Samenvatti ng Capita Selecta Therapy (PSMKB-10) - Psychosociale interventi es bij
auti sme spectrum stoornissen
Week 1.
1. Benevides (2020)
Interventions to address health outcomes among autistic adults: A systematic review
Introduction: Research has shown that autistic adults have more health problems then their same-
aged peers. Problems in health and healthcare among adults with ASD include: early death/mortality,
increased rates of psychiatric emergency department utilisation, less use of preventive care visits for
cancer screenings. Increased utilisation and costs for privately insured healthcare.
Aim = to identify interventions used with autistic adults to address health outcomes and to evaluate
the quality of available interventions.
RQ = “What interventions (I) implemented for individuals are currently documented in the literature
that evaluate the impact on health-related outcomes (O) for autistic adults (P)?”
Methods: 18 community research partners were included to make recommendations based on
available literature and community priorities.
Included studies that were published between 2007 and 2018 in the online research database
PubMed, English, peer-reviewed and included:
(1) an intervention
(2) an outcome that was related to individual-level health (not system-level), including at least 1
physical, mental and/or social health outcome.
(3) a sample population that included at least 50% autistic adults aged >18 years.
Studies were excluded if they were not peer-reviewed, had a focus on caregivers, were expert
opinions on specific interventions, untested protocols, or interventions without a primary health
outcome. Of 778 reviewed articles, 19 studies met all of the criteria above.
Specific intervention recommendation-searches: Cognitive Behavioural Therapy (CBT), use of medical
marijuana, animal-assisted therapy, trauma-informed interventions.
Results:
Based on the evidence gathered, two were considered emerging evidence-based approaches:
cognitive behavioural approaches and mindfulness. The remaining interventions included in the
review did not have sufficient evidence to support current use with this population. The majority of
the studies included samples of young autistic adults, primarily male, without an intellectual
disability. Anxiety, quality of life, depression, and behavioural issues were among the health
outcomes measured in the final included articles.
CBT: Cognitive behavioural interventions are considered an emerging evidence-based approach for
improving self-reported mood and anxiety symptoms among autistic adults, based on the availability
of six studies (of which 2 RCT’s). However, the two RCTs suggest that CBT is not significantly better
than other alternative interventions such as “anxiety management” or “recreational groups”. CBT
does result in small clinical effects on self-reported outcomes and large effect for blinded assessor
ratings of obsessive-compulsive behaviour outcomes.
Most studies provided group CBT, with mean of 18.75h of total therapy (range 12-108h); delivered
weekly. Adults with ASD without cognitive or verbal disabilities. The two RCT’s differed greatly group
vs. individual CBT. No negative effects. No comparison with alternative intervention.
Mindfulness: Mindfulness approaches are also considered an emerging evidence-based approach for
autistic adults based on two studies (1 RCT and 1 quasi-experimental design, of which one compared
,mindfulness to group CBT). Used manualized group mindfulness approaches to address self-reported
health outcomes of depression and anxiety.
No negative outcomes, effect sizes ranged from d=0.07– 0.78 for self-reported depression symptoms
and effects between d=0.37–0.76 for self-reported anxiety symptoms. Mindfulness approaches were
implemented once a week for 1.5–2.5h a session, for 9–12weeks (= total number of hours 19.5-
22.5h). Adults with ASD without intellectual disability.
Medical interventions: 6 studies implemented medical interventions to address health outcomes
among autistic adults. All medical interventions are considered to be unestablished evidence for
intervention (weak study designs, high risk of bias).
3 studies used “electroconvulsive therapy” (ECT), 1 study used a pharmacological intervention, 1
study used a multi-component intervention in the intensive care unit for respiratory distress, and 1
study used deep transcutaneous magnetic stimulation to the brain (TMS).
For ECT specifically, only four cases of adults ages 19–38years, primarily with co-occurring intellectual
disability, have been reported. None of the participants provided their own consent to participate.
ECT is an invasive medical procedure in which electrical waves are transmitted to the brain. All of the
studies which implemented this type of intervention described the effects on social behaviours,
psychological symptoms such as obsessive-compulsive behaviours, and self-injurious behaviours. One
ECT study reported a negative response with worsening symptoms prompting discontinuation of ECT
treatment.
(marked are the studies underneath)
Discussion:
More research on preferred interventions with prioritized health outcomes of the autistic adult
population is needed.
,The two primary intervention approaches considered to have emerging evidence were cognitive
behavioural interventions and complementary/integrative mindfulness interventions, both aimed at
reducing psychiatric symptoms (e.g. depression, anxiety, obsessive-compulsive disorder) in autistic
adults without intellectual disability. Others have found that cognitive behavioural interventions are
of benefit to autistic children (Weston et al., 2016), as are mindfulness interventions (Cachia et al.,
2016) and our study suggests there is evidence for these approaches in adults 18 years and older.
