant effect of phase on the grand means of parent ratings of OCB, F(3, 18) = 16.98, p < .01 (η² = .74). Post hoc pairwise Bonferroni corrected comparisons indicated parent ratings did not show a significant difference from baseline to PM (p > .05) but significantly decreased from baseline to individualized OCB treatment (p = .02) and PM to individualized OCB treatment (p = .01). Baseline to follow-up approached significance (p = .09), and PM to follow-up showed a significant decrease (p = .001). A significant difference was not found between intervention and follow-up (p > .05).

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Figure 3.

Mean parent ratings of OCB for all participants across all phases.

Across seven participants, 68% (25 of 37) behaviors responded to treatment, and of those 25, 14 behaviors were reduced to a parent rating of 1 (desired post-treatment levels). Following treatment, all participants showed decreases in OCBs, with the percentage of improved behaviors per participant ranging from 20 to 100 (M = 69%).

Consumer Satisfaction

Using a 7-point Likert-type scale, all seven parents participating in Fb-CBT were generally satisfied with the effectiveness of our therapy (M = 5.29, SD = 1.80). One parent said, “It worked!” and another said, “The study has helped us greatly at home with dealing with every aspect of [my daughter’s] anxiety.”

Manualized Treatment Based on Evidence-Based Practice for ASD

In line with previous research (Reaven, 2009; Sukhodolsky et al., 2013), our treatment is tailored to the unique characteristics of individuals with high functioning ASD who present with varying cognitive-developmental levels. In the present study, children who received Fb-CBT had estimated Full Scale IQs (WISC-IV; Wechsler, 2004) ranging from 80 to 124. Our treatment is based on evidence-based educational interventions recommended for children with ASD above the age of 5 years, which includes individualized and systematic programming, structure, addressing goals related to ASD challenges, use of positive behavioral interventions, and family involvement (Iovannone, Dunlap, Huber, & Kincaid, 2003). Our multimodal treatment involves creating individualized goals and treatment plans for each OCB, structure and predictability, as well as behavioral support strategies.

Participating in a treatment group may have helped the children’s social-communicative skills, although these behaviors were not directly measured. Therapists did report that children formed friendships, and one child initiated the exchange of contact information with another child to get together after treatment.

Limitations

Although this RCT should be considered preliminary because of the small sample size, significant between- and within-group differences in OCB symptom severity emerged. It should be noted that due to resource limitations, we were unable to administer the Autism Diagnostic Observation Scale (Lord, Rutter, DiLavore, & Risi, 1999) to complete our own diagnostic assessment of ASD. Although RBS-R follow-up data were available for all seven treatment participants, due to parental time constraints in the follow-up period, the CY-BOCS was not administered and OCB parent ratings were available for five of seven participants. Future studies using Fb-CBT should collect interobserver agreement data on the descriptive analyses.