News and Knowledge

In November, OAR’s Board of Directors authorized funding for seven new applied autism research studies in 2020. These new grants, totaling $275,000, bring OAR’s total research funding to more than $4 million since 2002. This is the first of seven previews to be featured in The OARacle this year.

Anxiety disorders are prevalent in children with autism spectrum disorder (ASD) and often begin in the preschool years. For children with ASD, anxiety negatively impacts functioning and increases risk for psychiatric disorder. Although modified cognitive behavioral therapy (mCBT) is used with older children with ASD, it has not been used for preschool children with similar needs. Thus, they have no available treatment options.

With funding from OAR, Amy Keefer, Ph.D., supervising clinical psychologist at the Hugo W. Moser Research Institute at Kennedy Krieger, Inc., Baltimore, Md., is piloting an integrated treatment model for anxiety in preschool children with ASD. This study, Piloting an Integrated Anxiety Intervention for Preschool Children with Autism Spectrum Disorder, is the first to pilot an anxiety treatment designed for preschoolers with ASD and offers a first step toward an early intervention model for anxiety in this group.

Methodology

Strategies for Anxiety and Intolerance of Uncertainty Reduction (DINOSAUR), a program Dr. Keefer created, will be used in the study. The DINOSAUR program targets anxiety; intolerance of uncertainty, which contributes to anxiety symptoms; and parental accommodation, an established maintaining factor of child anxiety. She and a therapist will lead the groups that participate in the study.

Dr. Keefer will recruit participants from a larger study at Kennedy Krieger to participate in her study. Children between 3 and 5 years of age with an ASD diagnosis as confirmed by meeting algorithm criteria on the Autism Diagnostic Observation Schedule, Second Edition and parent interview confirming DSM-5 ASD criteria and a DSM-5 anxiety will be eligible to participate.

The first phase of the study will be a pilot of the treatment program with six child-parent pairs. Based on parental feedback from that pilot, the program will be revised.

In the next phase, four groups of six child-parent pairs will be recruited and enrolled over 15 months. A new waitlist group will be formed and baseline assessment completed every three months. After 12 weeks on the waitlist, a pre-treatment assessment will be conducted and the group will then complete the DINOSAUR program. The research team will conduct post-treatment testing with each group when they finish the intervention.

Parents will complete weekly ratings of treatment satisfaction, video record their implementation of treatment strategies at weeks 8 and 11, and complete a final assessment and post-treatment assessments. Throughout enrollment in the study, parents will be asked to report any new interventions or educational programs as well as significant transitions the child may experience (e.g., family moves, start of school) to control for the potential effects of these factors on anxiety levels.

The first six group sessions will be for parents only and include education about anxiety and intolerance of uncertainty. In addition, they will learn how to teach their children effective coping skills and recognize and reduce reinforcement of triggers that cause anxiety and uncertainty.

The next six sessions will involve both the parent and child. Parents will learn how to systematically expose their child to stimuli related to the child’s fears and to uncertainty during sensory, social, and daily living situations that are often distressing to preschool children with ASD. Exposures will be practiced during treatment sessions so that parents can receive coaching from the group leaders. Materials for the children will be presented using an engaging dinosaur theme. Parents will then practice exposures with children at home to generalize their skills.

Evaluation

To assess the feasibility of DINOSAUR, the research team will look at how many participants participated throughout the study and the percentage of treatment sessions participants attended. They will also compare parents’ implementation of intervention skills to expected benchmarks and assess parents’ performance on a final evaluation of treatment concepts.

Parents and treatment leaders will rate treatment satisfaction weekly to evaluate the program’s acceptability.

The intervention’s effectiveness will be measured by comparing the children’s anxiety at baseline and pre- and post-treatment. Response to uncertainty will be measured through a parent-report measure and parental accommodation will be assessed through a parent report scale, both administered at baseline and pre- and post-treatment.

Outcome Recommendations

If the feasibility and acceptability of this project are supported, it would suggest that treatments can be successfully modified and delivered to children in this age range. Additionally, if the DINOSAUR model is successful in reducing child anxiety, this would be the first evidence that providing high doses of interventions targeting the causes of anxiety may be an effective treatment strategy.

Successful study findings would also represent the first step toward making anxiety treatment for preschool children with ASD more widely accessible. Following the conclusion of this study, large-scale randomized controlled trials of DINOSAUR will be conducted to study treatment efficacy.