Many of the interventions reviewed in this study did not have sufficient evidence supporting their use
in autistic adults. Future research is needed to better understand the effect of social skill
interventions to address social anxiety, vocational interventions to address quality of life, and
technology applications for reduced anxiety. Whether an intervention is viewed positively by autistic
people is an important consideration, in addition to its evaluated effectiveness, given autistic people
will be participants in these interventions. In addition, none of the included studies in our review
reported using community–stakeholder partnership in evaluating the interventions.
No studies were found that addressed integrative health approaches through yoga, animal-assisted
therapy, or tai-chi for this population, despite autistic community reported interest in research for
these topics. In addition, the adult autistic community desires evidence-based information about
medical marijuana for anxiety and other mental health symptoms but no studies were identified that
examined this intervention for this population. Although these interventions are being reported as
useful anecdotally in the adult autistic community, well-designed comparative effectiveness research
has not yet been developed.
Community council review of findings:
CBT for improving mental health:
In the general population, CBT is a well-established, evidence-based intervention for anxiety. Some
people with autism spectrum conditions find CBT very helpful in alleviating their anxiety or
depression symptoms. The goal of CBT is to enable people to take control of how they interpret and
deal with things in their environment. Modifications to CBT for young autistic individuals in order to
tailor approaches for coping skills and exposure appear to be an important component of evaluated
studies. The implementation of these protocols always incorporates modifications to standard CBT
and should be considered as one approach to assist the individual in self-management of their
anxiety. Additional evaluation of these approaches for older autistic adults and the long-term impact
of such interventions is necessary. It should be noted that some autistic people report that CBT is
unhelpful for them. There is not a “one-size-fits-all” approach to therapy. However, others find the
practical and action-based nature of it helpful.
Mindfulness-based interventions for improving mental health:
Contrary to CBT, mindfulness-based interventions focus on modifying an individual’s thoughts and
emotions, by separating themselves from these thoughts and emotions, with the goal of improved
emotional regulation and self-awareness. In everyday settings, mindfulness approaches are being
used by autistic adults because of the ease and availability of apps and other online tools. When used
outside of the context of research, the implementation of mindfulness techniques varies in duration,
frequency, and intensity; they are not likely implemented in the same manner as those that were
researched in this review. Mindfulness is often seen by autistic adults as being helpful for decreasing
stress, anxiety, ruminating thoughts, anger, and aggression because it enables people to safely
observe their world and themselves. It can be a positive and self-caring strategy that both centres a
person to reality but grounds them in a less volatile or stressful way of being at the same time. Future
research should aim to examine the ease of use, cost, and long-term benefits of mindfulness
, approaches, including those that are accessed through apps by individuals on their own, as compared
to other available approaches.
Social skills interventions for improving health:
The use of PEERS® for Young Adults intervention (McVey et al., 2016), which is a group-based
intervention targeting social skills, has preliminarily been shown to address social anxiety in a
moderately sized sample. Community Council member contributors reflected on the importance of
social skills for ensuring relationships with others in work and personal lives are healthy. Some
autistics who ascribe to a social model of disability see some social skills interventions as teaching
camouflaging. Camouflaging has been identified as one of the predictors of suicidality. In addition,
some social skills interventions present specific behaviours as negative or wrong, and therefore might
promote feelings of shame as related to features of autism that are part of one’s identity. It is
recommended that all interventions which involve and aim to support autistic adults, including social
skills interventions, include their feedback and input during the development and evaluation of the
content.
Vocational interventions and health:
Remarkably, while there are many vocational and employment interventions that exist within the
field of autism research, only one was identified as measuring a health outcome, quality of life (Gal et
al., 2015). Community Council members reflected on the importance of measuring quality of life
outcomes, no matter the intervention, as quality of life is an essential indicator of health.
Prescription medication and dosing:
Few studies examined the impact of pharmacological or medical interventions, despite the high rate
of use by medical practitioners. The autistic community has anecdotally reported that medication
side effects and dosing are not well evaluated, and use of medications is felt to be poorly tolerated.
Evaluation of medication use and side effects among autistics is needed and should involve the
autistic community in their development of research. Along with prescription drugs, other
Community Council members described the need for studies on cannabidiol drugs (CBDs) and other
forms of medical marijuana which has possible anxiety-reduction effects. The careful study of this for
the autistic adult population has not been addressed in the peer-reviewed literature, despite
increasing numbers of states that consider autism a qualifying condition for its use.
ECT:
It is important to note that none of the Community Council felt that ECT was an appropriate
intervention for autistic individuals. Major concerns from the Community Council were raised related
to this intervention approach, including possible damage to the brain, memory, and the extensive
risks associated with this approach.
TMS:
Community Council members did emphasize the importance of distinguishing ECT from TMS. The
majority of Community Council members asked for more information about this approach, as very
little is known about its use.
Gaps in the literature:
Many Community Council members identified the lack of studies on aging and interventions to
address the health of aging autistic adults. Palliative and end-of-life care, dementia care, and
addressing chronic health conditions that occur during the course of normal aging are unaddressed
topics, especially given the preponderance of studies on young adults in the found literature.
Addressing the sensory, social, and physical environmental changes that occur as someone ages in
place is an un-researched area in autism; moreover, there is a need to understand proprioceptive and
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