Scholarship PDF
Scholarship PDF
Abigail Hennigan
April 8, 2018
I pledge.
INTEGRATIVE LITERATURE REVIEW !2
Abstract
Purpose: The purpose of this integrative review is to determine the efficacy of cognitive
Background: Children diagnosed with autism spectrum disorders are at high risk of developing
Method: There is an integrative review in which research was collected from online nursing
databases. The five quantitative articles were chosen based on specific criteria. The articles used
Limitations: Limitations of the review include the author’s lack of experience in conducting an
integrative review, lack of research articles available, and the short time span allowed to conduct
the review.
Results and Findings: The evidence complied for this integrative review supports the
conclusion that CBT is an appropriate treatment modality for reducing symptoms of co-occurring
co-occurring psychiatric disorders included increasing positive patient outcome sin home,
school, and community environments. Recommendations for further research should include a
broader sample size and the use of objective data collection sources.
INTEGRATIVE LITERATURE REVIEW !3
The purpose of this integrated review is to determine if cognitive behavioral therapy can
be used to decrease the symptoms of co-occurring disorders in children diagnosed with autism
spectrum disorder. Co-occurring disorders in children diagnosed with autism spectrum disorder
include, but are not limited to, obsessive compulsive disorder, anxiety, and depression. The need
for this research is supported by the Journal on Developmental Disabilities' recognition that
there are few studies evaluating interventions for these specific conditions (Vause, Hoekstra, &
Feldman, 2014).
For children diagnosed with autism spectrum disorder, co-occurring disorders can
interfere with their functionality in school, home, and community environments (Reaven,
for these children in order to increase positive patient outcomes. Indications for this review
includes the fact that, according to the CDC, autism spectrum disorder crosses racial, ethnic, and
socioeconomic boarders (2016). The aim of this literature review is to examine the “literature”
related to the author’s PICOT question: Does cognitive behavioral therapy decrease the
This integrative review of the literature concentrated on five research articles. The articles
utilized pertain to the author’s PICOT question, “Does cognitive behavioral therapy decrease the
symptoms of co-occurring disorders in children diagnosed with autism spectrum disorder?” The
author’s initial search method used PubMed and EBSCO Discovery Service. The search words
INTEGRATIVE LITERATURE REVIEW !4
were autism spectrum disorder and cognitive behavioral therapy. The results yielded 987
articles. The articles were then filtered by year, language, status of publication, peer review
status, and relevance to the PICOT question. The articles were limited to publication dates
between 2013 and 2018. Only peer review, English language articles were selected for review.
Full-text availability was the last filter applied. Many articles were disqualified due to these
filters.
The remaining articles were chosen based on relevance to the author’s PICOT question.
An evaluation of the effectiveness of cognitive behavioral therapy was a requirement for each
research article. The article’s research subjects had to focus on the pediatric population
diagnosed with autism spectrum disorder. Based on these requirements, five articles were
selected for the following integrative literature review. All five articles are quantitative studies
(Reaven et al., 2012; Russell et al., 2013, Storch et al., 2013; Storch et al., 2015, Vause et al.,
2014).
Findings
The results of the articles clearly identify a decrease in symptoms severity when children
diagnosed with autism spectrum disorder are treated with cognitive behavioral therapy (Reaven
et al., 2012; Russell et al., 2013, Storch et al., 2013; Storch et al., 2015, Vause et al., 2014). A
summary of the five research articles is located in Table 1- Article Evaluation. The following is a
behavioral therapy could decrease the symptoms of anxiety in children diagnosed with autism
INTEGRATIVE LITERATURE REVIEW !5
spectrum disorder. The authors of the study analyzed the severity of anxiety in patients who
spent 16 weeks in cognitive behavioral therapy compared with adolescents who spent 16 weeks
in their normal treatment modalities. The authors conducted a experimental design with a
randomized control trial. The sample consisted of 50 youth ages seven to fourteen from
Colorado. Quantitative data was collected using the Clinical Global Impression Scale and the
SCARED, Screen for Child Anxiety and Related Emotional Disorders, tool. Independent clinical
evaluators were blind to the participant’s treatment group and analyzed anxiety symptoms before
treatment, after treatment, and at a 3 month follow-up appointment. Findings were in favor of
cognitive behavioral therapy. There was a significant reduction in the number of anxiety
disorders for children who were randomly assigned to the cognitive behavioral group.
