A Multiple Single Case and Mixed-Methods Evaluation of a Parent-Mediated CBT Intervention for Children with ASD and Difficulties with Emotional Regulation: Feasibility, Acceptability and an Initial Estimate of Efficacy

Background:  In addition to the core deficits, many young people with Autism Spectrum Disorder (YPASD) have difficulties with emotional regulation which can present as elevated levels of anger and aggression. Such problems left untreated can disrupt the child’s psychosocial development and have a longstanding and negative impact on the child and their family. However, in comparison to anxiety management, there is a paucity of research on therapeutic interventions for anger management in this population. Furthermore, there has been no research on individually administered CBT for anger management for YPASD.

Objectives:  The aim of this study was to obtain an initial estimate of efficacy and investigate the acceptability and feasibility of an individually administered, parent-mediated cognitive behavioural intervention for YPASD (8-14 years old) with emotional regulation difficulties relating to anger.

Methods:  The study employed a mixed-methods, small-N design which consisted of a series of seven systematic case studies. Participants acted as their own controls. Frequency data was collected fortnightly over a baseline period, during the intervention period and at six week follow-up. The primary outcome measure was a parent report frequency measure of anger outbursts. Secondary outcome measures included the Strengths and Difficulties Questionnaire, the Parenting Stress Index– Short Form, personalised Goal Based Outcomes and post-intervention interviews. Visual analysis of the primary outcome was supplemented by a Tau-U statistical analysis (Parker, Vannest, Davis & Sauber, 2011). The reliable change index (Jacobson and Truax, 1991) was used to calculate reliable differences of pre/post data of the secondary outcome questionnaires. Qualitative interview data were analysed using thematic analysis (Braun and Clarke, 2006).

Results:  The quantitative and qualitative results indicated preliminary evidence that the intervention was acceptable to most families. Analysis revealed that the intervention led to statistically significant reductions in anger outbursts in two cases. Parents also reported additional improvements to the intensity and duration of outbursts which were not captured by the frequency measure. Qualitative data also revealed other positive child behaviour changes as well as positive changes in parental stress and improved communication between parents and child. The outcome varied across participants which suggests there is a need to better understand how such interventions can be modified to benefit a greater proportion of individuals. Obstacles to progress highlighted through post-intervention interviews with parents and therapist checklists related to the young person’s motivation to change, their ability to generalize skills outside sessions and underlying anxiety.

Conclusions:  Our findings provide preliminary evidence that an individually administered CBT intervention is acceptable and can lead to a number of positive outcomes for families of YPASD. Some obstacles to progress were highlighted by qualitative feedback and this data suggests ways in which CBT interventions could be improved for this population. Overall, the findings support further investigation of a refined version of the intervention through a larger, controlled study.