In a study conducted by Russell (2013), a randomized trial was conducted to analyze the
compulsive disorder in adolescents diagnosed with autism spectrum disorder. The authors
randomly assigned participants into a cognitive behavioral therapy group and an anxiety
management (AM) control group. The sample consisted of 46 participants from London, United
Kingdom. Qualitative data was collected using the Yale-Brown Obsessive Compulsive Severity
Scale (YBOCS), CGI scale, and the use of self reporting. The clinical evaluators who analyzed
the participants were blind to the participant’s treatment group. The participants were evaluated
before treatment and after the treatment and then at a 3, 6, and twelve month follow-up
appointment. For the participants randomly assigned to the CBT group, their YBOCS scores
steady declined from 25 to 15. Finds favored both AM and CBT. For the participants randomly
assigned to the AM group, there was still a steady decline, but only from 25to 20. While the
INTEGRATIVE LITERATURE REVIEW !6
decline in YBOCS scores for the CBT group was more significant, the authors of the study found
that both the AM group and the CBT group responded positively to the therapy.
This integrative review analyzed two studies conducted by Storch (2013, 2015). The first,
a study conducted by Storch and Arnold (2013) sought to determine if children diagnosed with
autism spectrum disorder with co-occurring anxiety disorders could benefit from cognitive
behavioral therapy. The destined used randomized control trials and participants were randomly
assigned to either the CBT group or the treatment-as-usual group. The treatment-as-usual
participants were instructed to continue their current interventions; these interventions included
psychotherapy and psychotherapy. The same size consisted of 45 children ages 7 to 11 from St.
Petersburg, Florida. The authors of the study used Program and Activity Reporting System
(PARS), Anxiety Disorder Interview Schedule (ADIS), and Cognitive Impression-Severity (CGI)
tools to collect data. The quantitative data was analyzed by trained evaluators who were blind to
the participant’s intervention condition. Findings from the PARS, ADIS, and CGI were in favor
of CBT. The PARS calculated a 29% reduction in post treatment surveys when compared with
post treatment surveys. Adolescents who received CBT showed substantial improvements in
The second study conducted by Storch and Lewin (2015), evaluated the effectiveness of
cognitive behavioral therapy for children diagnosed with autism spectrum disorder and co-
occurring anxiety disorders. The designed of the study used randomized controlled trials to
compare children diagnosed with autism spectrum disorder participating in cognitive behavioral
therapy and treatment-as-usual interventions. Participants of the TAU group were instructed to
INTEGRATIVE LITERATURE REVIEW !7
counseling, social skills training, and pharmacological management. The sample consisted of 31
children ages 11 to 16 from Florida. Storch and Lewin used PARS, ADIS, and CGI tools to
collect data. Data was analyzed by trained graduate-lvil independent evaluators who were blind
to the participants treatment condition. Finds were in favor of the CBT group. There was a steady
decline from baseline in the PARS, ADIS, and CGI scores. Participants who were randomly
assigned to the CBT group demonstrated superior improvements when compared with
In a study conducted by Vause (2014), the author sought to determine the efficacy of
compulsive disorder in children diagnosed with autism spectrum disorder. The authors of the
study used a single-case experimental design. The sample consisted of two children ages ten and
eight from Ontario, Canada. Each child participated in the March and Mulle Treatment Protocol,
a from of function-based cognitive behavioral therapy. The March and Mulle Protocol included
prevention. Data was collected using the Autism Diagnostic Interview scale (ADIS), Quality of
Life Impact Questionnaire, and the Children’s Yale-Brown Obsessive Compulsive Scale. Each
child was evaluated for target behaviors before the interventions. Examples of target behaviors
include, but were not limited to, excessively digging fingernails into bars of soap and brining
garbage home from school. For both participants, the target behaviors were steady reduced
throughs treatment and painted at the 3 and 4 month follow-up. Using function-based cognitive
INTEGRATIVE LITERATURE REVIEW !8
behavioral therapy in a single-case experimental design can reduce the symptoms of obsessive
Discussion/Implications
The articles selected for review indicate a positive correlation between the use of
cognitive behavioral therapy and the reduction of anxiety disorder and obsessive compulsive
disorder symptoms. The researcher framed the review according to the following themes: anxiety
disorders and obsessive compulsive disorders. The following is a discussion on the implications
of the paper organized by the common themes in relation the researcher’s PICOT question.
The aim of this literature review is to examine the studies related to the author’s PICOT
question: Does cognitive behavioral therapy decrease the symptoms of co-occurring disorders in
children diagnosed with autism spectrum disorder? Cognitive Behavioral Therapy was utilized in
all five studies (Reaven et al., 2012; Russell et al., 2013, Storch et al., 2013; Storch et al., 2015,
Vause et al., 2014). Three of the studies were aimed at reducing symptoms of co-occurring
anxiety disorders (Reaven et al., 2012, Storch et al., 2013, Storch et al., 2015), while the other
two articles were aimed at reducing symptoms of obsessive compulsive disorders (Russell et al.,
2013, Vause et al., 2013). The following discussion addresses the themes of anxiety disorder and
Anxiety Disorder.
Three of the articles examined the use of cognitive behavioral therapy when aimed at
reducing symptoms of co-occurring anxiety disorders (Reaven et al., 2012, Storch et al., 2013,
Storch et al., 2015). In each of these articles, the authors of the study concluded that the
reduction of symptoms severity from baseline to follow up was more significant in the cognitive
behavioral therapy group than compared with the treatment-as-usual treatment group (Reaven et
al., 2012, Storch et al., 2013, Storch et al., 2015).Parents reported a decrease in disorder
interference for home, school, and community settings (Reaven et al., 2012, Storch et al., 2013,
Storch et al., 2015). Limitations of these studies included modest sample sizes and no follow-up
appointments after 6 months (Reaven et al., 2012, Storch et al., 2013, Storch et al., 2015). The
authors of the studies identified that, before implementation into practice, future research should
include a broader sample size along while implementing long term follow-up appointments
Two of the articles exampled the use of cognitive behavioral therapy when aimed at
reducing symptoms of co-occurring obsessive compulsive disorders (Russell et al., 2013, Vause
et al., 2013). In each of these articles, the authors of the study concluded that cognitive
behavioral therapy was an appropriate treatment modality for reducing the symptoms of
obsessive compulsive disorder (Russell et al., 2013, Vause et al., 2013). A study by Russell
(2013) found that anxiety management was also a treatment modality appropriate for reducing
compulsive disorders (Russell et al., 2013, Vause et al., 2013). Examples of these symptoms
include the following: excessively digging fingernails into a bar of soap, repetitive questioning,
the vocal ritual of listing people, places, and things, and bringing home garbage from school
(Vause et al, 2013). The authors identified that limitations of the studies included a limited
sample size and the fact that parent reporting is not subjective, and thus limit the reliability of
study results (Russell et al., 2013, Vause et al., 2013). Before implementing into practice, the
authors of the studies suggested that further research should include a broader sample size and
incorporate objective data sources along with parent reports (Russell et al., 2013, Vause et al.,
2013).
Limitations
In conducting this review of the literature, the author encountered many limitations. A
large inflating factor is the author’s inexperience and lack of known about the process of
conducting an integrative review. The author has few qualifications for providing a reliable, in
depth discussion. The author has no first hand insight into the subject matter at hand. The
researcher was only able to provide limited insight into the discussed PICOT question.
Furthermore, choosing the articles for review created a limitation. The author had
difficulty finding research articles pertaining to her initial research interests. This inhibited the
collection process, but was out of the author’s control. The author had to broaden her research
topic in order to have enough research articles to present in the review. All the while, only
choosing five research articles published since 2013 delimited the literature review. This is not a
INTEGRATIVE LITERATURE REVIEW 1! 1
comprehensive review of the literature as evidence by the review’s delimitations and the author’s
short writing time frame. These factors should be taken in consideration for further research.
Conclusions
The evidence compiled for this integrated review of the literature support the conclusion
that cognitive behavior therapy is an appropriate treatment modality in reducing symptoms of co-
occurring psychiatric disorders in children diagnosed with autism spectrum disorder (Reaven et
al., Russell et al., 2013, Storch et al., 2015, Vause et al., 2014). This answers the authors PICTO
question: Does cognitive behavioral therapy decrease the symptoms of co-occurring disorders in
children diagnosed with autism spectrum disorder? Positive treatment outcomes were seen in
children who participated in connive behavioral therapy. Future research should include a
broader sample size, objective data collection tools, and long term follow-up appointments. In
relation to the PICOT question, the literature reflects a positive response to cognitive behavioral
therapy in reducing the severity of anxiety and OCD symptoms for children diagnosed with
References
Centers for Disease Control and Prevention. (2016). Autism Spectrum Disorder (ASD).
Reaven, J., Blakeley-Smith, A., Culhane-Shelburne, K., & Hepburn, S. (2012). Group cognitive
behavior therapy for children with high-functioning autism spectrum disorders and anxiety: a
Russell, A. J., Jassi, A., Fullana, M. A., Mack, H., Johnston, K., Heyman, I., & ... Mataix-Cols,
functioning autism spectrum disorders: a randomized controlled trial. Depression & Anxiety
Storch, E. A., Arnold, E., De Nadai, Lewin, A. B., Nadeau, J. M., Jones, A. M., De Nadai, A. S,
Mutch, P. J., Selles, R. R., Ung, D., Murphy, T. K. (2013). The effect of cognitive behavioral
therapy versus treatment as usual for anxiety in children with autism spectrum disorders: a
randomized controlled trial. Journal of the American Academy of Child and Adolescent
Storch, E. A., Lewin, A. B., Collier, A. B., Arnold, E., De Nadai, A. S., Dane, B. F., & ... Murphy,
as usual for adolescents with autism spectrum disorders and comorbid anxiety. Depression
Vause, T., Hoekstra, S., & Feldman, M. (2014). Evaluation of Individual Function-Based
Appraisal/Worth For children diagnosed with autism spectrum who have co-
to practice occurring anxiety disorders, cognitive behavioral therapy can
be used to reduce the symptoms of anxiety.
First Author Russell, A. J., Jassi, A., Fullana, M. A., Mack, H.,
(Year)/ Johnston, K., Heyman, I., & ... Mataix-Cols, D. (2013).
Qualifications Cognitive behavior therapy for comorbid obsessive-
compulsive disorder in high-functioning autism spectrum
disorders: a randomized controlled trial. Depression &
Anxiety (1091-4269), 30(8), 697-708.
Conceptual/
theoretical
Framework
Findings/ - Both the AM group and the CBT group had positive results.
Discussion Obsessive compulsive disorder symptom severity was
decreased.
First Author Storch, E. A., Lewin, A. B., Collier, A. B., Arnold, E., De
(Year)/ Nadai, A. S., Dane, B. F., & ... Murphy, T. K. (2015). A
Qualifications randomized controlled trial of cognitive-behavioral therapy
versus treatment as usual for adolescents with autism
spectrum disorders and comorbid anxiety. Depression
And Anxiety, 32(3), 174-181. doi:10.1002/da.22332
Data Analysis There was a steady decline in the PARS, ADIS, and CGI-
Severity scores. From baseline to follow up there was a
steady decline.
Findings/ Subjects who participated in the CBT group demonstrated
Discussion superior improvements compared with the subjects who were
randomized into the TAU group.
First Author Storch, E. A., Arnold, E., De Nadai, Lewin, A. B., Nadeau,
(Year)/ J. M., Jones, A. M., De Nadai, A. S, Mutch, P. J., Selles,
Qualifications R. R., Ung, D., Murphy, T. K. (2013). The effect of
cognitive behavioral therapy versus treatment as usual for
anxiety in children with autism spectrum disorders: a
randomized controlled trial. Journal of the American
Academy of Child and Adolescent Psychaitry, 52(2),
132-142.
First Author Vause, T., Hoekstra, S., & Feldman, M. (2014). Evaluation
(Year)/ of Individual Function-Based Cognitive-Behavioural
Qualifications Therapy for Obsessive Compulsive Behaviour in Children
with Autism Spectrum Disorder. Journal On
Developmental Disabilities, 20(3), 30-41.